Cricothyrotomy
Encyclopedia
A cricothyrotomy is an incision made through the skin
and cricothyroid membrane
to establish a patent airway
during certain life-threatening situations, such as airway obstruction by a foreign body
, angioedema
, or massive facial trauma
. Cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation
are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy
, does not require manipulation of the cervical spine
, and is associated with fewer complications. However, while cricothyrotomy may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure until a definitive airway can be established.
The procedure was first described in 1805 by Vicq d'Azyr, a French surgeon and anatomist. A cricothyrotomy is generally performed by making a vertical incision on the skin of the neck just below the "Adam's apple
", or thyroid cartilage, then making another transverse 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.
In a typical cricothyrotomy procedure, a scalpel is used to create a 1 cm vertical incision through the skin and the cricothyroid membrane, and the resulting hole is opened by either inserting the scalpel handle into the wound and rotating 90 degrees or by using a clamp. A tracheostomy tube or endotracheal tube with a 6 or 7 mm internal diameter is then inserted, the cuff is inflated, and the tube is secured. A bag-valve device with the highest available concentration of oxygen is used to provide ventilation, the success of which is assessed by bilateral ausculation and observation of the rise and fall of the chest. No attempts are made to remove the tracheostomy or endotracheal tube in a prehospital setting.
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 three episodes:
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. It is also used many other times, especially in the trauma room, when an airway can't be established.
In the movie, "Playing God" (1997), David Duchovny
plays a famed LA surgeon, stripped of his license due to drug abuse, who finds himself witnessing 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.
In the BBC3 medical drama Bodies
, the main protagonist Rob Lake, a newly appointed obstetrics and gynaecology registrar (played by Max Beesley
), is called to a patient who is having difficulty breathing due to anaphylaxis. Lake calls for emergency assistance, but impatient and fearing for the patient's life decides to undertake a cricothyrotomy himself - a procedure he has not been trained in. The procedure is unsuccessful and the patient dies before help arrives. The guilt surrounding the event combined with the covering up by his consultant provides an important backdrop to the further development of the character and his relationship with his consultant.
On Dr.Quinn, Medicine woman; the white man raised by Indians who is her lover and companion, performs the procedure on one of Dr.Quinn's boys using a bird's feather (the base where it is hollow). The boy become okay after bird feather in cricothyroid membrane institutes a fresh air supply.
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
and cricothyroid membrane
Cricothyroid ligament
The cricothyroid ligament is the larger part of the laryngeal membrane, continuing inferiorly as a median or anterior part and twin lateral ligaments....
to establish a patent airway
Airway
The pulmonary airway comprises those parts of the respiratory system through which air flows, conceptually beginning at the nose and mouth, and terminating in the alveoli...
during certain life-threatening situations, such as airway obstruction by a foreign body
Foreign body
A foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....
, angioedema
Angioedema
Angioedema or Quincke's edema is the rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues. It is very similar to urticaria, but urticaria, commonly known as hives, occurs in the upper dermis...
, or massive facial trauma
Facial trauma
Facial trauma, also called maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw, as well as trauma such as eye injuries...
. Cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation
Tracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy
Tracheotomy
Among the oldest described surgical procedures, tracheotomy consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea...
, does not require manipulation of the cervical spine
Cervical vertebrae
In vertebrates, cervical vertebrae are those vertebrae immediately inferior to the skull.Thoracic vertebrae in all mammalian species are defined as those vertebrae that also carry a pair of ribs, and lie caudal to the cervical vertebrae. Further caudally follow the lumbar vertebrae, which also...
, and is associated with fewer complications. However, while cricothyrotomy may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure until a definitive airway can be established.
Indications
- Can't intubate
- Can't ventilate
- Severe facial or nasal injuries (that do not allow oral or nasal tracheal intubation)
- Massive midfacial trauma
- Possible cervical spine trauma preventing adequate ventilation
- AnaphylaxisAnaphylaxisAnaphylaxis is defined as "a serious allergic reaction that is rapid in onset and may cause death". It typically results in a number of symptoms including throat swelling, an itchy rash, and low blood pressure...
- Chemical inhalation injuries
Contraindications
- Inability to identify landmarks (cricothyroid membrane)
- Underlying anatomical abnormality (tumorTumorA tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
) - Tracheal transection
- Acute laryngeal disease due to infection or trauma
- Small children under 10 years old (a 12–14 gauge catheter over the needle may be safer)
Procedure
Adam's apple
The laryngeal prominence—commonly known as the Adam's Apple—is a feature of the human neck. This lump, or protrusion, is formed by the angle of the thyroid cartilage surrounding the larynx...
", or thyroid cartilage, then making another transverse 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.
Technique
Surgical procedureIn a typical cricothyrotomy procedure, a scalpel is used to create a 1 cm vertical incision through the skin and the cricothyroid membrane, and the resulting hole is opened by either inserting the scalpel handle into the wound and rotating 90 degrees or by using a clamp. A tracheostomy tube or endotracheal tube with a 6 or 7 mm internal diameter is then inserted, the cuff is inflated, and the tube is secured. A bag-valve device with the highest available concentration of oxygen is used to provide ventilation, the success of which is assessed by bilateral ausculation and observation of the rise and fall of the chest. No attempts are made to remove the tracheostomy or endotracheal tube in a prehospital setting.
Cricothyrotomy in popular media
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.In the 1980 Nicolas Roeg
Nicolas Roeg
Nicolas Jack Roeg, CBE, BSC is an English film director and cinematographer.-Life and career:Roeg was born in London, the son of Mabel Gertrude and Jack Nicolas Roeg...
film "Bad Timing
Bad Timing
Bad Timing is a 1980 British film directed by Nicolas Roeg, produced by Jeremy Thomas.-Plot:In Vienna, a young American woman in her twenties is rushed to the emergency room after apparently overdosing. With her is Alex Linden, an American psychiatrist teaching in Vienna...
," Theresa Russell's
Theresa Russell
Theresa Russell is an American actress.-Biography:Russell was born Theresa Paup in San Diego, California, the daughter of Carole Platt and Jerry Russell Paup. She attended Burbank High School, but did not graduate. She married English film director Nicolas Roeg , in 1982...
character Milena Flaherty has an emergency cricothyrotomy performed following an intentional overdose.
In Grey's Anatomy
Grey's Anatomy
Grey's Anatomy is an American medical drama television series created by Shonda Rhimes. The series premiered on March 27, 2005 on ABC; since then, seven seasons have aired. The series follows the lives of interns, residents and their mentors in the fictional Seattle Grace Mercy West Hospital in...
, emergency cricothyrotomy is mentioned in at least three episodes:
- In “Owner of a Lonely HeartOwner of a Lonely Heart (Grey's Anatomy)"Owner of a Lonely Heart" is the 11th episode of the second season of the ABC series, Grey's Anatomy. The episode was written by Mark Wilding and was directed by Dan Minahan. It originally aired on December 4, 2005, running for 43:08 min.-Starring:...
,” CristinaCristina YangCristina Yang is a fictional surgeon on the ABC television series Grey's Anatomy. The character is portrayed by actress Sandra Oh, who won a Golden Globe and a SAG Award in 2006 for the role...
almost performs an emergency cricothyrotomy on a patient who swallowed a light bulb. Before she is able to do so, however, Dr. BurkePreston BurkePreston Xavier Burke, more commonly known as Burke, is a fictional surgeon on the ABC television series Grey's Anatomy. The character was portrayed by actor Isaiah Washington, up until the third season.-Storylines:...
shows up and takes the patient to an operating room where he proceeds to perform an emergency thoracotomy. - In “The Heart of the MatterThe Heart of the Matter (Grey's Anatomy)"The Heart of the Matter'" is the 4th episode of the fourth season of the ABC series, Grey's Anatomy. The episode was written by Allan Heinberg and was directed by Randy Zisk. The episode originally aired on October 18th, 2007.-Episode Recap:...
,” IzzieIzzie StevensIsobel 'Izzie' Katherine Stevens is a fictional character from the medical drama television series Grey's Anatomy, which airs on ABC in the United States. The character was created by series producer Shonda Rhimes, and was portrayed by actress Katherine Heigl from 2005 to 2010...
performs her first “emergency crike” on Camille, a niece of Chief of Surgery Dr. Richard WebberRichard WebberRichard Webber is a fictional surgeon from the ABC television series Grey's Anatomy. The character is portrayed by actor James Pickens, Jr., and was created by Shonda Rhimes...
. - In "I Saw What I Saw"I Saw what I Saw (Grey's Anatomy episode)I Saw What I Saw is the sixth episode of the sixth season of Grey's Anatomy. This episode's format is different from the usual format of episodes from the show, since it depicts the events in a whodunnit style, exposing them from different points of view in a fast-paced way...
AlexAlex KarevAlexander "Alex" Michael Karev, is a fictional surgeon on the ABC television series Grey's Anatomy, portrayed by actor Justin Chambers. The character was not included in the original pilot script, but was added in after the pilot was shot, meaning initial scenes with him were either reshoots or...
performs a "crike" on the patient who later dies.
In the ER
ER (TV series)
ER is an American medical drama television series created by novelist Michael Crichton that aired on NBC from September 19, 1994 to April 2, 2009. It was produced by Constant c Productions and Amblin Entertainment, in association with Warner Bros. Television...
episode, "Reason to Believe" Dr. Kerry Weaver
Kerry Weaver
Dr. Kerry Weaver, portrayed by Laura Innes, was an fictional character on the NBC television series ER; she first appeared as a recurring character actor in season 2, and became a regular cast member in season 3. In January 2007, Innes left the show after 12 years and Kerry Weaver moved to...
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
Choking
Choking is the mechanical obstruction of the flow of air from the environment into the lungs. Choking prevents breathing, and can be partial or complete, with partial choking allowing some, although inadequate, flow of air into the lungs. Prolonged or complete choking results in asphyxia which...
fails, she performs a cricothyrotomy with a kitchen knife and a drinking straw. It is also used many other times, especially in the trauma room, when an airway can't be established.
In the movie, "Playing God" (1997), David Duchovny
David Duchovny
David William Duchovny is an American actor, writer and director. He has won Golden Globe awards for his work as FBI Special Agent Fox Mulder on The X-Files and as Hank Moody on Californication.-Early life:...
plays a famed LA surgeon, stripped of his license due to drug abuse, who finds himself witnessing 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.
In the BBC3 medical drama Bodies
Bodies (TV series)
Bodies is a BAFTA-nominated British television medical drama produced by Hat Trick Productions for the BBC. Created by Jed Mercurio, the series began in 2004 and is based on his book Bodies. The first series debuted on BBC Three as the channel at this time was trying to break out into hour-long...
, the main protagonist Rob Lake, a newly appointed obstetrics and gynaecology registrar (played by Max Beesley
Max Beesley
Maxton Gig Beesley Jr. , known simply as Max Beesley, is an English actor and musician.Beesley rose to fame for his role of Andy Simpson in Every Woman, Every Man from 1993 to 1998, and has since appeared in a variety of television shows including Bodies, Hotel Babylon, London Ink, Survivors and...
), is called to a patient who is having difficulty breathing due to anaphylaxis. Lake calls for emergency assistance, but impatient and fearing for the patient's life decides to undertake a cricothyrotomy himself - a procedure he has not been trained in. The procedure is unsuccessful and the patient dies before help arrives. The guilt surrounding the event combined with the covering up by his consultant provides an important backdrop to the further development of the character and his relationship with his consultant.
On Dr.Quinn, Medicine woman; the white man raised by Indians who is her lover and companion, performs the procedure on one of Dr.Quinn's boys using a bird's feather (the base where it is hollow). The boy become okay after bird feather in cricothyroid membrane institutes a fresh air supply.
External links
- Drawing of a cricothyrotomy
- Smiths Medical Cricothyroidotomy Kits (Cricothyroidotomy products for Adults and Children)
- Medstudents: Procedures: Cricothyrotomy
