Cricothyrotomy

Cricothyrotomy

A cricothyrotomy (also called thyrocricotomy, cricothyroidotomy, inferior laryngotomy, intercricothyrotomy, coniotomy or emergency airway puncture) is an emergency incision through the skin and cricothyroid membrane to secure a patient's airway during certain emergency situations, such as an airway obstructed by a foreign object or swelling, a patient who is not able to breathe adequately on their own, or in cases of major facial trauma which prevent the insertion of an airway through the mouth. A cricothyrotomy is usually performed by emergency physicians, trauma surgeons, or paramedics as a last resort when control of the airway by usual means (an endotracheal tube through the mouth) have failed or are not feasible. This technique is considered easier and faster than a tracheostomy, but is only used when oral or nasal intubation is not possible. This procedure does not require manipulation of the cervical spine. However, it does require special training and authorization from local medical direction prior to being performed, depending on local medical protocols.

Indications

  • Severe facial or nasal injuries (that do not allow oral or nasal intubation)
  • Massive midfacial trauma
  • Possible spinal trauma preventing adequate ventilation
  • Anaphylaxis
  • Chemical inhalation injuries

Contraindications

  • Inability to identify landmarks (cricothyroid membrane)
  • Underlying anatomical abnormality (tumor)
  • Tracheal transection
  • Acute laryngeal disease due to infection or trauma
  • Small children under 10 years old (a 12–14 gauge catheter over the needle may be safer)

Procedure

The procedure was first described in 1805 by Vicq d'Azyr, a French surgeon and anatomist. A cricothyrotomy is generally performed by making an incision on the skin of the neck just below the "Adam's apple", or thyroid cartilage, then making another incision in the cricothyroid membrane which lies deep to this point. One then inserts a tube into this opening, which allows one to breathe for the patient with a machine or bag.

Summarized technique

  1. With a scalpel, create a 2 cm horizontal incision through the cricothyroid membrane
  2. Open the hole by rotating the scalpel 90 degrees or by using a clamp
  3. Insert a size 6 or 7 endotracheal tube or tracheostomy tube
  4. Inflate the cuff and secure the tube
  5. Provide venilation via a bag-valve device with the highest available concentration of oxygen
  6. Determine if ventilation was successful (bilateral ausculation and observing chest rise and fall)
  7. No attempt should be made to remove the endotracheal tube in a prehospital setting.

Cricothyrotomy in popular media

On the TV show M*A*S*H, Father Mulcahy performs an emergency cricothyrotomy on a patient. With the direction of Dr. Pierce via radio, he uses a pen knife and an eye dropper to perform the operation. Needless to say, this would be extremely dangerous in real life. Even under ideal, clinical conditions, a cricothyrotomy is difficult and requires specific tools, preparation and a practiced knowledge of anatomy. There are many major blood vessels and nerves in the neck and cutting there, even with the best of intentions carries a high risk of harming the patient. For that reason, among others, it is illegal to attempt to perform a cricothyrotomy without a medical license.

In the 1980 Nicolas Roeg film "Bad Timing," Theresa Russell's character Milena Flaherty has an emergency cricothyrotomy performed following an intentional overdose.

In Grey's Anatomy, emergency cricothyrotomy is mentioned in at least two episodes:

In the ER episode, "Reason to Believe" Dr. Kerry Weaver performs an emergency cricothyrotomy on a student. She is shooting a news segment on childhood obesity in an elementary school cafeteria when one of the students begins to choke; after the heimlich maneuver fails, she performs a cricothyrotomy with a kitchen knife and a drinking straw.

In the movie, "Playing God" (1997), David Duchovny plays a famed LA surgeon, stripped of his license due to drug abuse, who finds himself witnessesing a gun fight at a bar. He saves a mafia crime figure by performing an emergency Cricothyrotomy. This endears him with the mafia family and drives the plot forward.

In the BBC3 Medical Drama Bodies_(TV_series), the main protagonist Rob Lake, a newly appointed obstetrics and gynaecology registrar (played by Max Beesley), is called to a patient who is having difficulty breathing due to anaphylaxis. Lake calls for emergency assistance, but impatient and fearing for the patient's life decides to undertake a cricothyrotomy himself - a procedure he has not been trained in. The procedure is unsuccessful and the patient dies before help arrives. The guilt surrounding the event combined with the covering up by his consultant provides an important backdrop to the further development of the character and his relationship with his consultant.

See also

References

External links

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