Introduction
Cricothyrotomy, also known as cricothyroidotomy or emergency tracheotomy, is a life-saving surgical procedure performed to establish an airway during situations where conventional methods such as intubation are not feasible. This guide will cover the indications, contraindications, equipment, procedural steps, and aftercare for performing a cricothyrotomy.
Indications
Cricothyrotomy is indicated in situations where other airway management techniques have failed or are not possible. These include:
- Severe facial trauma obstructing the airway
- Massive hemorrhage in the oropharynx
- Foreign body obstruction not removable by other means
- Angioedema or anaphylaxis causing complete airway obstruction
- Inability to intubate due to anatomical abnormalities
Contraindications
While cricothyrotomy can be lifesaving, there are certain contraindications, such as:
- Children under the age of 12 (due to the small size of the cricothyroid membrane)
- Patients with laryngeal trauma that might further complicate the procedure
- Severe coagulopathy, increasing the risk of bleeding complications
Equipment
The following equipment is essential for performing a cricothyrotomy:
- Scalpel with a #10 or #11 blade
- Tracheostomy tube or endotracheal tube (size 6-7 for adults)
- Curved hemostat or tracheal hook
- Antiseptic solution (e.g., povidone-iodine)
- Suction apparatus
- Syringe for inflating the tube cuff
- Local anesthetic (if time permits)
- Personal protective equipment (gloves, mask, etc.)
Procedural Steps
Preparation
1. Ensure that all equipment is readily available and that the patient is positioned supine with the neck slightly extended.
2. Identify the cricothyroid membrane by palpating the thyroid cartilage (Adam’s apple) and moving downward to the cricoid cartilage. The membrane is located between these structures.
3. Clean the area with an antiseptic solution.
Incision
1. Stabilize the larynx with one hand.
2. Use the scalpel to make a horizontal incision approximately 1.5 to 2 cm in length through the skin and cricothyroid membrane.
3. Extend the incision vertically if necessary to expose the underlying structures clearly.
Establishing the Airway
1. Insert the curved hemostat or tracheal hook into the incision to keep it open.
2. Insert the tracheostomy tube or endotracheal tube into the trachea through the incision.
3. Remove the hemostat or hook and stabilize the tube in place.
Securing the Airway
1. Inflate the cuff of the tracheostomy or endotracheal tube with a syringe to ensure a seal.
2. Connect the tube to a bag-valve mask or ventilator to provide ventilation.
3. Secure the tube with sutures or adhesive tape to prevent dislodgement.
Aftercare
After performing a cricothyrotomy, continuous monitoring and care are essential:
- Monitor the patient’s oxygenation and ventilation closely.
- Regularly check the tube for patency and secure positioning.
- Provide humidified oxygen to prevent drying of the airway.
- Prepare for potential complications such as bleeding, infection, or subcutaneous emphysema.
- Arrange for definitive airway management and surgical follow-up as needed.
Potential Complications
Complications, although rare, can occur and include:
- Hemorrhage from the incision site
- Infection at the incision site
- Subcutaneous or mediastinal emphysema
- Damage to surrounding structures such as the thyroid gland or vocal cords
- Tube dislodgement or blockage
Nursing Care of Patient with Cricothyrotomy Procedure
Cricothyrotomy is an emergency surgical procedure performed to establish an airway during critical situations where other methods of securing the airway are ineffective. The involvement of nursing care is crucial in managing the patient post-procedure to ensure proper healing and prevent complications.
Immediate Post-operative Care
- Monitor vital signs closely, including oxygen saturation, respiratory rate, and heart rate.
- Observe the incision site for signs of bleeding, swelling, or infection.
- Ensure the airway is patent and the tube is securely in place.
- Provide humidified oxygen to prevent drying of the airway.
- Assess for signs of subcutaneous or mediastinal emphysema, indicated by swelling or crepitus around the neck and chest area.
Ongoing Patient Monitoring
- Regularly check the tube for patency and clear any obstructions.
- Monitor for any signs of tube dislodgement or blockage, such as difficulty breathing or decreased oxygen saturation.
- Assess the patient for pain and provide appropriate pain management as needed.
- Observe for signs of infection, including redness, warmth, or discharge from the incision site.
- Encourage deep breathing and coughing exercises to prevent atelectasis.
Potential Complications
Complications, although rare, can occur and include:
- Hemorrhage from the incision site
- Infection at the incision site
- Subcutaneous or mediastinal emphysema
- Damage to surrounding structures such as the thyroid gland or vocal cords
- Tube dislodgement or blockage
Nursing Interventions for Complications
- For hemorrhage: Apply direct pressure to the bleeding site and notify the surgical team immediately.
- For infection: Administer prescribed antibiotics and maintain strict aseptic technique when caring for the incision site.
- For subcutaneous or mediastinal emphysema: Monitor the extent of swelling and crepitus, and report any significant changes to the physician.
- For damage to surrounding structures: Assess the patient’s voice and swallowing function, and report any abnormalities.
- For tube dislodgement or blockage: Prepare to reinsert the tube or provide an alternative airway management method as necessary.
Long-term Care and Follow-up
- Arrange for definitive airway management and surgical follow-up as needed.
- Educate the patient and family on signs and symptoms of complications to watch for.
- Ensure the patient has access to necessary medical supplies and follow-up appointments.
REFERENCES
- McMahon K, Tariq A, Morley EJ. Cricothyroidotomy. [Updated 2025 Apr 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537350/
- Hill, C, Reardon, R, Joing, S, et al. 2010. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med. 17: 666–669. PMID: 20491685
- Quick, JA, MacIntyre, AD, and Barnes, SL. 2014. Emergent surgical airway: comparison of the three-step method and conventional cricothyroidotomy utilizing high-fidelity simulation. J Emerg Med. 46: 304–307. PMID: 24188608
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