Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
A surgical airway procedure is indicated when other forms of endotracheal intubation have failed and ventilation is worsening or not possible. This is the feared "can't intubate, can't ventilate" scenario, and in the emergency setting, cricothyrotomy is the surgical procedure of choice.
Cricothyrotomy is preferred over tracheotomy because of the lower risk of complications, the predictable anatomy of the cricothyroid membrane, and the comparative rapidity with which the procedure can be performed—even by less experienced practitioners. Cricothyrotomy traditionally has been done in an "open" form; however, percutaneous cricothyrotomy using standard Seldinger technique has been advanced as a more successful approach when identification of the relevant anatomic landmarks is more difficult. Seldinger technique involves the introduction of a device into the body through the use of an introducer needle and a guide wire. The needle is used to locate the target; a guide wire is then fed through the thin-walled needle into the target, acting as a "placeholder" for the device, which is fed over the guide wire and into the target.
In the case of percutaneous cricothyrotomy, the practitioner first identifies the cricothyroid membrane by physical landmarks and makes a small vertical skin incision. A thin-walled 18-gauge needle (attached to a syringe) pierces the membrane, and the airway is positively identified when air is aspirated in the syringe. A guide wire is then fed through the needle. Standard cricothyrotomy sets include an airway catheter (similar to a tracheostomy tube) with a stiff dilator within its lumen. The catheter/dilator combination is fed onto the guide wire and the catheter/dilator is placed within the airway. The dilator and guide wire are subsequently removed, and the catheter is attached to a bag-valve device for ventilation.
1. Patient positioning and preparation for the procedure
- The patient in this situation has likely undergone attempted endotracheal intubation and should already be lying supine.
- Extend the patient's neck to better assess anatomic landmarks.
- The cricothyroid membrane is located below the laryngeal prominence ("Adam's apple") and is palpated as a soft indentation in the midline on the anterior neck. The superior thyroid arteries anastomose in the midline inferior to the cricothyroid membrane. The thyroid gland is located inferior to the superior thyroid arteries
- Gather supplies, including chlorhexidine, a needle cricothyrotomy kit, and airway management supplies (bag-valve-mask device, supplemental oxygen, and suction).
- There are several pre-packaged percutaneous cricothyrotomy kits available. Standard kits include an introducer needle, a 5mL syringe, a scalpel, a guide wire, a dilator, and an airway catheter, which may be cuffed or uncuffed.
- Open the needle cricothyrotomy kit and attach the introducer needle to the syringe. Assemble the airway catheter/dilator, prepare the guide wire, and lay out the scalpel for easy access
The context of this procedure is often the truly emergent situation. In this event, there may not be time for local anesthesia (if the patient is awake) or skin preparation with chlorhexidine. As with all emergent procedures, true sterile technique is sacrificed for rapidity. For example, it is unlikely that the situation that calls for an emergent cricothyrotomy would allow for sterile gowning and gloving.
- Stand at the head of the bed and identify the patient's anatomy by palpating the laryngeal prominence and moving your fingers inferiorly into the depression below, the cricothyroid membrane.
- Grab the paratracheal structures and move them around to be certain you can identify the midline. They will move as a unit. It is in the midline of this depression that the practitioner will make the incision and insert the needle.
- If time allows, the area should be cleaned with chlorhexidine. Ideally, the exam gloves that the practitioner is wearing should be traded for sterile gloves.
- Make a small (5mm) vertical incision with the scalpel in the midline previously identified.
- Advance the introducer needle into the neck through the skin incision and through the cricothyroid membrane at a 45° angle toward the patient's feet, withdrawing on the plunger as you advance.
- When the needle enters into the airway, you will be able to aspirate air. Note that some practitioners prefer to have 2-3 cc saline in the syringe prior to attaching the needle, to aid in identifying the aspiration of air by creating bubbles when the plunger is withdrawn.
- Remove the syringe from the needle, taking care to keep the needle within the air-filled lumen identified. This is best done by bracing the hand against the patient's neck, so that there is no migration of the needle tip.
- Advance the guide wire through the needle approximately 15 cm, so that the guide wire is well within the airway.
- Remove the needle, keeping the guide wire in place
- Thread the catheter/dilator assembly over the distal end of the guide wire, and advance along the wire
- Push the catheter/dilator assembly through the skin, anatomically oriented with the airway such that the curve of the catheter matches the curve needed from its entry point into the trachea. Keep pushing until the catheter is fully in place, which means the plastic flange is against the neck.
- If the catheter is cuffed, fill cuff with air by injecting several milliliters of air into it. Typically 10 mL of air is required. Check the pilot balloon to be sure the cuff is inflated.
- Remove the dilator and wire from the assembly
- Attach the catheter to the bag-valve manual resuscitator; auscultate for breath sounds, monitor end-tidal CO2, and obtain chest X-ray
- Secure airway catheter with appropriate necktie.
3. Alternative approach for percutaneous cricothyrotomy using Seldinger technique if pre-assembled kit is unavailable
- Place the patient in supine position as above, with the neck extended.
- Open central venous catheter tray. Separate out the 5 mL syringe, the introducer needle, the guide wire, and the scalpel.
- Gather a tracheostomy tube.
- Attach the introducer needle to an empty 5mL syringe (again, adding water to the syringe first is unnecessary and not advocated by this author).
- Prepare the guide wire by retracting it in its sheath and straightening out the J tip.
- Prepare the neck with chlorhexidine if time allows
- Identify the laryngeal prominence and palpate the depression just caudal to this, the cricothyroid membrane.
- Grab the laryngeal structures as a unit to be certain the midline is identified.
- From your position at the head of the bed, advance the introducer needle into the patient's neck, at the point just identified as the cricothyroid membrane. The needle is directed at a 45° angle from the horizontal, in a caudal direction, applying gentle pressure to the plunger of the syringe.
- Once air is easily aspirated into the syringe, the airway has been identified.
- Holding the needle steady with your non-dominant hand, remove the syringe with your dominant hand.
- Advance the guide wire through the introducer needle, to a depth of 15 cm
- With a #11 scalpel blade, make a 2 cm horizontal incision at the level of the needle. This incision is a complete incision, through both skin and cricothyroid membrane, a depth of approximately 2 cm.
- The needle is removed with the guide wire left in place
- Prior to advancing the tracheostomy tube through the neck, it will help if the incision made by the scalpel is dilated open. This can be facilitated with the handle of the scalpel.
- Retract the blade of the scalpel and advance the handle of the scalpel through the incision
- With the handle firmly in the incision, rotate the handle 90° so the handle is oriented parallel with the patient's neck and perpendicular to the horizontal incision. This will hold the incision aperture open and allow for easier passage of the tracheostomy tube.
- Advance the tracheostomy tube over the guide wire. This will assure that the tube follows the correct tract into the airway previously identified by the syringe with air aspiration.
- Advance the tracheostomy tube into position.
- Remove the guide wire.
- Inflate cuff of tracheostomy tube (if cuffed).
- Attach to appropriate ventilator device as above and secure with neckties.
Cricothyrotomy is a surgical airway procedure indicated when other forms of endotracheal intubation have failed and patient ventilation is declining or not possible.
The two forms of this procedure are open or surgical cricothyrotomy - discussed in a different video - and percutaneous cricothyrotomy, which will be discussed here. The latter is the method of choice for many practitioners especially when identification of the relevant anatomic landmarks is more difficult, such as in the patients with short neck and excessive soft tissue.
In this presentation, we will outline how to conduct the percutaneous cricothyrotomy procedure using a pre-packaged kit and when kit is not available.
Start by gathering the necessary supplies for the procedure including: chlorhexadine, a bag valve mask device, suction and oxygen supply equipment, and the pre-packaged percutaneous cricothyrotomy kit. A standard pre-packaged kit should include: a 18 gauge introducer needle, a 5 milliliter syringe, scalpel, guide wire, a dilator, an airway catheter and a neck-tie.
After opening the kit, attach the introducer needle to the syringe, make sure that the catheter and dilator are assembled, and lay out the guidewire and scalpel for easy access. The patient in this situation has likely undergone attempted endotracheal intubation and should already be lying supine. Stand at the patient's head, extend the neck (2.4.2) and palpate to locate the cricothyroid membrane. This membrane is located below the laryngeal prominence -- the "Adam's Apple". After locating the membrane, grab the paratracheal structures and move them around. They will move as a unit and create a depression. The needle insertion landmark is in the midline of this depression. If time allows, the area should be cleaned with chlorhexadine, and ideally, the exam gloves should be traded for sterile gloves. However, as with all emergent procedures, true sterile technique may be sacrificed for rapidity.
Make a small 5-millimeter vertical incision with the scalpel at the identified midline. Then, advance the introducer needle at a 45° angle into the incision and through the cricothyroid membrane toward the patient's feet. Withdraw on the plunger while advancing the needle. When the needle enters into the airway, you will be able to aspirate air easily. Next, brace your hand against the patient's neck and remove the syringe from the needle. Be sure to keep the needle opening within the air filled lumen.
Now, advance the guidewire through the needle approximately 15 centimeters to assure the wire is well within the airway. Then, remove the needle, keeping the guidewire in place. Next, thread the catheter-dilator assembly over the wire and push it through the patient's skin. While doing so, anatomically orient the device with the airway such the curve of the catheter matches the curve needed from its entry point into the trachea. Keep pushing until the catheter is fully in place -- that is till the plastic flange is against the patient's neck. Next, remove the dilator and the wire from the assembly and attach the catheter to the bag-valve manual resuscitator. Confirm correct placement by auscultating for breath sounds, and monitoring the end tidal CO2 -- the normal range for which is 35-45 mmHg.
Finally, secure the airway catheter with appropriate necktie.
Now let's review how to conduct the percutaneous cricothyrotomy procedure without a kit, which is not ideal, but may be the most preferable option in an emergency situation.
For supplies, open the central venous catheter tray and remove the following items : a 5-milliliter syringe, an introducer needle, a guidewire, and a scalpel. In addition, obtain a tracheostomy tube .
Attach the introducer needle to the empty 5-milliliter syringe. Then, prepare the guidewire by retracting it in its sheath and straightening out the J tip. Locate the cricothyroid membrane by palpating as shown previously and prep the neck with chlorhexadine if time allows. Grab the laryngeal structures as a unit to be certain that the midline is identified. Next, while applying gentle pressure to the plunger, advance the introducer needle at a 45° angle in caudal direction. Once the needle tip reaches the trachea, air can be easily aspirated into the syringe. Now, with your non-dominant hand, hold the needle steady and remove the syringe with your dominant hand. Then advance the guide wire 15 centimeters through the introducer needle. Next, with a number 11-scalpel blade make a horizontal incision at the level of the needle -- approximately 2 centimeter in length and 2 cm deep --, cutting through the skin and cricothyroid membrane. Now, remove the needle and leave the guidewire in place and load the tracheostomy tube onto the guidewire.
Next, to dilate the incision open, retract the scalpel blade and advance the handle of the scalpel through the incision. With the handle is firmly inside the incision, rotate it by 90° so that it is oriented parallel with the patient's neck and perpendicular to the horizontal incision. This will hold the aperture open and allow for easier passage of the tracheostomy tube. Advance the tube over the guidewire and through the opening created by the scalpel handle. This will assure that the tube follows the correct tract into the airway. After the tube is in position, remove the guide wire, attach the tube to the ventilator device and secure it in place with neckties.
Cricothyrotomy is a critical and life saving procedure. The decision to place a surgical airway must be made quickly, and the procedure itself should be completed in less than a minute. The procedure shown in this video on percutaneous cricothyrotomy using the Seldinger technique has been advocated over open cricothyrotomy, because of the potential for bleeding with open cricothyrotomy.
A major advantage of using a needle to locate the airway is that if the cricothyroid membrane is not encountered with the first needle insertion, the location may be re-adjusted and there is less likely to be a life threatening complication.
On the contrary, the open cricothyrotomy procedure relies on identification of the cricothyroid membrane and airway by visual inspection after a vertical incision is made with a scalpel. If there is a hemorrhage, visualization can become impossible. Furthermore, in the obese and in those with otherwise poor anatomic landmarks, identifying midline can be a challenge.
You have just watched a JoVE video demonstrating the percutaneous cricothyrotomy procedure, with and without a pre-packaged kit. As always, thanks for watching!
Applications and Summary
Percutaneous cricothyrotomy using Seldinger technique is a critical and life saving procedure. It was first described by Melker and is also referred to as "Melker technique." The decision to place a surgical airway must be made quickly. The procedure itself should be completed in less than a minute. Percutaneous cricothyrotomy with needle and guide wire has been advocated over open cricothyrotomy because the potential complications in an open cricothyrotomy can prove disastrous for the patient.
The benefit of Seldinger technique in performing cricothyrotomy is that the airway is located with a needle, and its access is "held" with the guide wire until the airway catheter is in place. If the cricothyroid membrane is not encountered with the first needle insertion, the location may be re-adjusted and there is less likely to be a life-threatening complication than if the location were misidentified with a scalpel blade. An open cricothyrotomy, by contrast, relies on identification of the cricothyroid membrane and airway by visual inspection after a vertical incision is made with a scalpel. In the event of hemorrhage, visualization can become impossible. Additionally, in obese patients and those with otherwise poor anatomic landmarks, identifying the midline can be a challenge.
Although there are a variety of commercially available percutaneous cricothyrotomy kits, this technique can be done easily with supplies commonly found in the emergency department. There are many procedures that rely on Seldinger technique. A central venous catheter kit could be utilized, for example. It should be noted that other versions of this technique have been described. Some feel that identification of the airway using a needle without the subsequent use of Seldinger technique is the best strategy, combining elements of open cricothyrotomy and needle identification of the airway.