cricothyrotomy

Cricothyrotomy is an emergency surgical procedure used to rapidly establish a definitive airway when conventional methods of airway management, such as orotracheal intubation, have failed or are not feasible. The procedure involves creating an access route through the cricothyroid membrane to the trachea and inserting a tube to permit ventilation.

Anatomy and indications: The cricothyroid membrane lies between the thyroid and cricoid cartilages in the midline of the neck. Cricothyrotomy is indicated in life-threatening situations where there is significant airway obstruction or failure to oxygenate and ventilate despite attempts at intubation or mask ventilation. Common causes include severe facial trauma, tumors, angioedema, extensive neck injury, or an inability to secure the airway quickly. Relative contraindications include uncorrected coagulopathy or local infection at the planned incision site, though in emergencies these considerations may be outweighed by the need for rapid airway access.

Techniques and alternatives: There are two main approaches: surgical cricothyrotomy and needle (transtracheal) cricothyrotomy. Surgical cricothyrotomy creates an aperture through the cricothyroid membrane with a scalpel or similar instrument and allows placement of a tracheal tube or cannula. Needle cricothyrotomy uses a large-bore needle or cannula inserted through the membrane to provide temporary ventilation, often with jet ventilation, and is generally considered a bridge to a more definitive airway. In some situations, a cricothyrotomy can be followed by a formal tracheostomy or endotracheal tube placement in the lower airway.

Complications and outcomes: Potential complications include misplacement, bleeding, damage to surrounding structures, subcutaneous emphysema, pneumothorax, infection, and injury to the larynx or esophagus. When performed promptly by trained providers, cricothyrotomy can be life-saving by restoring ventilation in critical airways.

Training and considerations: Cricothyrotomy requires specialized training and should be performed by clinicians experienced in airway management. In pediatric patients, cricothyrotomy is more challenging due to smaller anatomy, and alternative approaches such as needle transtracheal ventilation or early surgical airway via tracheostomy may be preferred when appropriate.