Overview
Cricothyrotomy is an emergency surgical airway procedure that involves creating an opening through the cricothyroid membrane to establish airway access when all other methods have failed. It is a life-saving procedure in the "Can't Intubate, Can't Oxygenate" (CICO) scenario.
Cricothyrotomy is the final rescue option in difficult airway algorithms when all other airway management techniques have failed. It provides immediate access to the trachea and can be life-saving in emergency situations. Mastery of this skill is crucial for all anesthesia providers.
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Indications
Can't Intubate, Can't Oxygenate emergency
All intubation attempts unsuccessful
LMA and other SGA devices failed
Complete upper airway blockage
Severe facial trauma preventing intubation
Direct laryngeal injury
Severe airway swelling
Emergency airway in resuscitation
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
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Pre-procedure Preparation
Preparation involves rapid assessment of the emergency situation, equipment check (scalpel, bougie, endotracheal tube), positioning the patient with neck extended, and understanding the anatomy of the cricothyroid membrane and surrounding structures.Step-by-Step Procedure
Step 1: Emergency Assessment
Rapidly assess the CICO situation, confirm all other airway options have failed, and prepare for immediate surgical airway.
⚠️ Common Mistakes to Avoid:
- Rushing without assessment
- Not confirming CICO
- Poor team communication
💡 Pro Tip:
Call for help immediately. Cricothyrotomy is a team effort requiring coordination.
Step 2: Patient Positioning
Position patient with neck extended, identify cricothyroid membrane (between thyroid and cricoid cartilages), and prepare sterile field if time permits.
⚠️ Common Mistakes to Avoid:
- Poor positioning
- Wrong anatomical landmark
- Inadequate preparation
💡 Pro Tip:
The cricothyroid membrane is palpable as a depression between thyroid and cricoid cartilages.
Step 3: Surgical Technique
Make a horizontal incision through the cricothyroid membrane, extend incision laterally, insert finger to confirm tracheal entry, and dilate the opening.
⚠️ Common Mistakes to Avoid:
- Wrong incision site
- Inadequate incision size
- Not confirming tracheal entry
💡 Pro Tip:
Make a 2-3cm horizontal incision. The membrane is typically 1cm below the thyroid cartilage.
Step 4: Tube Insertion
Insert endotracheal tube or tracheostomy tube through the opening, advance until resistance is felt, and inflate cuff.
⚠️ Common Mistakes to Avoid:
- Wrong tube size
- Too deep insertion
- Esophageal placement
💡 Pro Tip:
Use a size 6.0-7.0 endotracheal tube. Confirm placement with capnography.
Step 5: Position Confirmation
Confirm tube position with capnography, auscultation, and chest rise. Secure tube and connect to ventilator.
⚠️ Common Mistakes to Avoid:
- No position confirmation
- Poor tube securing
- Inadequate ventilation
💡 Pro Tip:
Always confirm position with multiple methods. Capnography is the gold standard.
Step 6: Post-procedure Care
Monitor for complications, plan for definitive airway management, and document the procedure details.
⚠️ Common Mistakes to Avoid:
- Inadequate monitoring
- No complication assessment
- Poor documentation
💡 Pro Tip:
Monitor for bleeding, infection, and airway complications. Plan for tracheostomy within 24 hours.
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Post-procedure Care
Post-procedure care includes securing the airway, confirming tube position, monitoring for complications (bleeding, infection, tracheal stenosis), and planning for definitive airway management.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Bleeding | 10-20% | Active bleeding, expanding hematoma, airway compromise | Direct pressure, surgical exploration, blood products | Careful technique, avoid major vessels, proper hemostasis |
| Infection | 5-15% | Erythema, purulent discharge, fever, neck pain | Antibiotics, wound care, surgical debridement if needed | Sterile technique, proper wound care, early definitive airway |
| Tracheal stenosis | 5-10% | Dyspnea, stridor, voice changes, exercise intolerance | Tracheal dilation, stenting, surgical reconstruction | Proper technique, appropriate tube size, early conversion |
| Esophageal injury | 2-5% | Subcutaneous emphysema, mediastinitis, dysphagia | Surgical repair, antibiotics, monitoring | Proper technique, confirm tracheal entry, avoid posterior wall |
| Vocal cord injury | 3-8% | Hoarseness, voice changes, aspiration | Speech therapy, ENT consultation, monitoring | Proper technique, avoid superior extension |
| Subcutaneous emphysema | 5-15% | Crepitus, neck swelling, chest pain | Observation, oxygen therapy, monitor for pneumothorax | Proper tube placement, adequate cuff inflation |
Clinical Pearls
Cricothyrotomy is a last resort - only when all other options have failed.
Practice the technique regularly - muscle memory saves lives in emergencies.
Call for help immediately - this is a team effort requiring coordination.
Confirm tracheal entry before tube insertion - avoid esophageal placement.
Document everything - timing, technique, complications, and outcomes.
Use appropriate tube size - too large can cause tracheal injury.
Be prepared for complications - bleeding and infection are common.
Plan for definitive airway - convert to tracheostomy within 24 hours.
Know the anatomy - the cricothyroid membrane is 1cm below thyroid cartilage.
Practice with simulation - this skill requires regular training and practice.