Airway – Cricothyroidotomy (surgical)

Procedure, instructions and discussion

Surgical Cricothyroidotomy (or Front of neck access, FONA) – inability to oxygenate and ventilate with (BVM, LMA, ETT) and age >10years

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Instructions

Indications

• Inability to oxygenate and ventilate by other means (BVM, LMA, ETT)

and

• Age ≥ 10 years

Contraindications (ABSOLUTE/relative)

• Tracheal rupture or transection
• Laryngeal fracture

Alternatives

• Bag-Valve-Mask (BVM )Ventilation
• Supraglottic Airway Device intubation (SAD, LMA)
• Endotracheal intubation
• Needle cricothyroidotomy and jet insufflation
• Tracheostomy

Informed consent

NOT REQUIRED

• Consent is not required.
• This is an emergency procedure to save a life

Potential complications

• Failure (unable to identify anatomy, false passage)
• Neurovascular, oesophageal, and laryngeal injury
• Coughing
• Bleeding (with potential aspiration)
• Infection

Infection control

• Standard precautions
• PPE: non-sterile gloves, aprons, surgical mask and protective eyewear or face shield

Area

• Resuscitation bay

Staff

• Procedural clinician
• Airway assistant (at least one)

Equipment

• Scalpel
• Bougie
• Size 6.0 endotracheal tube and lubricant
• 10ml syringe
• Suture
• Tape for endotracheal tube
• Hard collar

Positioning

• Patient supine with neck extended
• Assistant maintains head positions midline
• Procedural clinician lateral to patient
• Dominant hand towards head (patient’s left side if right-handed)

Locate the cricothyroid membrane by palpating the prominence of the thyroid cartilage and moving the finger inferiorly into the depression between the thyroid and cricoid cartilages. Consider marking the membrane but be aware the mark will move superiorly if the head is extended.

Medication

• 5ml lignocaine 1% with adrenaline (1:100,000)

Never apply local anaesthetic in a time critical emergency. It can be considered before predicted difficult intubations where the chance of failure is high and infiltrated after induction in the minute before the first attempt at intubation.

Sequence

Surgical cricothyroidotomy

• Brief team ‘I’m performing a surgical airway now’ and allocate roles
• Remove pillow and direct assistant to support head and neck extended in the midline
• Direct additional assistant to attempt ventilation with a laryngeal mask airway
• Identify cricothyroid membrane
• Stabilise larynx with thumb and middle finger of non-dominant hand ‘laryngeal handshake’
• Palpate cricothyroid membrane with index finger
• Make a 15mm transverse incision with dominant hand through cricothyroid membrane
• Remove scalpel and place finger into trachea, palpating posterior wall
• Insert bougie under pulp of inserted finger
• Advance bougie approximately 15cm (early hold up indicates false passage)
• Railroad a lubricated size 6.0 ETT over bougie, with rotation on insertion until cuff if just inside the trachea
• Remove bougie, inflate the cuff and confirm position with ETCO₂ trace on ventilation
• Secure with tape and allocate an assistant to hold the ETT until a definitive airway is placed
• Consider a suture placed close to the skin incision, wrapped tightly around the ETT and tied securely
• Consider placing a hard collar to maintain neck position
• Use pressure to control bleeding after you have secured your tube

If unable to palpate cricothyroid membrane

• Make an 8cm midline incision, starting two finger-widths above sternal notch
• Blunt dissection with fingers of both hands until larynx or trachea is palpated (blood will obscure vision)
• Laryngeal handshake when structures identified
• Transverse incision as above either in trachea or cricothyroid membrane

Post-procedure care

• Definitive airway (Anaesthetic/ENT urgently required)
• Dedicated team member continues to hold secured ETT until definitive airway placed
• Provide ongoing sedation and paralysis
• Chest X-ray to confirm placement
• Document after definitive airway placed (completion, complications)

Tips

• The most difficult part of procedure is making the decision to proceed to surgical airway
• This procedure is high risk for aerosolised spray of blood and sharps injury
• Passage of the bougie against resistance can create a long false passage with surprising ease
• Tracheal rings are not always felt on the bougie with correct placement
• Observe the first test ventilation closely for surgical emphysema suggesting false passage
• Ultrasound may be useful to identify the cricothyroid membrane prior to induction in high-risk patients

Discussion

We outline a simple scalpel-finger-bougie approach. Regular physical practice of your chosen method is recommended. Unfamiliar equipment is best avoided in an emergency

Asepsis is not required for an emergency airway. The risk of infection is insignificant compared to the risk of further hypoxia in a can’t ventilate situation.

If time allows for the identification and marking of the skin over the cricothyroid membrane prior to a high-risk intubation, then antisepsis might also be applied at this time.

Heavy bleeding is expected and should be ignored while placing the airway. Relying on palpation to complete the surgical airway. Use pressure to control bleeding after you have secured your tube.

We do not recommend ‘Seldinger can’t intubate can’t oxygenate kits’. Available evidence shows these are slower than open cricothyroidotomy and have higher failure rates.

References

• Paix BR, Griggs WM. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel-finger-tube’ method. Emerg Med Australas. 2012 Feb;24(1):23-30. 
• Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018 Feb;120(2):323-352.
• Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O’Sullivan EP, Woodall NM, Ahmad I; Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48
• Greater Sydney Area Helicopter Emergency Medical Service. Prehospital emergency anaesthesia manual. (Ver.3.) Sydney: NSW Ambulance; 2018
• Begley JL, Butson B, Kwa P. The emergency surgical airway. Emerg Med Australas. 2017 Oct;29(5):570-575.
• Chrimes N. The vortex approach to the difficult airway. 2016.
• Sakles JC. Emergency cricothyrotomy (cricothyroidotomy). In: UpToDate. Waltham (MA): UpToDate. 2020 Apr 23: Retrieved May 2020. Available from: https://www.uptodate.com/contents/emergency-cricothyrotomy-cricothyroidotomy

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