Surgical Cricothyroidotomy

OVERVIEW

Open procedure performed to secure the airway via a surgical incision in the cricothyroid membrane

• aka emergency surgical airway (ESA)
• it is used to provide emergency ‘front of neck access’ (eFONA or FONA) in Can’t Intubate, Can’t Oxygenate (CICO) situations
• distinct from needle cricothyroidotomy (aka emergency cannula cricothyroidotomy), which is a less preferred, alternative approach to FONA in most CICO situations

INDICATIONS

• Can’t Intubate, Can’t Oxygenate (CICO) situation

CONTRA-INDICATIONS

• ability to secure an airway with less invasive means
  • only perform when best attempts at rescue oxygenation with endotracheal intubation (ETT), face mask ventilation, and supraglottic airway (“Lifelines” in Vortex terminology) have failed
• airway trauma that renders access via the cricothyroid membrane futile
  • e.g. laryngeal fracture, tracheal transection
  • tracheostomy should be performed, or access achieved via the traumatic airway opening
• Children < 10 years of age
  • young children are prone to laryngeal trauma and they have a higher incidence of postoperative complications)
  • performing needle cricothyrotomy is generally advised, however life-saving surgical cricothyroidotomy has been successfully performed in children and tracheostomy may be performed if skilled

DESCRIPTION

Numerous surgical cricothyroidotomy techniques have been described, my preferred approach is the ‘knife-finger-bougie’ approach (described below)

• in an anticipated difficult airway requiring emergency intubation a ‘double set up’ approach should be used if possible
  • one person attempts intubation
  • another person prepares to perform the ESA
    • dons mask, visor, gown and gloves
    • marks the skin marked with surgical pen to identify cricothyroid membrane
    • locates cricothyroid membrane (CTM) area and infiltrate skin and fascia with lignocaine with adrenaline (can be done while patient is awake if cooperative)
    • Has equipment opened and ready to procedure with the procedure when advised by the team leader
• in a true emergency there may not be time for sterile preparation of the skin
• consider sedation (e.g. IV ketamine 20 mg prn) – there may not be time in a true emergency and the patient will become obtunded as hypoxia supervenes
• ESA is a tactile procedure and must be able to be performed without visual cues
• During transition to FONA:
  • Explicitly declare:
    • “This is a CICO situation, perform FONA”
  • Continue attempts at oxygen delivery via nasal oxygen, FMV, or SGA if feasible
  • Ensure adequate neuromuscular blockade
  • Ensure optimal positioning of patient for FONA
  • Avoid further repetitive attempts at upper airway rescue that delay definitive management

Knife-finger-bougie approach

• Equipment
  • scalpel blade (e.g. size 10)
  • bougie
  • size 6-0 ETT (or tracheostomy tube)
  • artery forceps (optional)
  • syringe to inflate cuff
• once decision made to proceed with ESA extend neck in supine position to make anatomy more accessible by palpation (aka the ‘laryngeal handshake’)
  • note that airway has priority over suspected c-spine injury
• stabilise the thyroid cartilage with the non-dominant hand
• dominant hand holds scalpel and rests on the patients sternum for stability and support
• 4 cm vertical incision through skin over cricothyroid membrane (CTM)
  • may need to extend from mandible to sternum if impalpable anatomy
  • step may not be necessary if easily palpable anatomy – can go straight to the horizontal incision but must be 100% confident that CTM is identifiable
• Once skin incised, palpate cricothyroid membrane position and blunt dissect with fingers (some prefer forceps) through subcutaneous tissue until the membrane is readily identifiable. Ignore bleeding until airway is secure (ETT placement usually has a tamponade effect)
• Horizontal incision through membrane, drag scalpel blade from one side to the other then turn knife through 180 degrees and extend to the other side
  • some prefer to extend the membrane with forceps
  • The criciothyroid membrane is bound by a ‘cartilagenous cage’ so resistance will be felt at the margins of the membrane when the scalpel blade abuts cartilage.
• Dilate with gloved finger and palpate tracheal lumen, identifying the cartilage of the posterior wall of the trachea/ cricoid ring
  • depending on size of fingers, airway, and incision either the index finger or the little finger may be used
• Pass bougie alongside finger into trachea
• Confirm bougie position with finger, ensuring it passes through membrane
• Bougie usually holds up at carina <10cm from the skin
  • you may feel tracheal rings as the bougie advances
  • do not force if hold up as may perforate carina
• Pass ETT over bougie and intubate trachea
  • Ensure the ETT balloon is fully deflated and twist ETT as it passes the skin (hold up here is common)
  • Only advance the ETT until the balloon is within the airway and no longer visible (if advanced further then endocbronchial intubation is likely)
• Ensure ETT is held secure while bougie is removed and ETT is connected to BVM
• Confirm ETT placement with ETCO2
  • check with other adjunctive measures: auscultation, bilateral rise and fall of chest, fogging of tube and subsequent CXR

Rich Levitan demonstrating the “knife-finger-bougie” emergency surgical airway technique (this is the preferred approach as taught on the Critically Ill Airway course):

An alternative acceptable technique is the three step bougie-assisted cricothyroidotomy technique described by Andy Heard and endorsed by DAS/ICS/FICM/RCA guidelines for intubation in the critically ill (Higgs et al, 2018).

• This is similar to the ‘knife-finger-bougie’ technique described above, except the bougie is inserted alongside the vertically orientated scalpel while it is in the airway, rather than the little finger
• Steps:
  • Make a midline longitudinal incision with scalpel blade over cricothyroid membrane (CTM) and use non-dominant index finger to palpate CTM
  • Make a 5-mm transverse incision through CTM and twist the scapel so it is orientated vertically, then insert a gum elastic bougie into trachea alongside the vertically orientated scalpel
  • Place cuffed 6.0-mm ET tube over bougie and slide into trachea; once in place remove bougie and secure ET tube

For a demonstration see Andy Heard’s bougie-assisted cricothyroidotomy video.

COMPLICATIONS

acute

• bleeding
• right main bronchus intubation (common)
• subcutaneous emphysema
• pneumothorax and/or pneumomediastinum (false passage, posterior tracheal injury, or barotrauma)
• cricoid fracture
• damage to other local structures — e.g. larynx, vessels, nerves, esophagus, cartilage, muscle
• failure
• hypoxia and/or death (if delayed, fails, or catastrophic complication)

chronic

• infection
• scarring
• cricoid stenosis
• fistula formation

OTHER INFORMATION

Incision

• An initial horizontal incision can be used if palpable anatomical landmarks allow easy identification of the cricothyroid membrane (CTM)
• In patients where the anatomy cannot be easily palpated (e.g. obesity, short neck, neck swelling), a long midline longitudinal incision should be made to facilitate accurate identification of the CTM
• Landmark identification of the cricothyroid membrane is often unreliable, in a small study only 30% attempts by anaesthetists accurately marked the skin area over the cricothyroid membrane and only 10% marked over the centre point of the membrane (Elliot et al, 2010)

Surgical cricothyroidotomy versus cannula cricothyroidotomy

• Guidelines for intubation of the critically ill (Higgs et al,2018) state that surgical cricothyroidotomy is the preferred technique becuase of the following advantages
  • Rapid and reliable
  • High success rate
  • Familiar equipment
  • Ability to confirm placement with waveform capnography
  • Definitive cuffed airway
  • Allows positive pressure ventilation and PEEP
  • Provides some protection against aspiration
• Systematic reviews
  • Langvad et al (2013) performed a systematic review that concluded, given the low quality of evidence and heterogeneity of studies that exist, no firm conclusions can be made about the relative success and complication rates of cannula cricothyroidotomy and surgical cricothyroidotomy.
  • Duan et al (2023) found that scalpel cricothyroidotomy was faster that puncture (needle) techniques, but found no difference in other measrues.
• The NAP4 audit (Cook et al, 2016) in the UK found a ~60% failure rate for emergency cannula cricothyroidotomy, whereas surgical cricothyroidotomy was almost universally successful
  • It is not clear if the cannula approach is intrinsically inferior, or whether other factors may have contributed to the low success rate
  • Nevertheless, this data supports the use of surgical cricothyroidotomy

Speed of surgical cricothyroidotomy

• Most traditional surgical cricothyroidotomy procedures are faster than percutaneous techniques, with the average speed 83 ± 44s (range, 28–149s) (Paix and Griggs, 2011)
• Hill et al (2010) found that a bougie-assisted technique is even faster than standard open cricothyroidotomy techniques in a sheep model (median time of 67s (interquartile range [IQR] = 55-82) versus 149s (IQR = 111-201) for the standard technique (p = 0.002)
• The CricKey is a novel surgical cricothyroidotomy device combining the functions of a tracheal hook, stylet, dilator, and bougie incorporated with a Melker airway cannula. Mabry et al (2014) found that first-attempt success was 100% (15/15) for CricKey surgical cricothyroidotomy and 66% (10/15) for open surgical cricothyroidotomy (odds ratio 16.0; 95% CI 0.8 to 326). Surgical cricothyroidotomy insertion was faster for CricKey than open technique (34 versus 65s; median time difference 28s; 95% CI 16 to 48s).

Training

• While clinical correlates are unknown, some recommendations are that providers of emergency airway management be trained on mannequins for at least five attempts or until their cricothyroidotomy time is 40 s or less (Wong et al, 2003)
• Performance fade with the Melker Seldinger cricothyroidotomy set has been demonstrated after 3 months (Frerk and Frampton, 2006)

Ultrasound

• Ultrasound can be used to assist with placement of surgical airway and quick assessment of successful intubation.

References and Links

LITFL

• CCC – Can’t Intubate Can’t Oxygenate (CICO)

Journal articles

• Cook TM, Woodall N, Frerk C. A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department. Br J Anaesth. 2016 Aug;117(2):182-90. doi: 10.1093/bja/aew177. PMID: 27440629. [Free Full Text]
  Duan Q, Yang D, Gao H, Liu Q, Zhi J, Xu J, Xia W. Scalpel cricothyrotomy versus punctured cricothyrotomy in the context of the CICO crisis. A systematic review and Meta-analysis. Anaesth Crit Care Pain Med. 2023 Aug;42(4):101211. doi: 10.1016/j.accpm.2023.101211. Epub 2023 Mar 5. PMID: 36871625. [ Free Full Text]
• Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark identification for cannula cricothyroidotomy. Anaesthesia. 2010 Sep;65(9):889-94. doi: 10.1111/j.1365-2044.2010.06425.x. Erratum in: Anaesthesia. 2010 Dec;65(12):1258. PMID: 20645953. [Free Full Text]
• Frerk C, Frampton C. Cricothyroidotomy; time for change. Anaesthesia. 2006 Oct;61(10):921-3. PMID: 16978303.
• Hessert MJ, Bennett BL. Optimizing emergent surgical cricothyrotomy for use in austere environments. Wilderness Environ Med. 2013 Mar;24(1):53-66. doi: 10.1016/j.wem.2012.07.003. Epub 2012 Oct 10. PMID: 23062323. [Free Full Text]
• Higgs A, et al; 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. doi: 10.1016/j.bja.2017.10.021. Epub 2017 Nov 26. PMID: 29406182. [full text article]
• Hill C, Reardon R, Joing S, Falvey D, Miner J. 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 Jun;17(6):666-9. PMID: 20491685.
• Langvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy–a systematic review. Scand J Trauma Resusc Emerg Med. 2013;21:43. [article]
• Mabry RL, Nichols MC, Shiner DC, Bolleter S, Frankfurt A. A comparison of two open surgical cricothyroidotomy techniques by military medics using a cadaver model. Ann Emerg Med. 2014 Jan;63(1):1-5. PMID: 24094476.
• 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. PMID: 22313556.
• Patel SA, Meyer TK. Surgical Airway. Int J Crit Illn Inj Sci [serial online] 2014
• Wong DT, Prabhu AJ, Coloma M, Imasogie N, Chung FF. What is the minimum training required for successful cricothyroidotomy?: a study in mannequins. Anesthesiology. 2003 Feb;98(2):349-53. PMID: 12552192.

FOAM and web resources

• ACEP Now — Tips and Tricks for Performing Cricothyrotomy by Richard Levitan (2014)
• EMCrit — Podcast 119 – Rich Levitan on the Surgical Airway (2014)
• EMCrit — Podcast 053: Needle vs Knife: Part 1 (2011)
• EMCrit Wee – Bougie Prepass and CricCon for Difficult Airway (2012)
• You are here: Home / wee / EMCrit Wee – Mind Blowing Cricothyrotomy Video
• EMCrit Wee – Mind Blowing Cricothyrotomy Video (2015)
• EP Monthly — A primer on the surgical airway by Richard Levitan (2012)
• ICN — Podcast 102. Mac Partlin on Emergency Airway Access (2013)
• SMACC — Bouncing back from the beach: cutting to air by Thomas Dolven (2015)
• SMACC — Emergency Surgical Airway by Scott Weingart (2014)
• NAP4 Report — Major Complications of Airway Management in the UK (2011)
• Ultrasound Podcast — Episode 19. Full Cric (2012)