Emergency surgical cricothyrotomy (cricothyroidotomy)
- Aaron E Bair, MD, MSc, FAAEM, FACEP
Aaron E Bair, MD, MSc, FAAEM, FACEP
- Professor of Emergency Medicine
- University of California, Davis
Cricothyrotomy (also called cricothyroidotomy) is a procedure that involves placing a tube through an incision in the cricothyroid membrane to establish an airway for oxygenation and ventilation.
The procedure has a controversial past. In 1909, Dr. Chevalier Jackson, a laryngologist at the Jefferson Medical School in Philadelphia, described the surgical techniques and critical considerations related to performing cricothyrotomy, which he called "high tracheostomy" . Before the advent of antibiotics, cricothyrotomy was often performed because of severe infection or an inflammatory process (eg, diphtheria). Dr. Jackson became famous for popularizing the procedure. However, he then began to receive hundreds of referrals for patients who had developed tracheal stenosis following the procedure. After investigating nearly 200 of these cases, he condemned cricothyrotomy in a well-publicized paper .
Following this report, cricothyrotomy fell out of favor until the 1970s when two physicians, Brantigan and Grow, reported a series of 655 patients who had undergone elective cricothyrotomy for prolonged mechanical ventilation. They reported a low rate of complications, 6.1 percent overall . Only eight patients (0.01 percent) developed subglottic stenosis, none of whom developed a chronic condition. Consequently, cricothyrotomy, which is generally considered easier to perform than emergency tracheostomy, was revisited and has now become the surgical rescue technique of choice for the failed airway in adults.
Because cricothyrotomy is a rarely performed but potentially life-saving procedure of last resort in the patient with a failed airway, clinicians responsible for airway management must retain familiarity with the necessary equipment and relevant anatomy. While debate continues regarding the merits and risks of various approaches or techniques for performing the procedure, it remains clear that skill acquisition and maintenance are vital. We suggest that emergency clinicians responsible for airway management review the anatomy and practice with the equipment needed for cricothyrotomy several times each year.
Performance of cricothyrotomy in adults is reviewed here. Other aspects of difficult airway management are discussed separately. (See "Rapid sequence intubation for adults outside the operating room" and "The failed airway in adults" and "The difficult airway in adults".)
- Jackson, C. Tracheotomy. Laryngoscope 1909; 18:285.
- Jackson, C. High tracheotomy and other errors the chief cause of chronic laryngeal stenosis. Surg Gyneco Obstet 1921; 32:392.
- Brantigan CO, Grow JB Sr. Cricothyroidotomy: elective use in respiratory problems requiring tracheotomy. J Thorac Cardiovasc Surg 1976; 71:72.
- Bair AE, Panacek EA, Wisner DH, et al. Cricothyrotomy: a 5-year experience at one institution. J Emerg Med 2003; 24:151.
- Erlandson MJ, Clinton JE, Ruiz E, Cohen J. Cricothyrotomy in the emergency department revisited. J Emerg Med 1989; 7:115.
- Fortune JB, Judkins DG, Scanzaroli D, et al. Efficacy of prehospital surgical cricothyrotomy in trauma patients. J Trauma 1997; 42:832.
- Chang RS, Hamilton RJ, Carter WA. Declining rate of cricothyrotomy in trauma patients with an emergency medicine residency: implications for skills training. Acad Emerg Med 1998; 5:247.
- Scrase I, Woollard M. Needle vs surgical cricothyroidotomy: a short cut to effective ventilation. Anaesthesia 2006; 61:962.
- Schroeder AA. Cricothyroidotomy: when, why, and why not? Am J Otolaryngol 2000; 21:195.
- Bramwell KJ, Davis DP, Cardall TV, et al. Use of the Trousseau dilator in cricothyrotomy. J Emerg Med 1999; 17:433.
- Strange, GR, Niederman, LG. Surgical Cricothyrotomy. In: Textbook of Pediatric Emergency Procedures, Henretic, FM, King, C (Eds), Williams and Wilkens, Baltimore 1997. p.351.
- Salvino CK, Dries D, Gamelli R, et al. Emergency cricothyroidotomy in trauma victims. J Trauma 1993; 34:503.
- Aslani A, Ng SC, Hurley M, et al. Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesth Analg 2012; 114:987.
- Elliott DS, Baker PA, Scott MR, et al. Accuracy of surface landmark identification for cannula cricothyroidotomy. Anaesthesia 2010; 65:889.
- You-Ten KE, Desai D, Postonogova T, Siddiqui N. Accuracy of conventional digital palpation and ultrasound of the cricothyroid membrane in obese women in labour. Anaesthesia 2015; 70:1230.
- Hiller KN, Karni RJ, Cai C, et al. Comparing success rates of anesthesia providers versus trauma surgeons in their use of palpation to identify the cricothyroid membrane in female subjects: a prospective observational study. Can J Anaesth 2016; 63:807.
- Bair AE, Chima R. The inaccuracy of using landmark techniques for cricothyroid membrane identification: a comparison of three techniques. Acad Emerg Med 2015; 22:908.
- Nicholls SE, Sweeney TW, Ferre RM, Strout TD. Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy. Am J Emerg Med 2008; 26:852.
- Curtis K, Ahern M, Dawson M, Mallin M. Ultrasound-guided, Bougie-assisted cricothyroidotomy: a description of a novel technique in cadaveric models. Acad Emerg Med 2012; 19:876.
- Siddiqui N, Arzola C, Friedman Z, et al. Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy: A Randomized Control Trial. Anesthesiology 2015; 123:1033.
- Kristensen MS, Teoh WH, Rudolph SS, et al. A randomised cross-over comparison of the transverse and longitudinal techniques for ultrasound-guided identification of the cricothyroid membrane in morbidly obese subjects. Anaesthesia 2016; 71:675.
- Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identification of the cricothyroid membrane: best evidence, techniques, and clinical impact. Br J Anaesth 2016; 117 Suppl 1:i39.
- Hill C, Reardon R, Joing S, et al. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med 2010; 17:666.
- Schaumann N, Lorenz V, Schellongowski P, et al. Evaluation of Seldinger technique emergency cricothyroidotomy versus standard surgical cricothyroidotomy in 200 cadavers. Anesthesiology 2005; 102:7.
- Mutzbauer TS, Munz R, Helm M, et al. [Emergency cricothyrotomy--puncture or anatomical preparation? Peculiarities of two methods for emergency airway access demonstrated in a cadaver model]. Anaesthesist 2003; 52:304.
- Brofeldt BT, Panacek EA, Richards JR. An easy cricothyrotomy approach: the rapid four-step technique. Acad Emerg Med 1996; 3:1060.
- Holmes JF, Panacek EA, Sakles JC, Brofeldt BT. Comparison of 2 cricothyrotomy techniques: standard method versus rapid 4-step technique. Ann Emerg Med 1998; 32:442.
- Benkhadra M, Lenfant F, Nemetz W, et al. A comparison of two emergency cricothyroidotomy kits in human cadavers. Anesth Analg 2008; 106:182.
- Chan TC, Vilke GM, Bramwell KJ, et al. Comparison of wire-guided cricothyrotomy versus standard surgical cricothyrotomy technique. J Emerg Med 1999; 17:957.
- Schober P, Hegemann MC, Schwarte LA, et al. Emergency cricothyrotomy-a comparative study of different techniques in human cadavers. Resuscitation 2009; 80:204.
- Kanji H, Thirsk W, Dong S, et al. Emergency cricothyroidotomy: a randomized crossover trial comparing percutaneous techniques: classic needle first versus "incision first". Acad Emerg Med 2012; 19:E1061.
- McGill J, Clinton JE, Ruiz E. Cricothyrotomy in the emergency department. Ann Emerg Med 1982; 11:361.
- Johnson DR, Dunlap A, McFeeley P, et al. Cricothyrotomy performed by prehospital personnel: a comparison of two techniques in a human cadaver model. Am J Emerg Med 1993; 11:207.
- Gillespie MB, Eisele DW. Outcomes of emergency surgical airway procedures in a hospital-wide setting. Laryngoscope 1999; 109:1766.
- Mace, SE, Hedges, JR. Cricothyrotomy and Translaryngeal Jet Ventilation. In: Clinical Procedures in Emergency Medicine, 4th ed, Roberts, JR, Hedges, JR, Chanmugam, AS, et al (Eds), Saunders, Philadelphia 2004. p.115.
- Eisenburger P, Laczika K, List M, et al. Comparison of conventional surgical versus Seldinger technique emergency cricothyrotomy performed by inexperienced clinicians. Anesthesiology 2000; 92:687.
- Bair AE, Laurin EG, Karchin A, et al. Cricoid ring integrity: implications for cricothyrotomy. Ann Emerg Med 2003; 41:331.
- Davis DP, Bramwell KJ, Vilke GM, et al. Cricothyrotomy technique: standard versus the Rapid Four-Step Technique. J Emerg Med 1999; 17:17.
- Spaite DW, Joseph M. Prehospital cricothyrotomy: an investigation of indications, technique, complications, and patient outcome. Ann Emerg Med 1990; 19:279.
- Gerling MC, Davis DP, Hamilton RS, et al. Effect of surgical cricothyrotomy on the unstable cervical spine in a cadaver model of intubation. J Emerg Med 2001; 20:1.
- Curran C, Dietrich AM, Bowman MJ, et al. Pediatric cervical-spine immobilization: achieving neutral position? J Trauma 1995; 39:729.
- Intsuka IKh. [Correlation between the neurologic and x-ray data in fracture-dislocation of the cervical vertebrae]. Vopr Neirokhir 1972; 36:46.
- Horlyck E, Rahbek M. Cervical spine injuries. Acta Orthop Scand 1974; 45:845.
- Barnes, R. Paraplegia in cervical spine injuries. J Bone Joint Surg 1948; 30:234.
- CONTRAINDICATIONS AND PRECAUTIONS
- Absolute contraindications
- Relative contraindications
- Fundamental considerations for the clinician
- Patient counseling and informed consent
- CLINICAL ANATOMY AND IDENTIFICATION OF THE CRICOTHYROID MEMBRANE
- ULTRASOUND FOR CRICOTHYROTOMY
- Standard precautions
- General considerations
- Analgesia and sedation
- Skin preparation
- - Standard technique
- - Rapid four step technique
- - Seldinger technique
- Time and ease of completion
- FOLLOW-UP CARE
- SUMMARY AND RECOMMENDATIONS