Cricothyroidotomy is an emergency surgery procedure where a surgeon or another trained person cuts through the membrane of the patient’s neck to access the windpipe and allows air to enter the lungs.
Cricothyroidotomy, a subtype in the tracheotomy surgical procedure, is sometimes considered an elective option to other types.
Cricothyroidomy’s primary purpose is to provide emergency breathing passages for patients whose airway has been damaged by trauma to the neck, burn injuries, allergic reactions, or unconsciousness.
Some patients who have structural abnormalities in their necks may also require it. When treating patients in intensive care units, some surgeons prefer a cricothyroidotomy to a standard-sized tracheotomy.
There are two methods of cricothyroidotomy, needle cricothyroidotomy or surgical cricothyroidotomy.
A needle cricothyroidotomy is a procedure that uses a needle and a syringe to puncture the cricothyroid membrane. Once the needle has reached its destination, the catheter is passed through the windpipe to attach to a bag-valve device.
A surgical cricothyroidotomy is when a doctor or another emergency worker injures the cricothyroid membrane to access the trachea and insert ventilation tubing.
When to perform a cricothyroidotomy
The ABCs dominate emergency medical treatment, which are airway patency (openness), circulation, and breathing. To ensure the survival of an injured individual, it is crucial to keep their airway open.
A blocked airway can cause a person to have a bluish complexion (cyanosis), choking, noisy breathing, abnormal breath sounds or choking, emotional agitation, panic, and sometimes loss of consciousness.
If you are in an emergency, these are the reasons to perform a cricothyroidotomy immediately.
- Major injuries to the jaw or face, such as multiple fractures or severe fractures to the midface or jawbone, can occur. Broken teeth, fragments, or bone fragments from the jaw and cheekbones can block the airway in many cases of facial injuries.
- Burns around or in the mouth
- A condition or damage to the brain that causes teeth to close.
- Fractured larynx. Fractures of the larynx are most often caused by automobile or motorcycle accidents. However, they can also be caused by strangulation or attempts to commit suicide by hanging.
- The allergic reaction to wasp or bee venom can cause larynx swelling.
Both needle and surgical cricothyroidotomies require the same preparation steps. With a towel underneath the shoulders, the patient lies down on his back with the neck hyperextended.
A local anesthetic is applied to the patient if they are conscious. The doctor will then feel the patient’s throat to determine if there is the thyroid cartilage. This cartilage piece is an anatomical landmark that allows for the identification of other structures.
The Adam’s apple can be easily identified in men by running your finger along the middle of the neck. However, women have less obvious thyroid cartilage.
Below the thyroid cartilage, there is a soft area approximately the size of a finger. This is the cricothyroid Membrane. It is a small piece of tissue that lies between the thyroid cartilage and the cricoid.
Once the doctor has found the cricothyroid membrane, the doctor will scrub the skin with a povidone/iodine solution to prevent infection.
A needle cricothyroidotomy is performed using a catheter with a gauge of 12 or 14 and a needle assembly. The needle is advanced through the cartilage at 45 degrees until it reaches the trachea.
The doctor will know that the catheter is at the right spot to withdraw air from the syringe.
The catheter is then moved forward over the needle, and then it is removed. The catheter’s end is connected to an oxygen reservoir via an endotracheal tube connector.
The needle cricothyroidotomy will provide oxygen to the patient for approximately 40-45 minutes. However, it is not able to efficiently escape carbon dioxide from the bloodstream. However, it does help ventilate the patient until they can be transported to a hospital.
Children below the age of 12 can only have needle cricothyroidotomy. This restriction is since children’s tracheas are not fully developed.
A surgical incision through the Cricothyroid membrane can increase the chance of subglottic Stenosis.
Subglottic stenosis is a condition where the trachea narrows below the level of the vocal cords. This condition is common in infants who were intubated.
A surgical cricothyroidotomy involves the doctor stabilizing the patient’s thyroid cartilage using one hand, and making a transverse (horizontal), incision across the Cricothyroid membrane. The incision is then made until the airway can be reached.
To receive an endotracheal tube or tracheostomy tube, the doctor rotates the blade of the scalpel 90 degrees. The doctor may use a hemostat or surgical clamp to keep the incision open as he prepares to insert the tube into the trachea.
The doctor taps the tube in place after confirming that it is correctly positioned. The doctor may also use suction to clean the patient’s airway.
Sometimes, a doctor or another medical professional may not provide an antiseptic to clean the skin around the patient’s throat.
In these cases, they may need to use any sharp-edged instrument available to make the incision.
Cricothyroidomies can be performed using scissors, hunting or pocket knives, and razor blades. You can hold the airway open using paper clips, nail clippers, and the plastic barrel of a ballpoint pen.
Within 45 minutes, a needle cricothyroidotomy must be replaced with a formal surgical traceotomy or another means of ventilating the patient.
The surgical cricothyroidotomy should be left in place for approximately 24 hours. However, it should be replaced by a formal tracheotomy in an operating room hospital.
The nature of the injuries and the cause of the blockage will determine the extent of the aftercare. Major blood vessels are found in the head and neck.
They also contain large portions of the central nervous systems, the organs that sense, hear, smell, taste, and sight, as well as the central airway.
All of this is located within a small area. Specialists in neurology, trauma surgery, and ophthalmology are often required to treat neck and face injuries.
A needle cricothyroidotomy can pose risks:
- External scarring from the needle puncture
- Accidental perforation to the esophagus
- Hypercarbia (excessive levels of carbon dioxide within the blood)
There are several risks associated with surgical cricothyroidotomy:
- Large visible external scarring from the incision
- Subglottic Stenosis
- Accidental perforation to the esophagus
- Fracture of the larynx
- Pneumothorax is an illness where air enters the space around your lungs.
- Damage to the vocal cords can cause hoarseness and/or a change in voice
A cricothyroidotomy is a procedure that allows for adequate ventilation to a patient who has a blocked airway.
MORBIDITY and MORTALITY RATE
Cricothyroidotomy, in general, has a low mortality rate even when performed outside of a hospital. Patients who have lost their airway patency are 33% more likely to die.
Emergency cricothyroidotomy, in general, is a good way to make an emergency surgical airway. It has low overall morbidity.
Cricothyroidotomy, which is usually performed after other methods of opening the patient’s airway have failed, or are not possible, is generally considered a last resort procedure.
This is often done when endotracheal Intubation has failed or if the nature of the patient’s injuries makes it impossible to perform intubation.
A procedure where a breathing tube is introduced into the trachea directly through the patient’s nose or mouth using a laryngoscope.
This is commonly done under general anesthesia, but it can also be done to aid breathing.
A technique called transtracheal Jet Ventilation (TTJV) is an alternative to cricothyroidotomy. TTJV uses a syringe to insert a catheter through a patient’s cricothyroid membrane.
The catheter is connected with a high-pressure oxygen source. TTJV is almost as likely to cause complications in hospital settings as a surgical cricothyroidotomy. The downsides of TTJV are that it can’t be used outside of a hospital and takes longer to perform.
The surgical cricothyroidotomy can be done in as little as 30 seconds, while the TTJV takes two to three times as long.
ROLES OF THE HEALTHCARE TEAM
Cricothyroidotomy should be performed in an emergency room, hospital ICU, or trauma center by a general or otolaryngologist or anesthesiologist.
Cricothyroidotomies are an emergency procedure. However, it may be required by medical students, paramedics, and nurses, as well as physician’s assistants, paramedics, and paramedics.
Paramedics and nurses who specialize in emergency medicine must perform cricothyroidotomies at minimum twice per year in a clinical lab.
This is to maintain their skills. It is important that emergency personnel feel confident with the equipment and techniques, as the procedure can be dangerous.
Military personnel is trained to perform emergency cricothyroidotomies in combat situations. There are also cases reported of cricothyroidotomies being done in emergencies by civilian bystanders with some medical training.
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Center for Emergency Medicine of Western Pennsylvania, Inc., 230 McKee Pl., Ste. 500, Pittsburgh, PA 15213, (412) 647-5300, (412) 647-4670, http://centerem.org.
National Association of Emergency Medical Technicians, 132-A E. Northside Dr., Clinton, MS 39056, (601) 924-7744, (800) 34-NAEMT (346-2368), Fax: (601) 924-7325, [email protected], http://www.naemt.org .
R. Adams Cowley Shock Trauma Center, University of Maryland, 22 S. Greene St., Baltimore, MD 21201-1595, (800) 492-5538, https://www.umms.org/ummc/health-services/shock-trauma.