Taking the Fear Out of a Surgical Cricothyrotomy

It is 1056 hours, and you are finishing teaching a CPR class at your local high school when you are sent to a small manufacturing company where electric motors are made. On arrival a security guard escorts you to the plant nurse’s office, where you find a male victim of a small electrical fire and explosion. 

He introduces himself as Dale and says he was working on a machine in a small enclosed area when it arced and caught fire, burning his face, head, chest and arms. You note his voice is hoarse and raspy and his face is black with soot. He is breathing rapidly, with shallow breaths. Something tells you this is not going to be a routine call. 

Gene: Few situations strike more fear into a medic than an unexpected rapidly deteriorating airway. And few situations are scarier than the patient with burns to the airway who is having breathing difficulty.

Jason: Pretty much any severe burn to the airway is going to result in breathing problems. Since the trachea and bronchi are lined with living cells, unlike the layers of dead cells covering your skin’s epidermis, they are extremely sensitive to the presence of hot gases. Interestingly, though, between the low heat-carrying capacity of air and the protection of airway reflexes, thermal injury rarely reaches past the carina (except in steam inhalation, thanks to water’s higher heat-carrying capacity). Once the surface epithelial cells are damaged, a chain of reactions ends up forming reactive oxygen and nitrogen molecules, which allow cell membranes to become permeable, causing edema.

Sometimes this edema can happen within minutes. Other times it’s a slow, insidious process, and the edema doesn’t become clinically relevant until hours later (sometimes 12–24 hours!) when fluid resuscitation is underway.¹ A patient who looks good initially can go downhill very quickly, since stridor is a late sign. 

Kelly: In that inhalation-injury patient, the presence of stridor heralds impending airway failure. Whether it is an acute failure that happens within minutes or the end result of that slow, insidious process that took 24 hours, stridor seems to be the final clinical indicator that airway compromise is imminent, and thus our trigger for advanced airway management. 

Make no mistake, this is no time for half measures. Our patient has a subglottic injury, and supraglottic airways aren’t going to manage it. Whatever solution we choose, an endotracheal tube is going to be part of it, whether by means of direct laryngoscopy or a scalpel.

You need to start airway management now, not later. The narrowest portion of your patient’s airway is the vocal cords, and the swelling indicated by the presence of stridor and hoarseness is unlikely to reverse itself quickly with any conventional treatment. This is one of those “red flag” conditions that tells you it’s time to skip directly to the tip of the Airway Continuum Pyramid (Figure 1). You need to intubate your patient, and the only question is how. 

Your choices are to perform RSI/DSI and apneic oxygenation techniques and secure an airway via direct or video laryngoscopy—and soon, maybe even now, that may not even be an option—or prepare to obtain a surgical airway. Communicate with your partner, start planning your moves now, prepare yourselves mentally and prepare your equipment. This is going to be an airway unlike any you’ve ever encountered: Internal structures are likely to be obscured, anatomy distorted, and the time window to get it all done is compressed. Your greatest resources will be your knowledge of airway anatomy, especially those structures unlikely to become obscured and distorted, your partner and a cool head. Use them.

You tell your partner to begin CPAP on your patient at 10 mm Hg as you rapidly strip and examine him. You find second- and third-degree burns on his face and neck and second-degree burns over almost his entire torso and anterior arms. You mentally begin figuring the surface area of the burns in preparation for starting fluid resuscitation. You ask the nurse if she can stab a bag of Ringer’s lactate for you, and she starts working on that. Calculating his burn surface area at 45% and his declared weight at 80 kg, you determine to start the man on fluids at 4 mL per kg of body weight times the percent of body area burned, for a total of 14,400 mL of fluid during the first 24 hours, half of which will be given in the first eight hours. This turns out to be 900 mL per hour to begin. You rapidly calculate your drip rate with a 10-gtt set as 150 gtt/min. 

Jason: At this point in the scenario, if you’re calculating the Parkland formula, you’re focusing on the wrong thing. I’m generally all for being conservative and not exposing people to potentially dangerous treatments when they don’t need them, but this is a time when your patient needs an airway. NEEDS—in all caps, as if you’re shouting. That edema that’s starting to choke the patient is going to get worse before it gets better. In a marginal case I have the luxury of slipping a fiber-optic laryngoscope into someone’s nose and actually looking at the trachea while awake, maybe even intubating using that scope—but you won’t, and I’m not even sure this guy counts as a marginal case.

Kelly: In the prehospital realm the Parkland formula for a patient with burns this extensive is “two lines of Ringer’s, wide open.” The calculation can be performed in the ambulance or aircraft during transport, after the lifesaving interventions have been completed. So that line you’re planning on using for administration of your RSI/DSI drugs, open it wide and let it run while you’re preparing your equipment.

Airway management usually consists of an A-B-C approach to planning, where A is your primary airway device, B is your backup airway and C is surgical cricothyrotomy. Airway burns turn that approach on its head, because B for most EMS providers is a supraglottic rescue airway. A supraglottic airway for this patient is not going to rescue anything. You need an intervention whose distal tip reaches within an inch or so of the carina.

This patient needs oxygenation right now, both to reverse his hypoxia and to build a physiologic reserve during the airway procedure that is to come, so the provision of CPAP in the scenario is spot-on. Keep in mind that facial burns are a contraindication to CPAP primarily because of the issues maintaining a mask seal and because CPAP is assumed to be the primary oxygenation technique. In our patient CPAP is our preoxygenation technique. It’s going to help with alveolar recruitment and help overcome any V/Q mismatch and shunting that may have developed.

So get to oxygenating and prepare your drugs and equipment. Your actions need to be rehearsed and well-considered here. As that noted philosopher Admiral Painter said in The Hunt for Red October, “Russians don’t take a dump, son, without a plan.” Your patient’s status is about to take the ultimate dump, and you need a plan.

Gene: Planning is of the essence in managing calls such as this. In our previous article a year ago on RSI/DSI [https://www.emsworld.com/article/12106319], we outlined a strategy for planning for airway emergencies using a “pit-crew” approach. Now we take things a step further and show you how to prepare for a crash surgical cricothyrotomy. 

It’s really quite simple. You will need the following items placed into a dedicated case, bag or roll (double this list in case you drop something on the floor): 

• A scalpel; 
• A 7.0 cuffed ET tube; 
• An Eschmann endotracheal tube introducer (bougie); 
• A 10-mL syringe for cuff inflation; 
• Suction; 
• Alcohol swabs; and 
• Gauze pads (4x4s). 

As you look for a place to start your IV, your partner announces the patient’s SaO₂ is now 76% and his airway is swelling rapidly. Abandoning your IV attempts, you administer 80 mg of ketamine IM and begin to ventilate with the BVM. There is practically no compliance, and you’re fighting to get oxygen into your patient. He is no longer responsive, so you attempt a look at his airway with your laryngoscope, but to no avail—you can see nothing but pink. An attempt at external laryngeal manipulation does not help. You can see nothing. You try with the bougie but can’t feel tracheal rings. Your patient is dying in front of you. You quickly ask your partner to attach the monitor/defibrillator pads and try to get your head together to figure out what to do next. 

Gene: At this point many medics would adapt the words of the rhyme, “When in trouble, when in doubt, run in circles, scream and shout.” Fortunately you are not one of those. You quickly realize you have to do a surgical crich on this patient, and now. So without further delay you grab and open your preloaded cric kit. Now your actions are all logically driven toward your goal: an airway for your patient.

First lay all the items out in line. You should have practiced this with your partners before now, but in case you haven’t, now is the time to issue short, clear orders. Here is exactly what to do:

1) Direct your partner to clean the patient’s anterior neck with alcohol swabs.

2) Open your scalpel and get it in your dominant hand, holding it with the fourth and fifth fingers.

3) With your nondominant hand, take your thumb and forefinger and palpate either side of the thyroid cartilage (Adam’s apple) and stretch the skin tightly. With the forefinger of your dominant hand, feel for the cricoid cartilage, which is the indention just below the point of the Adam’s apple. If you anchor the heel of your nondominant hand against the chin and your dominant hand on the manubrium, it will stabilize your field and lessen movement. 

Once you feel the cricothyroid space, take the scalpel and, starting from the point of the Adam’s apple, cut downward and through the cricothyroid membrane, continuing to spread the skin to either side with the fingers of your other hand. Don’t worry about harming underlying tissues, because there is nothing but cartilage below your knife. Expect that the skin will be thicker than you thought and there may be fat between the skin and membrane. Keep cutting downward with repeated cuts until you get through this tissue. 

4) If bleeding occurs, have your partner put pressure on it with gauze pads and clear the blood away. Continue until you see the membrane. Repeat as needed. Then pop your scalpel through the membrane with the blade sideways. Immediately insert the bougie into the wound with your other hand.

5) Advance the bougie downward until it stops. Remove your scalpel from the wound and secure it safely. Never remove the scalpel until the bougie is fully into the wound. If your scalpel doesn’t pass easily into the trachea, you are not yet into the trachea. Cut some more! You should be able to move the scalpel blade back and forth easily once it’s in the trachea, and the bougie should enter the trachea easily.

6) Pass the ET tube over the bougie until the cuff is about 2 inches below the opening and inflate the cuff. Remove the bougie.

7) While carefully holding onto the tube so it doesn’t come out, attach the EtCO₂ monitor and BVM to the ET tube and ventilate the patient. Note chest rise, breath sounds and EtCO₂ return. Secure the ET tube in place with tape or a commercial device. 

8) Monitor the patient’s respirations and oxygen saturation and treat accordingly.

We believe using a bougie to secure the airway is the easiest and safest way, but there are other ways. There is a device called a tracheal hook that some airway practitioners, particularly anesthesiologists and CRNAs, may use. The problem with a tracheal hook is that you can drop it or it may not hold the wound open well. Some will use forceps or a hemostat to enter the wound once the scalpel has made the opening, and this is fine, but these are more cumbersome actions, and the devices may tear the cuff on the tube as it goes by. Some will poke a finger into the wound to secure it, but this runs the risk of cutting yourself with the scalpel. Overall the bougie is the ideal instrument to hold the wound open and insert your ET tube.

Kelly: I’ve never used a tracheal hook in training, but I was taught to use a curved hemostat to widen the scalpel cut through the cricothyroid membrane. We inserted the tip of the hemostat into the hole with the curvature pointed caudad, opened the forceps tips to widen the hole, then rotated the handle of the hemostat cephalad to elevate the cricoid ring to facilitate passage of the tube. 

However, that was pre-bougie. Our bougies have a coudé tip to facilitate advancement to the carina, so we have a guide all the way to optimal placement of the distal end of the endotracheal tube, unlike the cricothyrotomy technique I was taught. The hemostat also has teeth that can abrade and rupture the tube cuff as it passes, as Gene pointed out. 

One thing I’d add is to consider inflating your ET cuff with saline rather than air. While we don’t use hyberbaric therapy as often as we once did for carbon monoxide poisoning, it still is a possibility. The overlap between inhalation burns and carbon monoxide poisoning is pretty big. 

Jason: At this point what can go wrong? Well, there are plenty of complications to the procedure, but the only one you have to worry about at the time you’re doing this is failure to secure an airway. It is fairly rare to have a moment in your career when a life is truly on the line, but this is it.

The only reason to worry about bleeding is insofar as it can cause you to fail. That’s why you make the incision vertically: Very few blood vessels cross the midline (the aorta and some of the communicating arteries in the circle of Willis are about all).

Obese patient? That just means you’ll have to dig a bit deeper to find the trachea, and you’ll probably want to use blunt dissection to do so: Push the subcutaneous fat apart with your fingers or the blunt end of the scalpel.

Obstruction below the level of the cricoid? This might be an instance where you are truly out of luck. If it’s food or an object, you might be able to push it into the right mainstem bronchus and ventilate the left lung. If it’s tracheal stenosis, try a smaller tube. I’m not proud of this, but on the one cric I’ve done, I couldn’t get the tiny tube I was using through the trachea, so I stuck my small finger down the trachea to open it up a bit, and it worked.

And speaking of incisions: When people ask how long an incision you should make, I answer with a question: “How long is the patient’s neck?” Time is of the essence, and making one big incision is faster than making a little one, realizing you need more room and having to extend the original incision. Also, suture material is cheap.

Lastly, you should always approach the patient such that your dominant hand can rest on the patient’s sternum. This gives you a nice, stable base to make a relatively straight, confident incision and has the added benefit of hiding how much your hand is shaking. (If your hand isn’t shaking, either you need to rethink your approach to airway management or you make Captain Sullenberger look like the poster child for Valium.)

You quickly assemble your tools and address the patient’s anterior neck. Your partner has cleaned the skin with alcohol swabs, and you have no trouble finding the Adam’s apple. Stretching the skin tightly around and under it, you quickly feel the indention of the cricothyroid cartilage. Taking your scalpel, you make a swift cut downward vertically and see there is still tissue above the membrane, so you make a couple of additional cuts, and the membrane comes into sight, shining a pinkish-gray. You quickly poke the scalpel blade through it and insert the bougie downward until it stops. The ET tube easily passes over the bougie into place, and you inflate the cuff, attach the EtCO2 monitor and BVM and ventilate the patient. His SaO₂, which is now 60%, quickly rises to 98%. By now the nurse has a line, and you begin your fluid resuscitation and start the trip to the burn center. You monitor your patient and administer more ketamine as needed to maintain sedation en route. 

Kelly: Like any high-risk, low-frequency procedure, there is a significant amount of pucker factor involved. Unlike a procedure like needle thoracostomy (pucker factor: 0, skill factor: 2), surgical cricothyrotomy (pucker factor: 10, skill factor: 8) requires a great deal more skill on your part. 

But let’s not mythologize it. The procedures you’re doing are no more difficult than, say, obtaining an IV access on a patient with bad veins, and we do that every day. What makes them difficult and scary is the pucker factor. And the key to overcoming pucker factor is planning and communication. You can do this. 

Jason: Just remember that the hardest part of any surgical cric is deciding you have to do one. After that—well, failure isn’t an option, is it?

Gene: Even though surgical cricothyrotomy may not be within your scope of practice now, it could be at some time in the future. Having a clear understanding of how it is done can make the transition to an advanced airway practitioner easy and stress-free.

Reference

1. Demling RH. Smoke inhalation lung injury: an update. Eplasty, 2008; 8: e27. 

William E. “Gene” Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings and in the offshore oil industry. He lives in Tucson, AZ.

Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 22 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is a frequent EMS conference speaker and author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between and the popular blog A Day in the Life of an Ambulance Driver.

Jason Kodat, MD, EMT-P, has been in EMS for more than 15 years. He has reviewed EMS textbooks and the USFA’s EMS Medical Director Handbook, and lectures at regional EMS conferences regularly. He currently works as an emergency physician and associate EMS medical director at hospitals near Pittsburgh, PA.