Emergent 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 emergent 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 in adults" and "The failed airway in adults" and "The difficult airway in adults".)
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- 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
- 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