Cricothyrotomy
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In cricothyrotomy, the incision or puncture is made through the cricothyroid membrane in between the thyroid cartilage and the cricoid cartilage.

A cricothyrotomy (also called thyrocricotomy, cricothyroidotomy, inferior laryngotomy, intercricothyrotomy, coniotomy or emergency airway puncture) is an emergency incision through the skin and cricothyroid membrane to secure a patient's airway during certain emergency situations, such as an airway obstructed by a foreign object or swelling, a patient who is not able to breathe adequately on their own, or in cases of major facial trauma which prevent an airway through the mouth. A cricothyrotomy is usually performed by emergency physicians, trauma surgeons, or paramedics as a last resort when control of the airway by usual means (an endotracheal tube through the mouth) have failed or are not feasible. This technique is considered easier and faster than a tracheostomy, but is only used when oral or nasal intubation is not possible in the patient. This procedure does not require manipulation of the cervical spine. However, it does require special training and authorization from local medical direction prior to being performed, dependending on local medical protocols.

Indications

• Severe facial or nasal injuries (that do not allow oral or nasal intubation)
• Massive midfacial trauma
• Possible spinal trauma preventing adequate ventilation
• Anaphylaxis
• Chemical inhalating injuries

Contraindications

• Inability to identify landmarks (cricothyroid membrane)
• Underlying anatomical abnormality (tumor)
• Tracheal transection
• Acute laryngeal disease by infection or trauma
• Small children under 10 years old (a 12-14 gauge catheter over the needle may be safer)

Procedure

The procedure was first described in 1805 by Vicq d'Azyr, a French surgeon and anatomist. A cricothyrotomy is generally performed by making an incision on the skin of the neck just below the "Adam's apple", or thyroid cartilage, then making another incision in the cricothyroid membrane which lies deep to this point. One then inserts a tube into this opening, which allows one to breathe for the patient with a machine or bag.

Summarized technique

1. With a scalpel, create a 2 cm horizontal incision through the cricothyroid membrane
2. Open the hole by rotating the scalpel 90 degrees or by using a clamp
3. Insert a size 6 or 7 endotracheal tube or tracheostomy tube
4. Inflate the cuff and secure the tube
5. Provide venilation via a bag-valve device with the highest available concentration of oxygen
6. Determine if ventilation was successful (bilateral ausculation and observing chest rise and fall)
7. No attempt should be made to remove the endotracheal tube in a prehospital setting.

Cricothyrotomy in popular media

Lists of miscellaneous information should be avoided. Please relocate any relevant information into appropriate sections or articles. (July 2007)

On the TV show M*A*S*H, Father Mulcahy performs an emergency cricothyrotomy on a patient. With the direction of Dr. Pierce via radio, he uses a pen knife and an eye dropper to perform the operation. Needless to say, this would be extremely dangerous in real life. Even under ideal, clinical conditions, a cricothyrotomy is difficult and requires specific tools, preparation and a practiced knowledge of anatomy. There are many major blood vessels and nerves in the neck and cutting there, even with the best of intentions carries a high risk of harming the patient. For that reason, among others, it is illegal to attempt to perform a cricothyrotomy without a medical license.^{where?citation needed}

In the 1980 Nicolas Roeg film "Bad Timing," Theresa Russell's character Milena Flaherty has an emergency cricothyrotomy performed following an intentional overdose.

In Grey's Anatomy, emergency cricothyrotomy is mentioned in at least two episodes:

• In “Owner of a Lonely Heart,” Cristina almost performs an emergency cricothyrotomy on a patient who swallowed a light bulb. Before she is able to do so, however, Dr. Burke shows up and takes the patient to an operating room where he proceeds to perform an emergency throacotomy.
• In “The Heart of the Matter,” Izzie performs her first “emergency crike” on Camille, a niece of Chief of Surgery Dr. Richard Webber.

In the ER episode, "Reason to Believe" Dr. Kerry Weaver performs an emergency cricothyrotomy on a student. She is shooting a news segment on childhood obesity in an elementary school cafeteria when one of the students begins to choke; after the heimlich maneuver fails, she performs a cricothyrotomy with a kitchen knife and a drinking straw.

In the movie, "Playing God" (1997), David Duchovny plays a famed LA surgeon, stripped of his license due to drug abuse, who finds himself witnessesing a gun fight at a bar. He saves a mafia crime figure by performing an emergency Cricothyrotomy. This endears him with the mafia family and drives the plot forward.

See also

• Laryngotomy
• Tracheotomy

References

External links

• Drawing of a cricothyrotomy
• Smiths Medical (Cricothyroidotomy products for Adults and Children)
• Medstudents: Procedures: Cricothyrotomy