TY - JOUR
AU1 - USA, William G. Huber, MC
AU2 - USA, Marc H. Dahman, MC
AU3 - USA, Deanna Thomas, DC
AU4 - USA, Joshua H. Lipschutz, MC
AB - ABSTRACT By the time a cricothyroidotomy is deemed necessary, the patient is in critical need of an emergency airway before anoxic damage ensues. Two things are necessary for the delivery of the requisite oxygen. First, an airway must be rapidly established. Second, the airway must be large enough to facilitate ventilation. Present methods for emergency cricothyroidotomy include needle cricothyroidotomy, which suffers from difficulties in both establishment and ventilation. We describe here a practical and widely available method for establishing a timely effective airway that has been used successfully for five patients since 1992. Introduction The earliest surgical technique for obtaining an alternate airway was the tracheostomy. This procedure was portrayed on Egyptian tablets as early as 3600 BCE.1,–3 A more modern advance was surgical cricothyroidotomy.4 Needle cricothyroidotomy, which is much easier to perform than surgical cricothyroidotomy, involves the insertion of an intravenous catheter through the cricothyroid membrane; however, needle cricothyroidotomy is greatly inferior to surgical cricothyroidotomy in providing adequate ventilation because of the small diameter of the intravenous catheter, which limits airflow.5 For this reason, needle cricothyroidotomy is considered an emergency procedure that should be used for only 15 to 45 minutes until a more permanent airway can be established through surgical cricothyroidotomy, endotracheal intubation, or tracheostomy.5,6 Although others have attempted to improve the procedure,7 needle cricothyroidotomy, as shown in Figure 1, remains the current recommended modality for establishing an emergency airway when standard endotracheal intubation or surgical cricothyroidotomy cannot be performed.5 After needle placement, intermittent jet insufflation is necessary. Intermittent jet insufflation is accomplished by generating a small hole in the tubing, covering the hole and insufflating for 1 second, and then releasing the occlusion for 4 seconds. To achieve the required high pressure (50 psi), it is best to use a jet injector regulated by a flowmeter attached to a wall unit on a tank.5 It is important to note that the precise combination of components shown in Figure 1 must be used. For example, the body from a 10-mL syringe will not connect to the adaptor from the endotracheal tube. As shown in Figure 2, the cricothyroidotomy apparatus that we describe in this article can be simply generated and rapidly used. Jet insufflation is not necessary for adequate ventilation. The technique that we describe is at least as simple as needle cricothyroidotomy to use and provides for much better ventilation. We suggest that this technique be used for adults instead of needle cricothyroidotomy. Fig. 1 View largeDownload slide Needle cricothyroidotomy apparatus. (A) The parent components necessary to assemble a needle cricothyroidotomy apparatus are shown. These include a 14-gauge intravenous catheter, a 3-mL syringe, and an endotracheal tube, from which the connector is obtained (arrow). (B) The actual components are shown separately. (C) A completely assembled cricothyroidotomy apparatus, attached to a ventilation system, is shown. It should be emphasized that only these components will fit together properly. Fig. 1 View largeDownload slide Needle cricothyroidotomy apparatus. (A) The parent components necessary to assemble a needle cricothyroidotomy apparatus are shown. These include a 14-gauge intravenous catheter, a 3-mL syringe, and an endotracheal tube, from which the connector is obtained (arrow). (B) The actual components are shown separately. (C) A completely assembled cricothyroidotomy apparatus, attached to a ventilation system, is shown. It should be emphasized that only these components will fit together properly. Fig. 2 View largeDownload slide Modified cricothyroidotomy apparatus. (A) Intravenous line tubing (e.g., injection site male Luer slip adaptor; Baxter Healthcare, Deerfield, Illinois) is widely available. To generate a cricothyroidotomy apparatus, the drip chamber is simply cut (dotted lines and arrow). (B) The ventilation system fits precisely over the cut drip chamber. Fig. 2 View largeDownload slide Modified cricothyroidotomy apparatus. (A) Intravenous line tubing (e.g., injection site male Luer slip adaptor; Baxter Healthcare, Deerfield, Illinois) is widely available. To generate a cricothyroidotomy apparatus, the drip chamber is simply cut (dotted lines and arrow). (B) The ventilation system fits precisely over the cut drip chamber. Technique Once it has been decided that an emergency airway is necessary, and endotracheal intubation is not possible, the following steps should be taken. First, a 0.5-inch horizontal incision should be made with a no. 11 scalpel over the cricothyroid membrane. The incision should be just through the skin and not too deep into the subcutaneous fat. This limits potential bleeding from the many vessels that traverse the region. Also, with deeper tissues not being dissected, the spike, when inserted, performs a tamponading function on directly adjacent tissue that might bleed. Second, with stabilization of the trachea between the index finger and the thumb, the spiked end of the intravenous tubing can be easily guided into the lumen of the trachea. The drip chamber of the intravenous tubing should be cut in half before the procedure is performed (Fig. 2). Third, the spike should be directed into the tracheal lumen at an ∼30° angle, thereby minimizing the risk of “backwalling” the trachea. It should be emphasized that tactile sensation is a crucial part of the procedure, and significant resistance may indicate that the tip of the spike is abutting a tracheal ring. This can be easily overcome by gently withdrawing a short distance and redirecting the tip superiorly or inferiorly. As long as the tip remains in the midline of the trachea, there is little fear of scathing the trachea laterally and entering the carotid sheath, which obviously would be a disastrous complication that would require an immediate neck exploration. Fourth, once the tip of the spike has come into contact with the trachea, the index finger and thumb can be readjusted to stabilize the shaft of the spike, to provide more-precise control as it enters the lumen of the trachea. Entry into the tracheal lumen is felt as a sudden reduction in resistance, and the angle of the spike should then be adjusted to the angle of the tracheal lumen. Fifth, after placement, the device needs to be stabilized in place, because it is prone to easy dislodgement, with resultant injury to the tracheal mucosa, during rapid transport and vigorous ventilation. Stabilization can be accomplished by improvising a “tracheostomy brace,” using umbilical tape or engineering tape. Also, the patient should be monitored for bleeding from the incision site, which can be easily controlled with gentle direct pressure or packing of a small piece of gauze into the defect adjacent to the spike. There is a potential risk of injuring the posterior tracheal wall and esophagus, as well as other adjacent structures, but this risk should be minimal with knowledge of the anatomy. It should be emphasized that this procedure is recommended for desperate situations, and we think that the benefits far outweigh the risks in such circumstances. This is a nonsterile procedure that can be performed on the battlefield, if necessary, and should be considered a bridge to a definitive airway. Finally, this procedure has never, to our knowledge, been performed on children, and we do not know at what age the trachea would be able to safely accommodate the spike. This is something that could be explored further in an animal laboratory. Case Reports Case 1 A 25-year-old Vietnamese woman was admitted and sent to the operating room for elective laparoscopy and hysteroscopy. She initially underwent uneventful induction using intravenously administered and inhaled agents; however, an airway could not be maintained after administration of a paralytic agent. This was most likely attributable to anatomic features (flat facies) and a collapse of the pharyngeal musculature, resulting in the patient being unable to be mask-ventilated or orally intubated after multiple attempts. At that point, the modified cricothyroidotomy was performed and a functional airway was established. The patient subsequently fared well. Case 2 A 16-year-old female patient was brought to the emergency department by paramedics after a motor vehicle accident. Head and facial trauma precluded nasal or oral intubation. Ventilation was unsuccessful because of the aforementioned injuries. The modified cricothyroidotomy was performed, and a functional airway was established. Ventilation was successful, although the patient later died as a result of her injuries. Case 3 A 35-year-old man was brought to the emergency department by paramedics after a motor vehicle accident. Head and facial trauma precluded nasal or oral intubation. The modified cricothyroidotomy was performed, and a functional airway was established. Ventilation was successful, and the patient was taken to the operating room. Case 4 A 40-year-old man was brought to the recovery room after a successful operation in which the initial intubation had been difficult. The patient was extubated but soon suffered respiratory arrest. The patient was unable to be mask-ventilated. Reintubation was attempted several times but was unsuccessful. A laryngeal mask airway was also attempted but was unsuccessful. At that point, the modified cricothyroidotomy was performed, and a functional airway was established. A formal tracheostomy was later performed; the patient fared well and was subsequently extubated. Case 5 A 45-year-old obese man with a heavy beard was brought to the operating room for repair of an inguinal hernia. He was paralyzed, but an airway could not be obtained after several attempts. The oral pharynx was too bloody for fiberoptic intubation; therefore, the modified cricothyroidotomy was performed, and a functional airway was established. The patient subsequently fared well. We suggest that male patients with difficult anatomic features should be clean-shaven before general anesthesia induction. Discussion For the establishment of a temporary emergency airway, needle cricothyroidotomy is currently recommended, although with the aforementioned caveat that needle cricothyroidotomy is greatly inferior to surgical cricothyroidotomy in providing adequate ventilation because of the small diameter of the intravenous catheter, which limits airflow.5,6 We calculated the relative resistance of the needle cricothyroidotomy apparatus (Fig. 1), compared to the apparatus that we describe (Fig. 2), by using Poiseuille's Law, that is, R = 8ln/πr4, where R is resistance, l is length, n is viscosity, and r is radius. The length of the 14-gauge catheter used in standard needle cricothyroidotomy (Fig. 1) is 30 mm and the radius is 0.8 mm, whereas the length of the cricothyroidotomy apparatus we describe (Fig. 2) is 48 mm and the radius is 1.875 mm. This means that the relative resistance (which is inversely proportional to airflow) in standard needle cricothyroidotomy is 18.9 times greater than that in the cricothyroidotomy apparatus we describe. As a practical exercise, we recommend assembling the standard needle cricothyroidotomy apparatus (Fig. 1) and the cricothyroidotomy apparatus described in Figure 2 and performing ventilation through a resuscitator bag. The difference in resistance will be immediately obvious. In addition, the cricothyroidotomy apparatus we describe here is easier and simpler to use than needle cricothyroidotomy and does not require jet insufflation, making it ideal for field use. We have successfully used this apparatus five times for patients of various body habitus, and we recommend this technique over the currently used needle cricothyroidotomy. Acknowledgments We thank the personnel of the Onwardi-Shondee Troop Medical Clinic at Camp Liberty, Iraq, C Company, 199th Forward Support Battalion, 256th Brigade Combat Team, and CPT Marc Levsky for their helpful comments and reading of the manuscript. References 1. Pahor AL Ear, nose and throat in ancient Egypt. J Laryngol Otol  1992; 106: 773– 9. Google Scholar CrossRef Search ADS PubMed  2. Stock CR What is past is prologue: a short history of the development of the tracheostomy. Ear Nose Throat J  1987; 66: 166– 9. Google Scholar PubMed  3. Sittig SE, Pringnitz JE Tracheostomy, evolution of an airway.  Available at http://www.tracheostomy.com/resources/articles/evolution.htm; accessed May 16, 2005. 4. Brantigan CO, Grow JBSr Cricothyroidotomy revisited, again. Ear Nose Throat J  1980; 59: 289– 95. Google Scholar PubMed  5. Tintinalli JE, Kelen GD, Stapczynski JS Surgical airway management. In: Emergency Medicine: A Comprehensive Study Guide , Ed 6, pp 119– 24. New York, NY, McGraw-Hill, 2004. 6. American College of Surgeons Advanced Trauma Life Support.  Chicago, IL, American College of Surgeons, 1997. 7. Benmeir P, Weinberg A, Kugel C, Shapira, SC Percutaneous thyrotracheotomy by means of a large bore needle [letter]. J Trauma  1995; 38: 465. Google Scholar CrossRef Search ADS PubMed  Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - Practical Advance in Obtaining an Emergency Airway via Cricothyroidotomy
JF - Military Medicine
DO - 10.7205/MILMED.172.5.504
DA - 2007-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/practical-advance-in-obtaining-an-emergency-airway-via-3qo4wFqqUD
SP - 504
EP - 506
VL - 172
IS - 5
DP - DeepDyve
ER -