Indications

Emergency cricothyrotomy is indicated when there is an emergent or urgent need for an airway and the individual cannot be intubated orally or nasally for any reason. Cricothyrotomy is specifically useful when an airway obstruction has occurred at the glottis or supraglottic level. The American Society of Anesthesiologists (ASA) directs that an emergency cricothyrotomy is indicated as the final pathway in their algorithm for treatment of the difficult airway. The ASA defines a difficult airway as a “clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both.”

There are a myriad of events that can lead to a difficult airway and the “can’t intubate, can’t ventilate” scenario. Loss of the airway may arise unexpectedly, as in cases of acute trauma. For example, approximately 10% of penetrating cervical trauma cases lead to difficulty in establishing an airway. This situation is often a result of injury to major vessels of the neck causing an expanding hematoma at the level of the airway. Also, in cases of blunt facial trauma, the primary cause of death is airway obstruction. Such airway obstruction may occur because of hypopharyngeal obstruction from mandible fractures or aspiration of blood after uncontrolled facial bleeding. Loss of the airway may alternatively occur during planned, elective intubations or sedations. Such situations often are a result of difficult patient anatomy (short, obese neck) or a disease state such as retropharyngeal abscess, vocal cord paralysis, or laryngeal edema. According to one study, of all clinical situations using cricothyrotomy, 32% involved blood or vomitus in the airway, 32% facial fractures, 11% failed intubation in the absence of other specific problems, and 7% involved traumatic airway obstruction. There is no fail-safe method of predicting which patients will be more difficult to intubate or ventilate. However, as part of a preoperative anesthesia assessment, an airway history should be conducted to elicit medical, surgical, and anesthetic risk factors. Furthermore, an airway physical examination should be conducted, whenever feasible, before the initiation of anesthetic care and airway management ( Table 1 ).

Cricothyrotomy is generally preferred over tracheotomy for emergency airway access. Anatomic considerations are largely the reason for an up to 5-fold increase in complications with emergency tracheotomy over elective tracheotomy. Access to the trachea is more caudal than with the cricothyroid membrane, and therefore complications such as pneumothorax and mediastinal perforation are more likely to occur when using emergency tracheotomy rather than cricothyrotomy. Also, unlike the laryngeal and cricoid cartilages, the tracheal cartilage is absent posteriorly. Thus, damage to the esophagus and posterior tracheal wall is more likely in an emergent tracheotomy than in a cricothyrotomy.

General contraindications and precautions

There are few absolute contraindications to cricothyrotomy. However, a few notable exceptions exist. For example, the procedure is contraindicated when a complete or partial transection of the airway exists. Also, cricothyrotomy should not be performed in cases of significant injury to the cricoid cartilage or a severely fractured larynx. In all of these cases the airway should be accessed below the injury, and a tracheostomy would be the preferred method to secure the airway.

Emergency cricothyrotomy is generally contraindicated in neonates and younger children. The age cutoff varies in the literature; in practice, multiple factors such as size and weight, anatomic variables, and injury/illness will help determine what technique is utilized. However, a general upper age limit is 10 to 12 years. In the younger pediatric population, cricothyrotomy can damage the cricoid cartilage and lead to subsequent sublgottic stenosis. Because the pediatric airway is funnel shaped, with the narrowest airway diameter located at the cricoid ring, even a minor amount of stenosis can cause significant airflow impairment. Therefore, needle cricothyrotomy should be considered the emergency treatment of choice in the pediatric population.

General contraindications and precautions

There are few absolute contraindications to cricothyrotomy. However, a few notable exceptions exist. For example, the procedure is contraindicated when a complete or partial transection of the airway exists. Also, cricothyrotomy should not be performed in cases of significant injury to the cricoid cartilage or a severely fractured larynx. In all of these cases the airway should be accessed below the injury, and a tracheostomy would be the preferred method to secure the airway.

Emergency cricothyrotomy is generally contraindicated in neonates and younger children. The age cutoff varies in the literature; in practice, multiple factors such as size and weight, anatomic variables, and injury/illness will help determine what technique is utilized. However, a general upper age limit is 10 to 12 years. In the younger pediatric population, cricothyrotomy can damage the cricoid cartilage and lead to subsequent sublgottic stenosis. Because the pediatric airway is funnel shaped, with the narrowest airway diameter located at the cricoid ring, even a minor amount of stenosis can cause significant airflow impairment. Therefore, needle cricothyrotomy should be considered the emergency treatment of choice in the pediatric population.