EMERGENCY CRICOTHYROIDOTOMY

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EMERGENCY CRICOTHYROIDOTOMY
Vic Vernenkar, D.O. Department of Surgery St.
Barnabas Hospital
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EMERGENCY CRICOTHYROIDOTOMYOutline

• Indications for surgical airway placement
• Contraindications
• Complications
• Anatomy of the Trachea and landmarks
• Tools Required
• Performing the Procedure
• Securing the airway
• Credits

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EMERGENCY CRICOTHYROIDOTOMY

• DEFINITION -
• An emergency surgical procedure where an incision
  is made through the skin and cricothyroid
  membrane which allows for the placement of an
  endotracheal tube into the trachea when airway
  control is not possible by other methods.

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INDICATIONS

• Obstructed Airway - obstructions within the
  airway will usually prevent the passage of an
  endotracheal tube or prevent the establishment of
  a patent airway. Therefore, a surgical airway
  distal to the obstruction is required.

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INDICATIONS

• Congenital deformities of the oropharynx or
  nasopharynx which inhibit or prevent nasotracheal
  or orotracheal intubation
• Trauma to the head or neck which would preclude
  the use of an ambu-bag, oropharyngeal airway,
  nasopharyngeal airway, or endotracheal tube
  insertion

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INDICATIONS

• Cervical Spine fractures, or highly suspect
  fractures in a patient who requires an airway but
  whom nasotracheal intubation is contraindicated.
  Examples include
• Nasal bone fractures
• Cribiform fractures
• The healthcare provider is unable to establish an
  airway by any other means and this is the last
  resort.

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ADVANTAGES OF EMERGENCY CRICOTHYROIDOTOMY

• Provides a definitive airway for ventilating the
  patient
• Can be performed quickly and has few
  complications associated with the procedure

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ADVANTAGES OF EMERGENCY CRICOTHYROIDOTOMY

• For an emergency cricothyroidotomy the
  laryngeal prominence and cricoid cartilages are
  palpated and entry is made through the median
  cricothyroid ligament.This procedure is
  preferable to a tracheotomy as there are no large
  midline vessels in front of the median
  cricothyroid ligament whereas there are in front
  of the superior part of the trachea.

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CONTRAINDICATIONS

• Massive trauma to the larynx or cricoid
  cartilage
• Damage to the affected structures will make it
  impossible to perform the procedure properly
• If another means of establishing an airway has
  not been performed. Examples include
• Heimlich maneuver, nasotracheal or orotracheal
  intubation

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COMPLICATIONS

• Major bleeding is caused by the laceration of any
  major vessels (carotid artery or jugular vein)
  within the neck.
• NOTE Very Heavy bleeding is common and normal.
• Treatment Same as minor bleeding. However, if
  bleeding is not controlled with pressure, the
  vessel may need to be ligated.

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COMPLICATIONS

• Esophageal Perforation or Tracheoesophageal
  Fistula
• Definition The creation of a hole between the
  esophagus and trachea
• Causes
• Creating an incision too deep through the cricoid
  membrane
• Forcing the endotracheal tube through the cricoid
  membrane and into the esophagus

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COMPLICATIONS

• Treatment
• Requires surgical repair of fistula or
  perforation.

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COMPLICATIONS

• Hemorrhage
• Is the most common complication
• Minor bleeding is caused by the laceration of
  superficial capillaries in the skin tissue
• Note The Thyroid Gland may extend into the area
  of the cricothyroid membrane, heavy bleeding can
  be experienced.
• Treatment Direct pressure to control the
  bleeding and then the application of a simple
  pressure dressing

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COMPLICATIONS

• Subcutaneous Emphysema
• Definition The presence of free air or gas
  within the subcutaneous tissues
• Causes
• Creating too wide of an incision will encourage
  air entrapment under the subcutaneous tissue
• Air leaking out of the insertion site may get
  trapped under the subcutaneous tissues

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COMPLICATIONS

• Treatment
• No treatment is usually necessary. Subcutaneous
  emphysema will usually dissipate on its own
  accord within a few days.
• However, placing a petroleum gauze dressing
  around the incision / insertion site will help
  reduce the incidence of subcutaneous emphysema.
• Monitor the size of the subcutaneous emphysema.

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DISADVANTAGES OF EMERGENCY CRICOTHYROIDOTOMY

• Requires advanced training to properly perform
  procedure.
• Bypasses the nares function of warming and
  filtering the air.
• May increase respiratory resistance (due to
  smaller tube size).
• Improper placement.

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ANATOMICAL LANDMARKS AND STRUCTURES

• Trachea
• Thyroid Cartilage
• Cricoid Cartilage
• Cricothyroid Membrane
• Carotid Arteries
• Jugular Veins
• Esophagus
• Thyroid Gland

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ANATOMICAL LANDMARKS AND STRUCTURES-Closeup
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Pharynx and Trachea in Detail
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More Anatomy
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Anterior view of the larynx to show the median
cricothyroid ligament.1. Thyroid lamina.2. Arch
of cricoid cartilage.3. Median cricothyroid
ligament (cut here)
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Smallest Part of the Airway ???

• In Adults it is at the vocal cords
• In Infants and Children up to 8 it is the Cricoid
  ring (cartilage), this is why uncuffed ET tubes
  work in children.

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Required Equipment for Emergency Cricothyroidotomy
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Required Equipment

• 10 or 11 Scalpel
• Endotracheal Tube
• 10 cc Syringe
• Stethoscope

• Curved Kelly Hemostat, Straight will work
• Ambu-bag
• Sterile Dressing
• Vaseline / Petroleum Gauze
• Betadine or Alcohol Wipes

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Required Equipment (continued)

• Sterile or Clean Gloves
• Suture Material
• Suction Device
• Suture Scissors
• Tape

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Determine that the patients ABCs is in
  jeopardy.
• Determine that the patient requires an emergency
  cricothyroidotomy.
• Assemble required equipment, quickly.
• Do it. Dont hesitate

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Position the patients head/neck
• The patient is placed in a supine or
  semi-recumbent position
• The neck is placed in a neutral position

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Palpate the thyroid and cricoid cartilage for
  orientation
• A - Cricoid Cartilage
• B - Cricothyroid Membrane
• C - Incision Site
• D - Thyroid Cartilage

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Locate the cricothyroid membrane
• Stabilize the thyroid cartilage using your
  non-dominant hand
• Swab the incision site with alcohol or betadine
  swabs

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Make a vertical incision through the skin
  approximately 2-5 cm (1 inch) long over the
  cricothyroid membrane
• Visualize the cricothyroid membrane

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Discussion, Vertical or Horizontal incision?
• Vertical is best for emergencies, you will expose
  the membrane guaranteed.
• Vertical does not heal well, there may be a scar
  and some internal scaring/fibroids.
• You have to be alive to be inconvenienced by the
  scar.

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Make a transverse incision into the cricothyroid
  membrane
• DO NOT make the incision more than 1/2 inch deep
  or you may perforate the esophagus

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Insert the Curved Kelly Hemostat into the
  incision and blunt dissect the incision (turn the
  Curved Kelly Hemostat 90 degrees to open up the
  incision)
• If you only have a straight hemostat, use it.

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Insert the endotracheal tube (adult 6.5 or
  smaller, Ped ? whatever will fit), into the
  incision, directing the tube distally down the
  trachea

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Ventilate the patient with two breaths
• Check for proper placement of the endotracheal
  tube with these first two ventilations by
• Observing the chest rise and fall with each
  ventilation
• Auscultate for bilateral breath sounds

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Guideline for Breath Sounds

• Bilateral Breath Sounds present - the
  endotracheal tube has been properly placed
• proper placement will cause both lungs to inflate
  with each ventilation
• Bilaterally Absent Breath Sounds - the
  endotracheal tube is not within the trachea and
  has probably been placed within the esophagus.
• Remove the tube and attempt to reinsert into the
  trachea

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Guidelines for Breath Sound

• Right main-stem placement is common.
• Breath Sounds in the Right Lung Field - the
  endotracheal tube has been placed too far down
  the bronchial tree and is in the right mainstem
  bronchus.
• Pull back the tube 1/4 to 1/2 inch or until
  bilateral breath sounds have been established

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Auscultate over the epigastrium for gastric
  sounds
• Placement of the endotracheal tube into the
  stomach or esophagus will produce gurgling sounds
  in the epigastric area with ventilations

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Inflate the endotracheal tubes cuff with 10 ccs
  of air
• Inflation of the cuff serves two purposes
• Holds the endotracheal tube in place
• Acts as a barrier and prevents fluids from
  entering the lungs

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Apply petroleum gauze dressing to insertion site
• Apply a dry, sterile dressing to the insertion
  site
• Tape around the tube then neck, sutures can be
  done later

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PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

• Continue to ventilate the patient (1 breath every
  5 seconds) and suction as necessary.
• Loving Gentle Squeeze 2 in, 3 out.
• Continue to monitor the patient for changes

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