# Surgical Cricothyroidotomy

## Overview

This module describes how to perform surgical cricothyrotomy, a rescue airway preferred over needle cricothyrotomy in adults as it allows for more effective ventilation.

## Indications

1. “Can’t intubate, can’t ventilate” — patients with airway compromise in whom other airway management has failed

## Contraindications

1. None for emergency cricothyroidotomy

2. In elective cricothyrotomy, consider the risks and benefits in children, patients with laryngeal fractures, previous laryngeal surgery or other laryngeal abnormalities

## Patient information and consent

This procedure is usually done as an emergency measure with an unconscious patient. However, it may be explained to family members afterwards.

### How do I explain this procedure?

“The patient was unable to breathe because their airway was blocked and air was not getting into their lungs. I had to make a cut in their neck and put a thin tube into their windpipe so that I could help them breathe. This is a temporary emergency measure.”

## Preparation

###

### Documentation

1. Patient notes

### Equipment

1. Alcohol-based hand rub

2. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

3. Sterile or non-sterile gloves

4. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another. Caution: chlorhexidine solutions may be associated with burns and skin breakdown in infants < 2 months old.

   (or at least an alcohol swab)

5. Sterile pack with sterile drapes

6. Supplies for local anaesthetic (if patient is able to feel pain)

7. Scalpel

8. Artery forceps

9. Elastic bougie

10. A tracheotomy tube (usually size 6 for women and size 8 for men)

11. Yankauer suction

12. Tape

13. Self-inflating bag system or ventilator

## Site & Positioning

Position the patient supine. If you suspect a cervical spine injury, do not flex the neck. If the cervical spine has been cleared, a 1L bag of intravenous fluid placed behind their shoulders, so that their neck is hyperextended will assist in location of the cricothyroid membrane.

Identify the landmarks of the cricothyroid membrane. The Adam's apple is the thyroid prominence formed by the thyroid notch. Moving inferiorly, the next solid prominence is the cricoid cartilage. Immediately above the cricoid cartilage the finger slips into the depression of the cricothyroid membrane.

## Procedure

Follow medical asepsis with sterile gloves or non-sterile gloves depending on urgency and what is readily available. Since this is often an emergency procedure, non-sterile gloves and an alcohol swab may be the only aseptic preparations available.

1. Perform hand hygiene.

2. Open the sterile pack to create a sterile field. Open sterile supplies onto the field. Fill the well with skin disinfectant.

3. Don sterile gloves.

4. Clean and drape the neck.

5. Identify the cricothyroid membrane by palpation.

6. Stabilise the larynx and tighten the skin across the membrane between index finger and thumb.

7. Make a 4 cm longitudinal incision in the skin over the cricothyroid membrane.

8. Use a finger or the back of the scalpel handle to bluntly dissect down to the cricothyroid membrane.

9. Make a

   transverse puncture
   transverse puncture

   Prevent injury to the posterior wall of the trachea by monitoring the depth of the blade.

   through the membrane with the scalpel.

10. Continue to pull the skin tight while removing the blade from the incision.

11. Insert and open artery forceps first in a horizontal plane, then in a vertical plane to enlarge the incision.

12. You can either insert the bougie between the tips of the forceps or withdraw the forceps and insert your finger through the incision while continuing to stabilise the skin. Slide the elastic bougie into the trachea under your finger and use your finger to guide it inferiorly.

13. Pass the tracheotomy/ET tube over the bougie until the balloon is no longer visible,

    confirm tube placement
    confirm tube placement

    Observe for tube misting, auscultate the epigastrium and chest, and use ETCO2 to confirm tube placement. If no ETCO2 is available, monitor the oxygen saturation for a rise.

    , and inflate the cuff if there is one.

14. Attach the self-inflating bag or ventilator circuit to the adaptor and ventilate the patient.

15. Secure the airway with tape.

16. Dispose of medical waste safely.

17. Afterwards, record the completion of the procedure in patient notes and get a CXR to confirm placement of the tube.

## Troubleshooting

I don’t have a tracheotomy tube.

Use a size 5-6 endotracheal tube.

I have created a false passage.

This is extremely unlikely if you have performed a surgical cricothyroidotomy because there is minimal soft tissue overlying it. If you feel that you may have created a false tract, review your anatomy: you may be too high, too low or lateral to the cricothyroid membrane.

The neck tissue is very swollen prior to the procedure and I am struggling to locate landmarks.

While the thyroid cartilage is most visible, the cricoid cartilage is the most palpable landmark in the neck. Palpate for the cricoid cartilage and feel for the depression immediately above it. This is the cricothyroid membrane.

The neck tissue is very swollen after the procedure.

Palpate the neck. Air will present as surgical crepitus. Confirm placement of the tube and that the cuff is inflated, as it may have become dislodged and air may be tracking into the soft tissues. The patient may have developed a pneumothorax. Listen for chest sounds.

## Risks

1. Inadequate ventilation: hypoxia and death

2. Scarring

3. Subglottic stenosis

4. Aspiration

5. Injury to oesophagus, thyroid, or larynx

6. Haematoma or uncontrollable bleeding

7. Creation of a false passage into the tissue of the neck

8. Sharps injury to healthcare personnel

## References

1. Chung PH. How To Do a Percutaneous Cricothyrotomy. In: MSD Manual. 2020. Available from: https://www.msdmanuals.com/professional/critical-care-medicine/how-to-do-other-airway-procedures/how-to-do-a-percutaneous-cricothyrotomy

2. Engelbrecht D. How To Do a Cricothyrotomy. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 319-320.

3. McKenna P, Desai NM, Morley EJ. Cricothyrotomy. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537350/

4. Nicol A, Steyn E. Emergency Procedures. Chapter 6. Handbook of Trauma for Southern Africa. 2009. 4th ed. 67-69.