Cricothyrotomy

A cricothyrotomy (also called thyrocricotomy, cricothyroidotomy, inferior laryngotomy, intercricothyrotomy, coniotomy or emergency airway puncture) is an emergency incision through the skin and cricothyroid membrane to secure a patient's airway during certain emergency situations, such as an airway obstructed by a foreign object or swelling, a patient who is not able to breathe adequately on their own, or in cases of major facial trauma which prevent an airway through the mouth. A cricothyrotomy is usually performed by emergency physicians, trauma surgeons, or paramedics as a last resort when control of the airway by usual means (an endotracheal tube through the mouth) have failed or are not feasible. This technique is considered easier and faster than a tracheostomy, but is only used when oral or nasual intubation is not possible in the patient. This procedure does not require manipulation of the cervical spine. However, it does require special training and authorization from local medical direction prior to being performed, dependending on local medical protocols.

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Indications

• Severe facial or nasal injuries (that do not allow oral or nasal intubation)
• Massive midfacial trauma
• Possible spinal trauma preventing adequate ventilation
• Anaphylaxis
• Chemical inhalating injuries

Contraindications

• Inability to identify landmarks (cricothyroid membrane)
• Underlying anatomical abnormality (tumor)
• Tracheal transection
• Acute laryngeal disease by infection or trauma
• Small children under 10 years old (a 12-14 gauge catheter over the needle may be safer)

Procedure

The procedure was first described in 1805 by Vicq d'Azyr, a French surgeon and anatomist. A cricothyrotomy is generally performed by making an incision on the skin of the neck just below the "Adam's apple", or thyroid cartilage, then making another incision in the cricothyroid membrane which lies deep to this point. One then inserts a tube into this opening, which allows one to breathe for the patient with a machine or bag.

Summarized technique

1. With a scalpel, create a 2 cm horizontal incision through the cricothyroid membrane
2. Open the hole by rotating the scapel 90 degrees or by using a clamp
3. Insert a size 6 or 7 endotracheal tube or tracheostomy tube
4. Inflate the cuff and secure the tube
5. Provide venilation via a bag-valve device with the highest available concentration of oxygen
6. Determine if ventilation was successful (bilateral ausculation and observing chest rise and fall)
7. No attempt should be made to remove the endotracheal tube in a prehospital setting.

Cricothyrotomy in the popular media

On the TV show M*A*S*H, Father Mulcahy performs an emergency cricothyrotomy on a patient. With the direction of Dr. Pierce via radio, he uses a pen knife and ball point pen to perform the operation. Needless to say, this would be extremely dangerous in real life. Even under ideal, clinical conditions, a cricothyrotomy is difficult and requires specific tools, preparation and a practiced knowledge of anatomy. There are many major blood vessels and nerves in the neck and cutting there, even with the best of intentions carries a high risk of harming the patient. For that reason, among others, it is illegal to attempt to perform a cricothyrotomy without a medical license.^{[where? — see talk page][citation needed]}

In the 1980 Nicolas Roeg film "Bad Timing," Theresa Russell's character Milena Flaherty has an emergency cricothyrotomy performed following an intentional overdose.

In the Grey's Anatomy episode, "Owner of a Lonely Heart", Cristina mentions performing an emergency cricothyrotomy on a prison inmate (who had previously swallowed 4 taped-up razor blades so she could go the hospital to escape solitary confinement, and was in the recovery room after getting them removed) after she swallowed a light bulb. Before she is able to do so, however, Dr. Burke showed up and informed her that they would operate.

See also

• Laryngotomy
• Tracheotomy

References