Emergency Surgical Airway almost always happens in a midst of chaos since this is a rarely performed procedure. Regardless, regular simulation sessions and mental rehearsal can help us be more familiar with this and make this less stressful.
Nomenclature
Surgical cricothyrotomy
Incision in the cricothyroid membrane and an airway (tracheostomy tube or ET tube) is placed to ventilate the patient.
Needle cricothyrotomy
Insertion of a catheter via percutaneous needle puncture of the cricothyroid membrane to allow percutaneous translaryngeal ventilation (PTLV)
Tracheostomy
Incision is made between two of the tracheal rings
Relevant Anatomy
Surgical cricothyrotomy
Incision in the cricothyroid membrane and an airway (tracheostomy tube or ET tube) is placed to ventilate the patient.
Needle cricothyrotomy
Insertion of a catheter via percutaneous needle puncture of the cricothyroid membrane to allow percutaneous translaryngeal ventilation (PTLV)
Tracheostomy
Incision is made between two of the tracheal rings
Relevant Anatomy
Cricothyroid membrane (CTM) is an elastic membrane located anteriorly and midline in the neck.
Borders of CTM
Superior - Thyroid Cartilage (Note - Superior to the thyroid cartilage is thyrohyoid membrane connecting it to the hyoid bone)
Inferior - Cricoid Cartilage and Thyroid Gland
Lateral - Cricothyroid muscles and Blood vessels
Indications
Inability to maintain >90% SpO2 between intubation attempts or after 3 attempts
Inability to BMV between intubation attempts or after 3 attempts
Multiple Failed Endotracheal Intubation attempts
Contraindications
Obstruction below CTM, Tracheal fracture/transection
Age yonger than 12 years (some texts mention 5 years)
How to find the CTM
Techniques
Surgical Cric Videos
Common Complications
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Borders of CTM
Superior - Thyroid Cartilage (Note - Superior to the thyroid cartilage is thyrohyoid membrane connecting it to the hyoid bone)
Inferior - Cricoid Cartilage and Thyroid Gland
Lateral - Cricothyroid muscles and Blood vessels
The cricoid cartilage forms the inferior border of the CTM and is the only completely circumferential cartilaginous structure of the larynx. Also nothe that the cricothyroid arteries branch from the superior thyroid arteries and may form a small anastomotic arch traversing the superior aspect of the cricothyroid membrane.
Indications
Inability to maintain >90% SpO2 between intubation attempts or after 3 attempts
Inability to BMV between intubation attempts or after 3 attempts
Multiple Failed Endotracheal Intubation attempts
Contraindications
Obstruction below CTM, Tracheal fracture/transection
Age yonger than 12 years (some texts mention 5 years)
How to find the CTM
- Located between Cricoid Cratilage and Thyroid Cartilage
- If obscured by short neck/swelling, estimated locaton is at about 2 to 3 cm inferior to the laryngeal prominence or four fingerbreadths above the sternal notch.
Criciothroidotomy is a tactile procedure i.e you dont need to know where exactly the membrane is located before you make the skin incision if you use a 2 incision technique.
Techniques
- 2 incision (Vertical then Horizontal Technique)
- 1 incision (Horizontal only over CTM)
- Size 11 Scalpel
- Finger
- Bougie
- Tube 6' ETT
Surgical Cric Videos
Common Complications
- Bleeding
- Tube Malposition
More on Cric and Surgical Airway by Rich Levitan (Laryngeal Handshake and Sternal Stabilisation)
Posted by:
Lakshay Chanana
ST4 Trainee
Royal Infirmary of Edinburgh
Department of Emergency Medicine
Edinburgh
Scotland
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