Cricothyroidotomy

Emergency Cricothyroidotomy

• Horizontal stab incision between the Cricoid and Thyroid Cartilages
• Structures encountered: Skin, platysma, investing layer of deep cervical fascia and Cricothyroid Membrane
• Principles
  • Aseptic equipment if possible
  • Quick prep of the neck and some sterile gloves.
  • Positioned with their neck extended as much as possible
• Open procedure
  • 2-3 cm midline vertical skinned incision
    • centered over the cricothyroid membrane
    • midline incision avoids the anterior jugular veins and bleeding from those.
  • Dissecting sharply to the cricothyroid membrane and pierce this with my scalpel
  • Artery clip or similar clamp to insert it into the cricothyroid membrane and dilate
  • Place a small ET tube of size 5 or 6 directly into the airway.
• Scalpel bugie technique
  • Identify cricothyroid membrane and stabilise with nondominant (ND) hand
  • With scalpel in dominant (D) hand make a horizontal stab incision through cricothyroid
  • membrane
  • Rotate blade through 90 so that the blade points caudally
  • Pull scalpel towards you, maintain perpendicularity producing a triangular hole
  • Switch hands so that the ND hand now stabilises the scalpel
  • With the bougie pointing away and parallel to the floor, insert tip into trachea using the blade as a guide
  • Rotate and align bougie to allow insertion along the line of the trachea
  • Reoxygenate via bougie with jet ventilator
  • Railroad lubricated 6.0 ETT (remove 15-mm connector to aid passage over bougie).
  • Continually rotate tube to facilitate placement
  • Remove bougie
  • Reattach 15-mm connector and ventilate via circuit
  • Secure tube and check bilateral ventilation

Tracheostomy

Preparation

• Review indications and imaging
• Consent patient
• GA, ivabx
• Position supine on shoulder roll with head ring, neck + head extended
• Mark thyroid and cricoid cartilages, midline, suprasternal notch

Surgery

• Horizontal incision over trachea
• Raise subplatysmal flaps and retract with 2x Joll’s retractors
• Separate straps in midline
• Divide isthmus of thyroid and ligate with 3-0 vicryl
• Use tracheal tenaculum hook in cricoid cartilage to retract superiorly to better expose trachea Identify 2nd and 3rd tracheal rings
• Ask anaesthetics to turn down O2 as much as possible and deflate ETT balloon
• Incise tracheal rings vertically and horizontal above to raise inferior Bjork flap–hold up and open with a hook retractor.
• Suture flap to skin with silk sutures
• Ask anaesthesia to withdraw ETT until end can be seen just above level of tracheotomy
• Immediately place tracheostomy tube with obturator
• Inflate cuff, and swap ventilator tubing onto tube
• Check misting + CO2
• Haemostasis
• Layered closure with absorbable sutures, suture tracheostomy cuff to neck and secure with tie around neck

Postop

• Confirm adequacy of ventilation by checking CO2, chest rise, auscultate

• Haemostasis

• Regular suction

• Plan for trache removal/permanence

• Indications for Surgical Airway in trauma

  • Laryngeal #
  • Penetrating throat and neck injuries
  • Severe maxfax injuries with bleeding, deformity, oedema
  • Airway burns/inhalation injuries
  • Can’t intubate can’t ventilate

• Complications

• Immediate complications

  • Airway loss
  • Bleeding
    • Can be anterior jugular, carotid, IJV, innominate, isthmus of the thyroid.
  • Air leak
    • subcutaneous emphysema
  • Tube falling ou

• Late complications

  • Lack of spontaneous closure or healing of the tracheostomy once it’s removed
    • Requiring surgical repair
  • Infection
  • Scarring
  • Erode into large veins
    • Inominate vein
      • Can have herald bleed just prior to life-threatening hemorrhage.
      • Iinsert a gloved finger into the tracheostomy stoma and occlude the vessel against the sternum and call for help.
  • Tracheosophageal fistula
  • Tracheal stenosis.