Overview
Definition:
Surgical cricothyrotomy is an emergency procedure to establish an airway by incising the cricothyroid membrane, located between the thyroid and cricoid cartilages
It is a temporizing measure when intubation is impossible or contraindicated.
Epidemiology:
The incidence of emergent surgical cricothyrotomy is low, often cited in the range of 1-10 per 100,000 emergency department visits
It is most commonly performed in trauma patients with severe facial or neck injuries, or in cases of failed intubation.
Clinical Significance:
Surgical cricothyrotomy is a life-saving procedure that provides a definitive airway when less invasive methods fail
Prompt and correct execution is crucial to prevent hypoxia, brain damage, and death
It is a critical skill for surgeons and emergency physicians preparing for DNB and NEET SS examinations.
Indications
Absolute Indications:
Inability to intubate and inability to ventilate (Can't Intubate, Can't Ventilate - CICV scenario)
Profound facial trauma precluding oral or nasal intubation
Complete airway obstruction at or above the glottis.
Relative Indications:
Severe upper airway obstruction (e.g., angioedema, foreign body impaction)
Need for prolonged ventilation when intubation is difficult
Certain maxillofacial or laryngeal trauma.
Contraindications:
Ability to secure airway by less invasive means
Age less than 8-12 years (relative contraindication
needle cricothyrotomy may be preferred due to smaller anatomy)
Laryngeal fracture or transection
Known significant pathology of the cricothyroid membrane.
Preoperative Preparation
Patient Assessment:
Rapid assessment of airway patency and potential for intubation
Identify signs of impending airway loss: stridor, hoarseness, retractions, cyanosis
Assess for contraindications.
Equipment Preparation:
Surgical cricothyrotomy kit: scalpel (e.g., #10 or #11 blade), tracheal hook or hemostat, bougie or small endotracheal tube (e.g., 5.0-6.0 mm ID), syringe for cuff inflation, antiseptic solution, sterile gloves, local anesthetic (if time permits).
Positioning And Anesthesia:
Position the patient supine with the neck extended (unless contraindicated by cervical spine injury)
Identify landmarks: thyroid cartilage, cricoid cartilage, and cricothyroid membrane
Local anesthesia with lidocaine can be administered if the patient is awake and time allows.
Procedure Steps
Landmark Identification:
Palpate the thyroid cartilage (Adam's apple) and then slide the finger inferiorly to the depression of the cricothyroid membrane, just above the cricoid cartilage
This is the key landmark.
Skin Incision:
Make a longitudinal midline incision through the skin and subcutaneous tissue overlying the cricothyroid membrane, approximately 2-3 cm in length
Alternatively, a transverse incision can be made directly through the membrane.
Membrane Incision:
Using the scalpel, make a horizontal incision through the cricothyroid membrane
Be careful not to plunge the scalpel too deep, which can injure the posterior tracheal wall
A tracheal hook or curved hemostat can be used to stabilize the trachea and widen the opening.
Tube Insertion:
Insert a bougie or a small endotracheal tube (5.0-6.0 mm ID) through the incision into the trachea
Advance until resistance is met or cuff passes the membrane
If using a bougie, a cuffed endotracheal tube can be railroaded over it.
Confirmation And Securing:
Inflate the cuff of the endotracheal tube
Confirm placement by visualizing chest rise, auscultating bilateral breath sounds, and observing absence of epigastric sounds
Secure the tube with a tie or tape
Connect to a ventilation device.
Postoperative Care
Monitoring:
Continuous monitoring of vital signs, oxygen saturation, and end-tidal CO2
Assess for breath sounds and signs of airway obstruction
Frequent suctioning of secretions is essential.
Ventilation:
Provide mechanical ventilation with appropriate settings
Humidification of inspired air is crucial
Weaning from the artificial airway should be considered as soon as the patient's condition stabilizes and definitive airway management (e.g., tracheostomy) is planned.
Definitive Airway:
Surgical cricothyrotomy is typically a temporizing measure
Definitive airway management, usually a formal tracheostomy, should be performed by an experienced surgeon once the patient is stable
The tracheostomy will replace the cricothyrotomy tube.
Complications
Early Complications:
Hemorrhage (thyroid artery injury)
Esophageal perforation
Posterior tracheal wall injury
False passage formation
Subcutaneous emphysema
Mediastinal emphysema
Infection.
Late Complications:
Subglottic stenosis (most common and serious)
Tracheal stenosis
Voice changes or hoarseness
Tracheoesophageal fistula
Granuloma formation at the stoma site.
Prevention Strategies:
Accurate landmark identification
Proper technique with careful incision depth
Use of appropriate size equipment
Early conversion to tracheostomy when indicated
Diligent postoperative care and monitoring.
Key Points
Exam Focus:
The "Can't Intubate, Can't Ventilate" (CICV) scenario is a classic DNB/NEET SS question
Know the indications, contraindications, and steps of both surgical and needle cricothyrotomy.
Clinical Pearls:
In emergent situations, prioritize establishing an airway over perfect anatomy
Identify landmarks by feeling, not just seeing
A longitudinal incision in the skin allows better access to the transverse cricothyroid membrane
Consider needle cricothyrotomy in children.
Common Mistakes:
Failure to identify landmarks correctly, leading to incorrect incision
Plunging the scalpel too deep
Failure to secure the airway adequately
Delaying conversion to tracheostomy
Misinterpreting ventilatory findings.