Cricothyroidotomy

Tracheostomy
ANAM. AT-AT. ATTAPUN. BEDUYA. CAYETANO.

Cricothyroidotomy is an emergent procedure

performed on patients experiencing severe
respiratory distress in whom orotracheal or
nasotracheal intubation has failed.

Procedure involves making an incision in the

cricothyroid membrane which lies between the
cricoid and thyroid cartilage followed by
inserting a tracheostomy tube which allows
ventilation

Major indication:
inability

to establish an airway by orotracheal

or nasotracheal intubation
Failure

to secure an orotracheal or nasotracheal

intubation may be due to factors such as
Difficult

patient anatomy

Excessive
Massive
Airway

blood in mouth or nose

Facial Trauma

obstruction

Laryngeal
Trauma
Burns

edema

 Whenever

possible, cricothyroidotomy
should be performed by physicians fully
trained and skilled in carrying out the
procedure.
Emergency
Surgeons
Intensivists

physicians

A cricothyroidotomy performed under

emergency procedures can be left for up to
72 hours.

If the surgical airway is still necessary after

72 hours, the cricothyroidotomy should be
converted to a tracheostomy.

While tracheostomys preferred for long-term

management, it should be performed in a
controlled setting in the operating room.

In urgent situations, cricothyroidotomy should

needle cricothyroidotomy
o

In needle cricothyroidotomy, a catheter is placed over a needle

into the cricothyroid membrane allowing them to _____ via
pressurized stream of oxygen

Because the catheter has a small diameter, it is less effective in

providing effective ventilation and should only be used as a
temporizing measure while preparation is made for surgical
cricothyroidotomy or tracheostomy

needle cricothyroidotomy is the preferred method of establishing

airway in children 10 -12 years since the larynx is more easily
damaged by surgical cricothyroidotomy.

CONTRAINDICATION
Massive

trauma to larynx or cricoid

cartilage
Orotracheal and nasotracheal
intubation not yet attempted

Preparation
Since

this is an urgently performed

emergency procedure
There might not be time to get a
consent or the patient may not give
the consent
Should be perfomed emergently
even in the absence of a consent

Equipment

Equipments

Tube should
be not
larger
than 7 mm
diameter
-difficult to
insert into
the
cricothyroid
membrane

Tracheostomy Tube (3 parts)

Neck

plate extending
from the sides allows
the tube to be secured
to the neck, the sutures
or a clocktie

It

has an adaptor at the

end that attaches to a bag
valve device or mechanical
ventilator

It

provides a smooth
surface to guide
insertion of the tube

The

6 mm ET
tube may be
used an
alternative to
a tracheostomy
tube but is less
preferable
More

difficult
to secure in
patients neck

Certain

devices may
be used to
handle ET
tube to the
neck

 Supine

position

since

this procedure is
performed in extremely
urgent circumstances,
theres no time to
drape the patient

C-spine

immobilization
should be applied if
indicated.

Clerhexide

or
Betadine should be
applied if time
permits
Antiseptic

solution

If

the patient is awake,

administer local
anesthesia (Lidocaine)

 Identify

the
landmarks clearly

Right

handed
operator

Site

specific
designations should
be reversed in a left
handed operator.

Procedure

Stand on the patients right

side

Stabilize the larynx with your

left thumb and middle
finger

Use index finger to palpate

the thyroid cartilage

Move index finger down until

you palpate your cricothyroid
cartilage

ANATOMY

The

space
between the
thyroid and the
cricoid cartilages is
the cricothyroid
membrane

Cricothyroid membrane
This

is where you
will make an
incision

Use

the scalpel
(no. 10 or 11
blade) to make a
2.5 centimeter
vertical through
the skin and
subcutaneous
tissue

Use

the curve
hemostat to
make a blunt
dissection into
the subcutaneous
tissue

ANATOMY
First:

The initial
incision should be
vertical first to avoid
the recurrent laryngeal
nerves which run parallel
to the trachea

Second:

As an initial
incision above or below
the cricothyroid
membrane will allow

In

contrast, starting
with a horizontal
incision that is too low
or too high will
necessitate a
completely new incision
in the correct location.

 Next,

use the
scalpel to make a
horizontal incision
to cricothyroid
membrane

You

may feel a
pop as you enter
the trachea

Extend

the

incision
laterally turn
the blade and
extend it to the
opposite
direction

ANATOMY
To

avoid penetrating too

deeply and perforating
the esophagus which
lies posterior to the
trachea, do not go
more than 1.23
centimeters deep!

To minimize esophageal perforation, hold the

scalpel between your thumb and index finger and
allow your middle finger to extend down the side of
the scalpel, leaving the distal 1.3 cm of the
blade exposed.

if the patient is trying to breath once you enter the

trachea, airflow should be audible and may also
be visible

Once the trachea has been entered, make sure the

blade stays within the incision so that
communication with the trachea is never lost.

Insert a tracheal hook and pull upwards in the

distal portion of the incision elevating the

 Insert

a trusor dilator and open the membrane

vertically, then insert the tracheostomy tube

Hold

the canula in place and remove the

obturator and attache the adaptor

Inflate
Attach

the cuff with a 10 cc syringe

the bag valve and ventilate the patient

Look

for symmetric chest rise and auscultate for

symmetric breath sounds

Tie

or suture the tracheostomy tube in place.

Dispose

of needles and sharps in appropriate

containers

3 MAJOR COMPLICATIONS

Esophageal perforation when blade

penetrates too deeply

Subcutaneous emphysema if
horizontal incision is too wide allowing air
to become trapped in the subcutaneous
tissue

Excessive bleeding or hemorrhage

if a vessel has ruptured

If minor vessels has been injured, the bleeding

can be controlled by direct pressure

if major vessels, such as the carotid artery or

Internal jugular vein (IJV) ruptured,
ligation may be required.

POSTPROCEDURAL CARE

Obtain chest X-ray film: to confirm

placement of tracheostomy tube

Call for respiratory therapy: so

patient will be mechanically
ventilated

Obtain a surgical consult so that

affinitive tracheostomy can be
performed

An emergent cricothyroidotomy
can be left up to 72 hours

POSTPROCEDURAL CARE

Analgesic/Pain reliever as
needed
Anti-pyretic medications for
fever if
complications/infection arise

THANK YOU.