Knowing when to perform cricothyrotomy

Siamak Moayedi, MD
19th Nov 2020

Cricothyrotomy is the way to definitively secure the airway of a dying patient (who can't be intubated or ventilated) by cutting a hole through the neck and placing a breathing tube directly into the bronchus.

Cyanotic patient on a stretcher. Neck with cricothyrotomy and tracheal tube. Cartoon.

Figure 1. Cricothyrotomy requires cutting a hole through the neck and placing a breathing tube directly into the bronchus.

 

Indications for cricothyrotomy

You should perform a cricothyrotomy only when you are unable to secure a hypoxic patient’s airway by any other means.

There are four indications for the cricothyrotomy procedure: 

  1. Upper airway obstruction
  2. Laryngeal spasm
  3. Trismus
  4. Trauma 

Multi-component image of airway obstruction, laryngeal spasm, trismus, and trauma. Cartoon.

Figure 2. Indications for the cricothyrotomy procedure include obstruction of upper airway, laryngeal spasm, trismus, and trauma. 

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Contraindications for cricothyrotomy

There are three important contraindications for the cricothyrotomy procedure: 

  1. There is an alternative and less invasive way to secure the airway.  
  2. Your patient is younger than eight years old (underdeveloped cricothyroid membrane).
  3. The obstruction is below the cricothyroid membrane. 

Multi-component image of alternative way, child under eight years, and airway obstruction below the cricothyroid membrane. Illustration.

Figure 3. Contraindications for the cricothyrotomy procedure include availability of an alternative and less invasive procedure, patient younger than eight years old, and obstructions below the cricothyroid membrane.

 

Consent for cricothyrotomy

Consent is not possible for cricothyrotomy unless you anticipate a difficult airway before a patient is paralyzed for intubation. 

In general, you’ll only be performing this heroic procedure if the patient is already dying. If you’re performing a cricothyrotomy, you’ve already determined there is no other alternative, and if you don’t perform the procedure, your patient will die. 

 

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Recommended reading

  • Hill, C, Reardon, R, Joing, S, et al. 2010. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med17: 666–669. PMID: 20491685
  • MacIntyre, A, Markarian, MK, Carrison, D, et al. 2007. Three-step emergency cricothyroidotomy. Mil Med172: 1228–1230. PMID: 18274018
  • Quick, JA, MacIntyre, AD, and Barnes, SL. 2014. Emergent surgical airway: comparison of the three-step method and conventional cricothyroidotomy utilizing high-fidelity simulation. J Emerg Med46: 304–307. PMID: 24188608