EMERGENCY CRICOTHYROIDOTOMY

Vic Vernenkar, D.O. Department of Surgery St. Barnabas Hospital

EMERGENCY CRICOTHYROIDOTOMY Outline:

I. II. III. IV. V. VI. VII. VIII.

Indications for surgical airway placement Contraindications Complications Anatomy of the Trachea and landmarks Tools Required Performing the Procedure Securing the airway Credits

EMERGENCY CRICOTHYROIDOTOMY

DEFINITION An emergency surgical procedure where an incision is made through the skin and cricothyroid membrane which allows for the placement of an endotracheal tube into the trachea when airway control is not possible by other methods.

INDICATIONS

Obstructed Airway - obstructions within the airway will usually prevent the passage of an endotracheal tube or prevent the establishment of a patent airway. Therefore, a surgical airway distal to the obstruction is required.

INDICATIONS
Congenital deformities of the oropharynx or nasopharynx which inhibit or prevent nasotracheal or orotracheal intubation Trauma to the head or neck which would preclude the use of an ambu-bag, oropharyngeal airway, nasopharyngeal airway, or endotracheal tube insertion

INDICATIONS

Cervical Spine fractures, or highly suspect fractures in a patient who requires an airway but whom nasotracheal intubation is contraindicated. Examples include: Nasal bone fractures Cribiform fractures The healthcare provider is unable to establish an airway by any other means and this is the last resort.

ADVANTAGES OF EMERGENCY CRICOTHYROIDOTOMY

Provides a definitive airway for ventilating the patient Can be performed quickly and has few complications associated with the procedure

ADVANTAGES OF EMERGENCY CRICOTHYROIDOTOMY

For an emergency cricothyroidotomy the laryngeal prominence and cricoid cartilages are palpated and entry is made through the median cricothyroid ligament. This procedure is preferable to a tracheotomy as there are no large midline vessels in front of the median cricothyroid ligament whereas there are in front of the superior part of the trachea.

CONTRAINDICATIONS

Massive trauma to the larynx or cricoid cartilage: Damage to the affected structures will make it impossible to perform the procedure properly If another means of establishing an airway has not been performed. Examples include: Heimlich maneuver, nasotracheal or orotracheal intubation

COMPLICATIONS

Major bleeding is caused by the laceration of any major vessels (carotid artery or jugular vein) within the neck. NOTE: Very Heavy bleeding is common and normal. Treatment: Same as minor bleeding. However, if bleeding is not controlled with pressure, the vessel may need to be ligated.

COMPLICATIONS

Esophageal Perforation or Tracheoesophageal Fistula Definition: The creation of a hole between the esophagus and trachea Causes: Creating an incision too deep through the cricoid membrane Forcing the endotracheal tube through the cricoid membrane and into the esophagus

COMPLICATIONS

Treatment: Requires surgical repair of fistula or perforation.

COMPLICATIONS

Hemorrhage Is the most common complication Minor bleeding is caused by the laceration of superficial capillaries in the skin tissue Note: The Thyroid Gland may extend into the area of the cricothyroid membrane, heavy bleeding can be experienced. Treatment: Direct pressure to control the bleeding and then the application of a simple pressure dressing

COMPLICATIONS

Subcutaneous Emphysema Definition: The presence of free air or gas within the subcutaneous tissues

Causes: Creating too wide of an incision will encourage air entrapment under the subcutaneous tissue Air leaking out of the insertion site may get trapped under the subcutaneous tissues

COMPLICATIONS

Treatment: No treatment is usually necessary. Subcutaneous emphysema will usually dissipate on its own accord within a few days. However, placing a petroleum gauze dressing around the incision / insertion site will help reduce the incidence of subcutaneous emphysema. Monitor the size of the subcutaneous emphysema.

DISADVANTAGES OF EMERGENCY CRICOTHYROIDOTOMY

Requires advanced training to properly perform procedure. Bypasses the nares function of warming and filtering the air. May increase respiratory resistance (due to smaller tube size). Improper placement.

ANATOMICAL LANDMARKS AND STRUCTURES

Trachea Thyroid Cartilage Cricoid Cartilage Cricothyroid Membrane Carotid Arteries Jugular Veins Esophagus Thyroid Gland

ANATOMICAL LANDMARKS AND STRUCTURES-Closeup

Pharynx and Trachea in Detail

More Anatomy

Anterior view of the larynx to show the median cricothyroid ligament. 1. Thyroid lamina. 2. Arch of cricoid cartilage. 3. Median cricothyroid ligament (cut here)

Smallest Part of the Airway ???

In Adults it is at the vocal cords In Infants and Children up to 8 it is the Cricoid ring (cartilage), this is why uncuffed ET tubes work in children.

Required Equipment for Emergency Cricothyroidotomy

Required Equipment

#10 or 11 Scalpel Endotracheal Tube 10 cc Syringe Stethoscope

Curved Kelly Hemostat, Straight will work Ambu-bag Sterile Dressing Vaseline / Petroleum Gauze Betadine or Alcohol Wipes

Required Equipment (continued)

Sterile or Clean Gloves Suture Material Suction Device Suture Scissors Tape

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Determine that the patients ABCs is in jeopardy. Determine that the patient requires an emergency cricothyroidotomy. Assemble required equipment, quickly. Do it. Dont hesitate

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Position the patients head/neck The patient is placed in a supine or semirecumbent position The neck is placed in a neutral position

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Palpate the thyroid and cricoid cartilage for orientation A - Cricoid Cartilage B - Cricothyroid Membrane C - Incision Site D - Thyroid Cartilage

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Locate the cricothyroid membrane Stabilize the thyroid cartilage using your non-dominant hand Swab the incision site with alcohol or betadine swabs

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Make a vertical incision through the skin approximately 2-5 cm (1 inch+) long over the cricothyroid membrane Visualize the cricothyroid membrane

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Discussion, Vertical or Horizontal incision? Vertical is best for emergencies, you will expose the membrane guaranteed. Vertical does not heal well, there may be a scar and some internal scaring/fibroids. You have to be alive to be inconvenienced by the scar.

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Make a transverse incision into the cricothyroid membrane DO NOT make the incision more than 1/2 inch deep or you may perforate the esophagus

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Insert the Curved Kelly Hemostat into the incision and blunt dissect the incision (turn the Curved Kelly Hemostat 90 degrees to open up the incision) If you only have a straight hemostat, use it.

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Insert the endotracheal tube (adult 6.5 or smaller, Ped ? whatever will fit), into the incision, directing the tube distally down the trachea

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Ventilate the patient with two breaths Check for proper placement of the endotracheal tube with these first two ventilations by: Observing the chest rise and fall with each ventilation Auscultate for bilateral breath sounds

Guideline for Breath Sounds

Bilateral Breath Sounds present - the endotracheal tube has been properly placed proper placement will cause both lungs to inflate with each ventilation Bilaterally Absent Breath Sounds - the endotracheal tube is not within the trachea and has probably been placed within the esophagus. Remove the tube and attempt to reinsert into the trachea

Guidelines for Breath Sound

Right main-stem placement is common. Breath Sounds in the Right Lung Field - the endotracheal tube has been placed too far down the bronchial tree and is in the right mainstem bronchus. Pull back the tube 1/4 to 1/2 inch or until bilateral breath sounds have been established

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Auscultate over the epigastrium for gastric sounds Placement of the endotracheal tube into the stomach or esophagus will produce gurgling sounds in the epigastric area with ventilations

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Inflate the endotracheal tubes cuff with 10 ccs of air Inflation of the cuff serves two purposes: Holds the endotracheal tube in place Acts as a barrier and prevents fluids from entering the lungs

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Apply petroleum gauze dressing to insertion site Apply a dry, sterile dressing to the insertion site Tape around the tube then neck, sutures can be done later

PROCEDURAL STEPS FOR EMERGENCY CRICOTHYROIDOTOMY

Continue to ventilate the patient (1 breath every 5 seconds) and suction as necessary. Loving Gentle Squeeze 2 in, 3 out. Continue to monitor the patient for changes