- Supralaryngeal obstruction.
- Secure airway access.
- Prolonged intubation and mechanical ventilation.
- Inability to control secretions.
- Inability to obtain an oral or nasopharyngeal airway in a patient who requires emergent intubation.
- Severe facial or head and neck trauma.
- Acute loss of the airway due to supralaryngeal obstruction secondary to tumor, anaphylaxis, foreign body, trauma, or burn injury.
- Significant coagulopathy can be considered a relative contraindication because bleeding into the airway can be catastrophic.
- There are few contraindications to cricothyroidotomy in the emergent setting with a patient in extremis.
- The emergent circumstances under which cricothyroidotomy are considered typically preclude informed consent.
Expected Benefits (Tracheostomy)
- Provision of a secure airway and prevention of complications of prolonged oral or nasal intubation.
Potential Risks (Both Procedures)
- Surgical site infection.
- Tracheal stenosis (1.6–6%).
- Vocal cord injury.
- Subglottic stenosis.
- Tracheoesophageal fistula formation.
- Rates of complications and vocal cord injury are higher for emergent cricothyroidotomy as compared with elective tracheostomy.
- No special equipment is required, although a bronchoscope can be useful in some instances.
- Small self-retaining retractors are useful for exposing the operative field.
- If possible, patient preparation should include the use of a folded sheet, sandbag, or other supporting device placed transversely under the shoulders; this helps in extending the neck and exposing the operative area.
- Endotracheal intubation is also extremely useful to maintain the airway during the procedure.
- In emergent situations when the patient is in respiratory distress, there may not be any time for such preparations.
- Figure 45–1: The anatomy of the neck with pertinent landmarks.
- The location of the thyroid cartilage in relation to the cricoid cartilage and the trachea is shown.
- Incision for the tracheostomy is made either transversely or vertically, approximately 2 fingerbreadths above the sternal notch.
- An emergency cricothyroidotomy is performed between the thyroid cartilage and the cricoid cartilage.
- A vertical incision is preferred for emergency cricothyroidotomy to minimize bleeding secondary to venous laceration. Additionally, if the initial incision is off target, it is easier to extend a vertical incision rather than make another transverse incision.
- Figure 45–2: After incision (shown here as a transverse incision), dissection is carried down through the subcutaneous tissues.
- Often there is an anterior jugular vein crossing the field which may be tied off and divided.
- A small self-retaining retractor is useful to hold the incision open.
- Once the strap muscles are identified, they are divided vertically in the midline to expose the trachea.
- Often, the thyroid isthmus can be seen in the superior portion of the dissection; it may need to be divided for exposure.
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