Surgical Airways
Introduction
- For children <12 yo; especially under 8yo, tracheostomy is preferred
- Higher risk of damage to larynx in cricothyrotomy
- Compressible structures and less distinction between cartilages
- Unfortunately, many Emerg docs are not trained in this so percutaneous needle cricothyrotomy for oxygenation/ventilation while awaiting tracheostomy may be the best course of action
- Difficulty establishing an airway occurs in 10% of penetrating neck trauma
- If the trachea or larynx is disrupted, DO NOT attempt cricothyrotomy
- Emergency tracheostomy is required
- Any tube can be used but tracheostomy tube preferred as easier to secure and maintain in correct position
- 6mm or 6.0-7.0mm ET
- Vascular structure most at risk is a thyroid artery, branching off aorta and running superiorly in midline and rarely reaching the cricothyroid membrane
Indications
Traditional indication is CICO event
Can be plan A if any attempt at oral intubation and RSI poses too greater risk
Can be performed after RSI attempt (CICO), could be done under procedural sedation (e.g. ketamine + propofol) if plan A or could be done awake under local anaesthetic
Planning
If right-handed, usually stand on right-side of patient
Someone needs to manage the oral airway also
Can continue to attempt ventilation from top end while performing this procedure
Techniques
- Jet insufflation
- Perc tracheostomy
- Surgical cricothyrotomy (recommended as first-line in ED)
Complications
- Acute complications seen in 15% of cases
- Venous bleeding usually stops spontaneously
- Using a short vertical neck incision decreases the chance of ongoing bleeding
- If significant bleeding – gentle pressure, topical haemostatic agents or ligation may be necessary
- Misplacement anterior to the trachea (in obese patients) and into the mediastinum
- Curling of ET towards the mouth
- Laceration of trachea/oesophagus/recurrent laryngeal nerves is rare
- Pneumothorax
- Long-term use of cricothyroidotomy risks bacterial chondritis leading to stenosis and loss of laryngeal function
- Change to tracheostomy within 2-3 days
Jet insufflation
- This is the only small catheter option
- Need correct high-pressure equipment prepared ahead of time
- Small catheter with pressured oxygen source (35-50psi)
- Provides volume inhalation and native airway is the passive exhalation route
- With proper jet venilation, both oxygenation and ventilation can occur
- Duration limited by airway dessication from non-humidified gases (hours to days)
- High pressure dissipates rapidly and so harm to lower airways is minimal
- Absolutely contraindicated in complete expiratory airway obstruction
- Exceptionally rare as most airway obstruction is only inspiratory
- Complications
- Failure to properly secure the catheter
- Kinking of catheter
- Perforation of oesophagus or larynx is rare
- Massive subcutaneous emphysema
- Rarely causes long-term airway complications as opposed to cricothyrotomy
- Brands
- Manujet
- Ventrain
Perc Tracheostomy
Seldinger technique with needle insertion (using saline-filled syringe to recognise air bubbles) through cricothyroid membrane or trachea, guidewire, skin incision, all-in-one dilator/tracheostomy and wire removal
Most attempts at this failed in NAP-4 review
Surgical cricothyrotomy
Recommended as first-line procedure in CICO event in ED
Equipment
- Scalpel
- Tracheal hook (optional)
- Bougie
- 6.0mm ETT
- Syringe
Procedure
- Palpate cricothyroid membrane
- Horizontal stab incision through to trachea in midline
- Extend incision laterally each way ~2cm total
- Insert tracheal hook at head end of incision (optional) and remove scalpel
- Insert bougie aiming down towards lungs
- Pass ETT over bougie
- Remove bougie
- Inflate cuff
- Secure
Troubleshooting
- In the obese or significant anatomical changes in the neck, may require longer vertical incision over cricothyroid region to be able to palpate the membrane itself which can then be incised horizontally
Last Updated on August 30, 2024 by Andrew Crofton