Cricothyrotomy in the Emergency Department

doi:10.1016/S0196-0644(82)80362-4

Annals of Emergency Medicine

Volume 11, Issue 7, July 1982, Pages 361-364

https://doi.org/10.1016/S0196-0644(82)80362-4 Get rights and content

Thirty-eight emergency cricothyrotomies were performed over a 3-year period. This was the first airway control maneuver attempted in 5 patients, 3 of whom had facial and/or neck injury, one apneic with upper airway hemorrhage, and one with aortobronchial fistula. The remaining 33 procedures were performed only after other airway management failed. Five indications were identified among these cases: 1) excessive emesis or hemorrhage (11), 2) possible cervical spine injury with airway compromise (9), 3) technical failure (7), 4) clenched teeth (5), and 5) masseter spasm following succinylcholine administration (1). Fourteen immediate complications occurred in 12 patients (32%). The most frequent was incorrect site of tracheostomy tube placement (5), with 4 of 5 misplaced through the thyrohyoid membrane. Others included execution time greater than 3 minutes (4), unsuccessful tracheostomy tube placement (3), and significant hemorrhage (2). Twelve of the 38 patients were long-term survivors. There was one long-term complication, a longitudinal fracture of the thyroid cartilage during forceful placement of an oversized tube (8 mm inner diameter) through the cricothyroid membrane. This required operative repair and left the patient with severe dysphonia.

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Cited by (167)

Cricothyrotomy in difficult airway management: A narrative review
2023, Trends in Anaesthesia and Critical Care
According to a recent Closed Claims Analysis, airway management problems arose during induction in 67% of cases, and involved difficult intubation in 6% of patients. The incidence of Cannot Intubate-Cannot Oxygenate (CICO) is low, occurring in 1 in 3200 cases in the operating room and in 1 in 500 case in the Emergency Department, according to some studies. Early establishment of a safe surgical airway is vital in a CICO patient.
Surgical cricothyrotomy is preferable to tracheotomy in patients requiring an emergency surgical airway. The cricothyroid membrane is located between the cricoid cartilage inferiorly and the thyroid cartilage superiorly. Cricothyrotomy is an emergency surgical airway approach in which the physician makes an incision in the cricothyroid membrane and passes a cannula or tracheal tube into the trachea in order to oxygenate and ventilate the patient. The procedure is relatively quick and simple, and involves minimal bleeding.
Emergency cricothyrotomy is the final step in all emergency airway management algorithms. Failure to recognise a CICO situation and immediately establish a surgical airway can rapidly lead to brain hypoxia and death.
The most common complications of cricothyrotomy include incorrect technique leading to injury of anatomical structures and oxygenation-ventilation failure, haemorrhage, and pneumothorax.
Ultrasound improves percutaneous needle cricothyrotomy success in the novice anesthesia provider compared to the landmark technique
2023, Trends in Anaesthesia and Critical Care
This study tested ultrasound guidance on the success of student registered nurse anesthetists’ performance of ultrasound guided percutaneous needle cricothyrotomy versus the superficial landmark approach.
Using a quasi-experimental crossover design, students were randomized to two groups to determine order of procedural performance: (1) superficial landmark, and (2) ultrasound guided percutaneous needle cricothyrotomy. All students completed both conditions at different time points. Performance was measured using a task-specific checklist survey tool and a global rating scale. Time to successful guidewire passage and number of attempts were measured along with accuracy.
The median scores for respect for tissue, time and motion, and use of assistant categories were significantly lower when using landmark-guidance compared to ultrasound-guidance to perform the procedure (P = .021; P = .042; P = .049). Using ultrasound guidance for the percutaneous needle cricothyrotomy resulted in significantly fewer number of attempts for cricothyroidotomy access (P < .001). Post survey data indicated overall, 87.6% (CI _95%: 7.86–9.31) of the students felt the use of ultrasound improved their experience and was a valuable tool in teaching percutaneous needle cricothyroidotomy (95.9%; CI_95%: 8.56–9.77). Following the simulated experience, students felt more confident when performing the percutaneous needle cricothyrotomy procedure (87.4%; CI_95%: 1.44–3.40).
The use of ultrasound guidance during percutaneous needle cricothyrotomy showed a decrease in the number of attempts by student nurse anesthetists’ when performing cricothyrotomy. Students found ultrasound guidance enhanced the ease, speed, confidence levels, and overall experience.
The Big Five—Lifesaving Procedures in the Trauma Bay
2023, Emergency Medicine Clinics of North America
Citation Excerpt :
Although this procedure is known to be associated with complications, avoiding it results in high morbidity and mortality.5 Though performed less than 1% of the time and despite a decrease in training, success rates for cricothyroidotomy range from 89% to 100%.6–9 “Can’t oxygenate, Can’t Ventilate”—an adage used to describe a dangerous scenario where oral, nasopharyngeal demands emergent definitive airway management that requires cricothyroidotomy.
Developing Cricothyroidotomy Skills Using a Biomaterial-Covered Model
2020, Wilderness and Environmental Medicine
Cricothyroidotomy is an advanced and life-saving technique, but it is also a rare and a difficult procedure. The purpose of the present study was to produce a low-cost simulation model with realistic anatomic features to investigate its effectiveness in developing cricothyroidotomy skills.
This study was performed at a university simulation center with 57 second-year student paramedics and a cricothyroidotomy simulation model. Total scores were assessed using a checklist. This consisted of 13 steps and was scored as misapplication/omission=0, correct performance and timing with hesitation=1, and correct performance and timing without hesitation=2. One of these steps, local anesthesia of the area if time is available, was not performed owing to time limitations. The highest possible score was 24. Data are presented as mean±SD with range, as appropriate. Normal distribution was evaluated using the Kolmogorov-Smirnov test, Student t test, and Mann-Whitney U test, and correlation analysis was used for statistical analysis.
Students completed the cricothyroidotomy procedure steps in 116±46 (55–238) s. At performance assessment, the score achieved was 12±5 (2–24). The highest total score of 24 was achieved by 3 students (5%). Total scores exhibited negative and significant correlation with procedure time (r=−0.403, P=0.002).
The model developed in this study is an inexpensive and effective method that can be used in cricothyroidotomy training for student paramedics. We think that repeating the cricothyroidotomy procedure on the model will increase success levels.
The necessity of practical emergency cricothyroidotomy training during undergraduate medical education
2020, Translational Research in Anatomy
Citation Excerpt :
A tension pneumothorax and pneumo-mediastinum are more prevalent with needle type cricothyroidotomy tools, such as the Seldinger method [16]. Fistula and granuloma formation were other reported complications [23], while many other complications such as laryngeal injury, aspiration, recurrent laryngeal nerve injury, dysphonia secondary to thyroid cartilage fracture and considerable bleeding can occur [8,24]. The procedural failure or inability to secure the airway after completing the CCT is another significant real-life complication [9].
A cricothyroidotomy is a procedure which creates a laryngeal opening. Medical students are told that this procedure is without major complications and simple to perform; however, professionals who have witnessed a laryngotomy include considerable hemorrhage and issues locating the correct insertion site in procedure preparation. Various laryngeal devices were analyzed, and determination of superiority was based on ease and success of insertion.
Our study was limited to 30 healthcare professional volunteers and 3 devices: a scalpel, steak knife, and percutaneous cricothyroidotomy key-ring device (PCKD). Their task was to perform a laryngotomy within a set time period on a cadaver. ‘Success or failure’ was determined through dissection at a later date.
Among 30 volunteers, 21 successfully accessed the larynx. Success was highest with the steak knife and lowest with the PCKD, revealing device familiarity may be influential. Participants with previous clinical experience also had higher success, indicating practical experience may play a role in addition to anatomical knowledge.
Cricothyroidotomy is a procedure mentioned in medical school, where theoretical knowledge is readily taught. Yet those who are deemed familiar with the anatomy is not reassuring. This presses the importance of medical curriculums implementing practical training, while simultaneously teaching the underlying anatomy and physiology.
This study was approved by the St. George's University IRB, No. 06014.
Ultrasound for airway management: An evidence-based review for the emergency clinician
2020, American Journal of Emergency Medicine
Airway management is a common procedure performed in the Emergency Department with significant potential for complications. Many of the traditional physical examination maneuvers have limitations in the assessment and management of difficult airways. Point-of-care ultrasound (POCUS) has been increasingly studied for the evaluation and management of the airway in a variety of settings.
This article summarizes the current literature on POCUS for airway assessment, intubation confirmation, endotracheal tube (ETT) depth assessment, and performing cricothyroidotomy with an emphasis on those components most relevant for the Emergency Medicine clinician.
POCUS can be a useful tool for identifying difficult airways by measuring the distance from the skin to the thyrohyoid membrane, hyoid bone, or epiglottis. It can also predict ETT size better than age-based formulae. POCUS is highly accurate for confirming ETT placement in adult and pediatric patients. The typical approach involves transtracheal visualization but can also include lung sliding and diaphragmatic elevation. ETT depth can be assessed by visualizing the ETT cuff in the trachea, as well as using lung sliding and the lung pulse sign. Finally, POCUS can identify the cricothyroid membrane more quickly and accurately than the landmark-based approach.
Airway management is a core skill in the Emergency Department. POCUS can be a valuable tool with applications ranging from airway assessment to dynamic cricothyroidotomy. This paper summarizes the key literature on POCUS for airway management.

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: Presented at the American College of Emergency Physicians Scientific Assembly in New Orleans, Louisiana, September 1981.

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Original contributionCricothyrotomy in the Emergency Department

Ann Emerg Med

Ann Emerg Med

Chest

Cricothyroidotomy: Elective use in respiratory problems requiring tracheotomy

J Thorac Cardiovasc Surg

A clinical evaluation of cricothyroidotomy

Surg Gynecol Obstet

Cricothyroidotomy revisited again

Ear Nose Throat J

Emergency cricothyroidotomy: Is its use justified?

Surgical Rounds

The use of succinylcholine in emergency endotracheal intubation

Nasotracheal intubations in the emergency department

Crit Care Med

Original contribution
Cricothyrotomy in the Emergency Department