Episode 23 - Surgical Cricothyroidotomy: How I Do It

Took a little bit of a break these last couple of weeks from editing, spent some time getting a little R and R in gorgeous sunny San Diego, as well as Yosemite, which was for the most part empty. which made for some great walks with the fam jam and close friends, of course, wearing masks and staying socially distant. Secondly, we have two amazing guest professors joining us on rounds this week, including Dr. Clay Cothrin Berlou from Denver Health.

who will be discussing management of unstable pelvic ring fractures and doctor Megan Brenner from Riverside University Health System, who will discuss the present role and future of Reboa, that's resuscitative endovascular balloon occlusion of the aorta. in the management of the acutely injured patient, specifically those patients deemed transient or non responders to initial resuscitation efforts.

Today's rounds will focus on emergent airways, more specifically surgical cricothyroidotomy, AKA surgical cricothyrotomy, herein referred to as a crike. And there are three key objectives for today's podcast. By the end of rounds, you should be able to number one Understand the indications for performing a krike or surgical airway and other invasive non-surgical airways such as a needle krike.

Number two, describe the key steps or technical considerations when preparing for and performing a crike. And finally, number three, you should be able to discuss post-cricothyroidotomy care and management. Such that If you happen to find yourself in the fortunate circumstance that your patient is alive at the end of this procedure, you know what to do in terms of bleeding control. wound exploration and whether or not to convert that crichothyroidotomy to a tracheostomy.

So as the new academic year is well underway, we've been pushing or at least encouraging new hospital staff to get trained in our institutional team steps program. which are strategies and tools for enhancing performance and patient safety. And it's really a program designed to teach each other and encourage one another to communicate effectively. especially when it comes to patient safety issues. And so whether that's a check back

or having huddles and debriefs, this is a a great way to learn a common language so that we can identify issues as they arise. And it really does encourage our healthcare workers and partners slash colleagues to speak up when there are concerns regarding patient care. To start the course, we usually begin with a video. I think it's called just uh another routine surgery.

and it's uh a story of a gentleman who is a pilot who shares the unfortunate story of his wife who goes in for a a routine surgery and ends up developing a complication intraoperatively whereby the airway anesthesia surgical team nursing staff

failed to recognize that they were unable to intubate this patient and she suffered subsequent anoxic brain injury and eventually death. And You know, every time I watch this story or this video, it brings up concepts related to human factors and team performance. And, you know, throughout the entire video as it's kind of going down and and this husband is telling his story of what was going on in the OR.

Uh I can't help but cringe and just wish they would have performed a cricothyroidotomy in this patient that they could not intubate and could not ventilate. So I want to spend the next 20 minutes or so discussing surgical cricothyroidotomy. More specifically, I'd like to share with you how I do it.

I remember the first time I performed a crike was as a chief resident and to date, for whatever reason, I've performed or supervised, house staff performed just over a dozen or so of these, with relatively few complications save one major one. uh that I'll talk about a little bit later. In the process, I've refined my approach and technique and just wanted to share a few of these lessons with you.

I also want to give a shout out to Doctors Carrie Lou, Brian Goldner, Dr. Laura Spence, and Ted Gifford, who have all either assisted or outrightly performed a Craig during their training here at Harbour. It's really interesting to see how certain injuries or procedures uh kind of gravitate towards you or maybe that we gravitate towards. And in my particular case, for whatever reason, you know, these surgical cricothyroidotomies keep coming up at least once a year.

So in terms of our first objective, understanding the indications for performing a surgical airway or a non-surgical needle cricothyroidotomy, I think there's a few considerations and things to bear in mind. uh even before we get to thinking about doing this procedure. And one of the most important things I think is to really try to avoid or prevent yourself from getting into a situation

Where you may potentially lose the airway. Now, fortunately, these types of scenarios are few and far between, but you can imagine that if someone is coming in with a a very large neck mass. or has a known, for example, medullary thyroid carcinoma or head and neck tumor with documented strider In general, our approach to airway management and intubation is gonna be very different from the standard run-of-the-mill trauma patient.

Now, in the former case, you're definitely gonna wanna consider maybe getting that patient up to the OR with anesthesia and the airweight team and consider an awake fiber optic bronchoscopic assisted intubation. And you definitely want to avoid anything like a neuromuscular blockade whereby the airway may just completely collapse upon induction.

Now, in the latter case, which is much more common, specifically intubation of trauma patients, there still are some considerations to bear in mind when it comes to the approach to the airway. One of the things to always bear in mind is, especially in our patients with blunt polytrauma who require intubation. They're going to remain in C-spine precautions and immobilization. And that already puts that patient at a bit of a higher risk.

Than the standard elective intubation, insofar as we're gonna avoid hyperextension of the neck. And we know that that is so important. in terms of aligning all those key axes, the pharyngeal, laryngeal, and uh oral axes. in order to really get that ideal view. Now one quick and standard approach to assessing the difficulty of an airway is to assess for Tums, and that acronym stands for teeth, specifically the presence or absence thereof.

or the ability to see the oval, which equates pretty much to your Malin Potty score. M stands for mandible, and you should be able to fit three finger breadth. between the actual mentum or chin and thyroid cartilage, and finally S stands for spine, and as we've already alluded to in trauma patients,

Any attempts at intubation will be done with strict C spine immobilization. Further complicating the matter in trauma patients is that they may be bleeding, they can have expanding neck hematomas, or they may suffer from significant facial smash. So the whole idea behind this conversation is that as we're thinking about indications, we want to always be prepared. And a lot of that has to do with risk assessment.

even prior to administration of RSI meds. And the other thing to consider outside of patient or injury related factors, as well as anatomy, are resources. So where are you? Who are you surrounded by? I tell you I've got I've got a running little checklist here of airway personnel, some of which I get concerned about. or very closely sort of supervise the intubation procedure and that doesn't matter if it's a resident or an attending.

And then there are those in whom I completely trust to do whatever they need to do and I'll kinda stand back and take care of whatever else is going on. But of course all of the team's attention is always on the airway until it's known to be confirmed to be in the airway. with N title CO two and is secured before moving on to other parts of the resuscitation.

And back in San Diego as a fellow, they have a very rigorous airway protocol there. And as the trauma fellow or attending if a patient is going to be intubated, your job is to stand to the right of the patient, by the head of the patient. and apply cricoid pressure during attempts at intubation.

There was also a three strikes and your out policy. I don't know if that's still in place, but essentially the first two intubations are tried by the resident, and in this day and age I would imagine that most attempts, initial attempts for a trauma intubation are performed using video laryngoscopy, whether that's with a glidescope or CMAC. And if there are two failed intubation attempts by the resident, then the attending, either ER or anesthesia attending, gets one shot, followed by

Cricothyroidotomy. Perhaps a little overly aggressive. I can tell you that by the end of my two year fellowship, I was very comfortable performing a crichothyroidotomy. I think one of the major advantages of this protocol, however, is that it really does draw attention to the importance of the airway. And being the person applying cricoid pressure with your dominant right hand, you already have a sense as to the external landmarks as well as the anatomy of the neck.

in the case that attempts at intubation fail and you can't ventilate the patient. Again, just not being able to intubate obviously is not an indication to perform a cricothyroidotomy. You need to back valve mass the patient, insert oral and nasopharyngeal airway adjuncts. Maybe consider an LMA or comba tube. Honestly, I haven't seen a combat tube in years, but LMAs are certainly used. Um, but again, if you don't have a lot of experience sizing and placing these.

they can be a little bit more troublesome than helpful. So know your institutional algorithm and protocols. Always have a backup plan. I do have to say, whenever I hear the gum elastic bougie being called for, that always raises my concern that this is an airway that may be going sideways. Now before we get into the key steps and technical considerations, I do briefly want to talk about needle cricotharidotomy.

Uh in my humble opinion, at least in adults or those over the age of twelve, there's probably no good or strong indication to use the Melker needle cricothyroidotomy kit or to perform a needle cricothyroidotomy. I think this particular procedure is attractive or appealing to non surgeons, mainly because it's based on the Seldinger technique, which we're all familiar with, because we all have put in a central line or dialysis catheter.

And it really is the same basic technique. Further, many folks have done a percutaneous tracheostomy and the overall uh key steps as well as equipment are familiar. You gotta bear in mind when you're being asked to do a surgical cricothyroidotomy, uh, whether that's because you're being called emergently to an airway disaster or it's kind of unfolding in front of you in the trauma bay, oftentimes time is not your friend.

And so there really is a need to act emergently and you're not gonna have time to set up that Cricothyotomy kit. Really here what you need is a scalpel, your finger, and some airway device to be able to stick through that hole that you've made in the cricothyroid membrane. Now, among children, uh particularly younger than age twelve, there is a concern in terms of their specific anatomy.

that uh the airway is narrower because it is funnel shaped in and or around the cricothyroid membrane and that certainly may potentially place those children at an increased risk for subglottic stenosis. again, I think any tube in the airway, whether it's translaryngeally, transtracheally Is going to put you at risk for subglottic stenosis. And in these particular situations, you know, PEADs and PEDs EM, EM folk.

um have written about and talked about performing a needle cricothyroidotomy. This is something we used to teach in ATLS several editions ago. You can jury rig a setup kind of MacGyver using a 14 gauge angiocath with a 3cc syringe with a plunger out and get an adapter from 7.0 ET tube. It's uh way too much to think about. I mean, some ERs will have an actual jet

insufflator. You'll probably find it in some random cupboard covered in dust and no one's gonna know what it's used for. Maybe it looks like it's for watering the lawn. And so I'm not going to talk about that too much. If you want more information on that, happy to share some resources with you. The remainder of the conversation really is going to focus on the key steps or technical considerations for performing a crike.

So in terms of the equipment that's required to perform a cricothyridotomy, my personal preference is to use an eleven blade or knife. Again, any sharp cutting instrument will suffice. So whether that's a 10 blade or a 15 blade. I personally like the 11 blade because of the length. and depth of the blade and it's very easy to saw open both the skin and cricothyroid membrane in one incision if that's the way you choose to go.

Now I know that some hospitals have developed or made a sort of elaborate surgical cricothyroidotomy trays. and they're equipped with trach hooks and wheat laners and they may even have penetrating towel clamps and people have talked about actually placing those on the trachea to lift it up to the level of the incision. I think all that is a little overboard.

And in terms of what you really need, it used to be I used to focus a lot on having really good lighting. And I think in any surgical procedure, if you can have good lighting, that's not gonna be a harmful thing. With time, this procedure for me has really evolved to one that's really more about feel and palpation.

And I I think many of the surgeons out in the audience can relate to this uh because so often when we're operating we rely on our digits to kind of guide the way and find planes as well as thin out tissues. So if you haven't done many of these, I mean get the best light possible, even if that means a couple of iPhones with the uh flashlights turned on. I think you always wanna be prepared and have two well functioning suction catheters or yon cows as well.

And in terms of positioning, which is really, really important, if you're right hand dominant, you want to be standing on the right side of the patient. If you're left hand dominant, get your butt over to the left side of the patient. Why is that? Well, the airway is actually kinda mobile. I mean, provided that it's not fixed down in place due to a large tumor or fungating mass. And so with your non dominant hand, you're gonna use that to palpate the cricothyroid membrane.

Additionally, before you make your incision, you're actually going to hold that airway in place and steady with your non-dominant hand while your dominant hand is making the incision. Now, when it comes to the actual incision itself, uh it always kinda makes me laugh when people get so um dogmatic about the orientation of the incision. And anyone that says that if you make a vertical incision, you have less bleeding, they've never done a crite.

All right, the whole idea that you're gonna avoid the anterior jugular veins, well hopefully you're perfectly centered to do that. But the fact of the matter is by the time you've actually punched a hole in the trachea, there's gonna be a whole lot of stuff bleeding. Which is why the post crite care management that we're gonna discuss is also very, very important. Now, how do I decide if I'm going to do a vertical or a transverse? Well, it comes down to patient anatomy.

If you can easily palpate through the neck soft tissues and palpate the cricothyroid membrane, you're gonna do a single incision through the skin as well as the cricothyroid membrane. Saw that open, usually a couple of centimeters long, or enough to accommodate the tip of your dominant index finger. Now, if someone's got a large mask,

or they've got a very obese neck. And when you go to palpate, you're not absolutely convinced that you're feeling the cricothyroid membrane, then go ahead and make a vertical skin incision. That skin and soft tissue incision alone is enough such that when you place your index finger back into the soft tissue, you should be able to feel the trachea.

as well as the thyroid cartilage superiorly and the crichocartilage inferiorly, and that's your cricothyroid membrane. Then you're gonna make your transverse incision through the cricothyroid membrane. And I remember doing this in a patient who was having anaphylaxis due to an ACE inhibitor. This was several years ago. And he had a very difficult anatomy and I went with a transverse incision, which ended up being too low.

gave him like the mark of the cross'cause eventually I had to go vertical, find the actual cricotharid membrane, everything went in well without complication, but ended up with a gnarly incision. So, can feel the cricothyroid membrane convincingly, cut through the skin and membrane in one incision, not completely convinced where the cricothyroid membrane is. Vertical incision through the soft tissue, always a transverse incision through the cricothyroid membrane.

Now at this point you don't need snaps, you don't need a tracheal dilator. What you need is your index finger, and this is probably one of the best surgical instruments, and you don't have to rely on an instrument tray or a tech or someone to pass it to you. Take the index finger of your dominant hand, stick it through the hole that you've just made. This is a nice atraumatic dilator.

At the same time, you can absolutely convince yourself that you are in the trachea, because you'll feel the tracheal rings, and beneath that will be the esophagus. Now, once you've identified that you're in the actual airway, you're gonna have to put in an airway device. And my personal preference when it's available is a 4-0 up towards a 6-0 Shile Tracheostomy. I like the Shiley Trach.

uh because it's nice and rigid and so you can easily get it in and guide it in and not be concerned that you're gonna right main stem the patient. If you don't have a Shiley tracheostomy, then you're just gonna use a standard endotracheal tube. And remember, these cricothyroidotomies usually are not gonna accommodate a 7-0 or 8-0 tube. So if you can get in a 6-0, fantastic.

A 5040 will do, but just be careful because the last cricothyroidotomy that we performed, I ended up sticking a 60 tube down, and it's a very short distance. From where you're doing your crike to where the Carina is. And so this patient, even though they had N title CO2, ended up becoming very hypoxemic.

So what did we do? We took out the ultrasound, looked for lung sliding of which there was none on the right, looked for lung sliding of which there was on the left, realized that the tube was a bit deep, and without x ray we pulled the tube back. Reinflated, bagged. reassessed, SATS came up, lung sliding on the right. And so together with N title CO2, that was a great example of POCUS acutely in use to identify ventilation of bilateral lungs.

Now there are several reports and discussions on using a bougie. Um I'm not a big fan. I'm not a big fan of the bougie assisted technique. I think again it's another piece of equipment that most of us are gonna have readily available in the ER. But uh, you know, I think having your finger in the airway is really a definitive confirmation, more so than using a bougie to guide the trach or ET tube over. It's really an unnecessary and wasted step.

and absolutely not convinced that this is a helpful maneuver. There are those that like it, good for you.

Now once that cricothyroidotomy is done and your airway is in We've got to pay attention to what to do next'cause things don't end there. In fact, in the process of doing a crike, oftentimes there's quite a bit of bleeding, whether that's from veins, soft tissue, muscle, or the airway itself. Uh nine times out of ten, in in my experience, ten times out of ten, these patients go straight up to the OR where we can do a local wound exploration, get control of any hemorrhage.

lay down hemostatics if necessary, and then have a discussion of the need to convert that cricothyroidotomy to a formal tracheostomy. Now, in order to assess the wound properly, once we get up to the OR, the patient's been induced and is paralyzed and on the vent,

At this point, especially if it's a Shiley tracheostomy that's in, I typically like to swap this out for a 6-0 armored endotracheal tube. And the reason for that is Most of these tracheostomies have a fairly large flange that really prevents the ability to manipulate them to get a good look at the wound.

And so over a tube exchanger, and this is one time where I might use a bougie, I would swap out the tracheostomy, replace it with an armored 6-0 tube. And the whole idea behind using an armored tube is it has that metal reinforced wire within it. It actually makes it very easy to bend and move in a three hundred sixty degree fashion.

So you can obtain hemostasis, make sure you haven't done anything stupid, and then at that point you're really left with the decision as to whether or not to convert to a formal tracheostomy. So personally, my preference is not to convert these crichothyroidotomies to a formal tracheostomy. Given the rarity of this procedure, there's very little data to sort of guide our decision to formalize or not.

Back in twenty eleven, there was a study out of University of Texas Southwestern Medical Center that looked at this exact issue and potential long term outcomes, specifically complications like subglottic stenosis. of which uh there was a very low incidence.

in both groups, whether they were formally trached or were left with a cricothyroidotomy. And there was also a single center retrospective study from our friends at LACUSC looking at the same topic. And they found that prolonged use of a cricothyroidotomy tube really didn't have any significant impact in terms of complications and so they found no need or benefits to a routine conversion to a tracheostomy.

Now, in the one instance where I had a horrible complication following a cricothyroidotomy, that actually occurred in the process of switching over to a trach and In fact, on retrospective analysis, what we identified, and this was a a morbidly, morbidly obese. uh male who was already coding due to a failed intubation with hypoxemic PEA arrest. We kinda got called after the fact.

And you can imagine it was a pretty intense experience. But in the process of trying to get the Crike in Um we had very difficult time getting a six oh tube in and so we finally got a four oh tube and it was so floppy I could not get it into the actual trachea and direct it inferiorly. So I ended up using the stylet to ensure that the tip was not sticking out beyond the end of the E T tube. But if you've ever seen or felt what a 4-0 with a stylet, it's almost like a pencil.

and so I put an L shape on it just to be able to navigate it inferiorly towards the distal airway and in the process must have raised a bit of a tracheoesophageal membrane flap when we brought the patient to the OR, we got hemorrhage control, everything looked really good. And then at that point the decision was collectively made to convert to a trach. And I really wish we hadn't have done that. Uh in the process of doing that.

and pulling back the cricothyroidotomy uh trach that we had placed. Um, I believe that the lumen of the trachea became completely occluded as a result of the flap which was initially being stented open. with the crike. And so I always oftentimes wonder whether or not if we hadn't have done that, the patient would still be with us.

So in summary, surgical cricothyroidotomy is a potentially life-saving maneuver. And unfortunately when we're called upon to do this, particularly if we're not already present in the trauma bay were oftentimes very much behind the eight ball. So you need to be prepared to do this. It really takes minimal equipment and I hope you really do take home the fact that all you really need is a sharp instrument Together with your finger and an airway device, typically a tracheostomy or ET tube.

There are several complications associated with this procedure, the most common of which is going to be bleeding, which will happen in every crake you do, irrespective of the incision you make. And so just be prepared that if your patient is alive at the end of this procedure, you need to get up to the OR, get hemorrhage control, and then at that point have a discussion about the potential risks and benefits of formalizing that tricothyridotomy to a tracheostomy.

Well I wanna thank you for joining us uh and talking about surgical cries. This is uh a great procedure. I think this is something that very few of us get an opportunity to do once, let alone more than a dozen times. If you have any questions, comments, or concerns about the show content, this episode, or the podcast in general, we would love to hear from you. You can download the podcast on Spotify.

iTunes or wherever you normally download your podcast, please leave us a kind comment. And if you have any future ideas or topics you want us to cover, Let us know. You can reach us at traumaicurounds at gmail dot com or visit us at the website traumaicurounds.ca or traumaicurounds.com. Until next time, stay safe, keep reading, take care of yourselves and one another.