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CricothyroidotomyAuthor: Carlos Eduardo Reis, MD |
Cricothyroidotomy is an emergency procedure and must be performed only when a secure airway need to be maintained and attempts at orotracheal and nasotracheal intubation have failed. It is contraindicated if any other less radical means of securing airway is feasible.
The cricothyroid membrane lies between the thyroid cartilage superiorly and the cricoid cartilage inferiorly. It can be felt by palpating the neck anteriorly and finding first the thyroid cartilage that is the most prominent cartilage in the neck. After that you need scroll down your index finger until you can fell the space between the thyroid and cricoid cartilages. This space is the place of the cricothyroid membrane. The image below will help you to find it.
As an emergency procedure in some cases you perhaps will not have time to follow all the steps listed below. Nevertheless, it is very important to sterilize the skin and observe sterile technique.
1- Prepare all necessary equipment and test the tracheostomy tube by inflating the tube with air from 10-cc syringe. Place the material on a sterile towel placed on a Mayo stand or bedside table.
2- One of the most important aspects is to position the patient . He or she should be supine, with a rolled bath towel under the shoulders, and with the neck in hyperextension.
3- Sterilize the skin from the sternal notch to chin and laterally to the base of the neck.
4- Observe sterile technique
5- Identify the cricothyroid membrane as described above
6- Anesthetize the skin over the membrane using the 10-cc syringe with 25-gauge needle with the 1% lidocaine.
7- Make a transverse incision of the skin over the cricothyroid membrane using the No. 11 blade.
8- Identify the membrane and then continue the incision through it. approximately 1 cm on each side of the midline.
9- With the mosquito or kelly clamp in the left hand, insert the clamp into the incision and spread it . This is sufficient to provide an airway for a patient with supraglotic airway obstruction.
10- With the right hand insert the tracheostomy tube or the orotracheal tube through the incision into the trachea, directing it caudally.
11- Connect the bag-valve unit to the tube and ventilate the patient the patient with 100% oxygen.
12- Observe respiratory movements of the chest and breath sounds.
13- Inflate the tube balloon
14- Cut a sponge halfway down the middle, and wrap it around the tube if an orotracheal tube is being used and then fashion a necklace to place the tube in place. If you are using the tracheostomy tube secure the wings of the tube by tying the tapes around the patient's neck. In both cases don't tying the tape to tightly because it can cause erosion the skin.
15- Suction the trachea
16- Obtain a chest x-ray to check the position of the tube.
This procedure when done with a rigorous attention on anatomic landmarks rarely leads to complications.
Charles E. Saunders, Mary T. Ho(eds): In Current Emergency Diagnosis and Treatment. Fourth edition, 1992.
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