Danger Zone E001 – Surgical Airway

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Episode 1 – Surgical Airway

In this episode of Danger Zone, our hosts examine a relatively rare procedure performed in the ED – the Surgical Airway! They discuss indications, procedural considerations and important clinical pearls.

Key Concepts

  1. Cricothyrotomy is indicated for all patients who have deemed to be presenting with a C.I.C.O airway – can’t intubate, can’t oxygenate. Potential conditions that can produce this nightmare airway include but are not limited to:
    1. Massive GI bleed or hemoptysis 
    2. Profound emesis 
    3. Trismus secondary to a multitude of pathologies
    4. Obstructing airway lesions (e.g., tumor, polyps)
    5. Upper airway occlusion (e.g., from foreign body, edema, anaphylaxis)
    6. Maxillofacial trauma/traumatic airway obstruction
  2. There are no absolute contraindications for cricothyrotomy and placement of a surgical airway.
  3. Relative contraindications for cricothyrotomy include:
    1. Other means of airway control (e.g., SGA) can be used successfully
    2. Fracture of the larynx
    3. Laryngotracheal disruption
    4. Transection of the trachea with retraction of the distal trachea into the mediastinum
  4. While cricothyroidotomy is still performed in children, surgical cricothyroidotomy is relatively contraindicated in pediatric patients <12 years. In these patients, you would instead perform a needle cricothyroidotomy
  5. There are multiple techniques that will allow you to place a surgical airway. Learn one for surgical cricothyroidotomy and one for needle cricothyroidotomy and practice regularly.
  6. While knowing this content is foundational, be cognizant of the fact that it is exceedingly rare to perform either of these critical airway procedures in the ED. If you are working in a tertiary care centre with specialist support and are considering the need for placement of a surgical airway, consult early.

Procedure Breakdown

Clinical Pearls: 

  1. While knowing this content is foundational, be cognizant of the fact that it is exceedingly rare to perform either of these critical airway procedures in the ED. If you are working in a tertiary care centre with specialist support and are considering the need for a surgical airway, consult early.
  2. There are multiple techniques that will allow you to place a surgical airway. Learn one for surgical cricothyroidotomy and one for needle cricothyroidotomy and practice regularly.
  3. If time permits, take the time to thoroughly prepare for a surgical airway. This involves some forethought when developing your airway plan and the following:
    1. Prebriefing your team that you may need to perform emergent cricothyroidotomy and that when the decision is made, complete buy-in and synchrony is needed
    2. Landmarking appropriately and noting the location of the CTM with indelible ink 
    3. Having a double set-up in cases where there a reasonable suspicion that a surgical airway may need to be placed

1) Indications

This is a classic on-shift pimp question given to junior and senior residents alike. Cricothyrotomy is indicated for all patients who have deemed to be presenting with a  C.I.C.O airway – can’t intubate, can’t oxygenate. That is to say, you have a patient requiring advanced airway management, but attempts to capture the airway definitively or with other advanced airway technologies have failed or are projected to fail.  Potential conditions that can produce this nightmare airway include but are not limited to:

  • Massive GI bleed or hemoptysis 
  • Profound emesis 
  • Trismus secondary to a multitude of pathologies
  • Obstructing airway lesions (e.g., tumor, polyps)
  • Upper airway occlusion (e.g., from foreign body, edema, anaphylaxis)
  • Maxillofacial trauma/traumatic airway obstruction

2) Contraindications

Absolute Contraindications

This is one of the most important take homes from the episode today: THERE IS NO ABSOLUTE CONTRAINDICATION FOR CRICOTHYROIDOTOMY!

This procedure largely exists as a last resort to rapidly capture the airway of a patient that is rapidly deteriorating. If you wait too long to begin this procedure, your patient will only decompensate further.

Relative Contraindications

There are few reactive contraindications that you must consider when you forecast an emergency cric is fast approaching. These are:

  1. Other means of airway control (e.g., SGA) can be used successfully
  2. Fracture of the larynx
  3. Laryngotracheal disruption
  4. Transection of the trachea with retraction of the distal trachea into the mediastinum

Pediatric Considerations

While cricothyroidotomy is still performed in children, surgical cricothyroidotomy is relatively contraindicated in pediatric patients <12 (this age cut-off varies depending on the source). In these patients, you would instead perform a needle cricothyroidotomy (detailed in subsequent sections). This relative contraindication is largely due to:

  • The anatomic region with the greatest narrowing in pediatric patients is the cricoid cartilage, thus the risk for developing subglottic stenosis following this procedure increases
  • Increased risk of damage to the cricoid cartilage. Given that this structure is the only circumferential support for the trachea, if you damage it, the patient is at risk for future complications with airway stability in the future
  • The cricothyroid membrane is small and poorly developed in young children, making a surgical cricothyroidotomy quite difficult

3) Procedural Steps

Surgical Cricothyroidotomy

Preparation

  • While surgical cricothyroidotomy is often thought of as a procedure that is typically done without much preparation at all, this should not be the case in the vast majority of cases
    • Taking time to adequately formulate an airway management plan is essential when dealing with the potentially difficult airway
  • If you plan adequately, often you have time to prepare for a “double-set-up” intubation procedure in which you have all of the materials/team necessary to both place an advanced airway device AND a surgical airway. If the former fails, the latter procedure can be performed as quickly and effectively as possible
  • If you anticipate that a patient may require a surgical cric to secure their airway, plan ahead by landmarking the cricothyroid membrane
    • The anatomic borders of the CTM are the thyroid cartilage which exist cephalad, the cricoid cartilage that exists inferiorly, and the cricothyroideus muscles laterally
      • The CTM is usually 2 cm inferiorly to the laryngeal prominence of the thyroid cartilage in adults; in some patients, a slight depression may be palpable
    • In patients in whom you are anticipating may need a surgical airway, consider using ultrasound to locate the CTM
  • Once the airway is landmarked, consider using a skin pen to mark the CTM
  • If you anticipate you may need to secure a surgical airway, the next step is to ensure you have the neck prepped, cleansed, and draped
  • If possible, ensure you involve other physicians that can assist with this procedure (e.g., Anesthesia, General Surgery, etc…) 
  • Ensure to brief your ED team before the procedure if possible 

Materials

  1. Scalpel 
  2. Bougie
  3. Size 6-0 ETT

Steps

Remember, there are multiple techniques that can be used to perform this procedure successfully. Here, we present the “knife-finger-bougie” technique, as it is one of the most commonly cited. 

  1. Extend patient’s neck to ensure access to the relevant structures is optimized 
  2. Stabilize cartilage using the non-dominant hand, using the laryngeal handshake maneuver (i.e., palpate the CTM with the index finger and stabilise the larynx with the thumb and middle finger).
  3. Holding the scalpel in the dominant hand, stabilize your forearm on the patient’s sternum
  4. Create a vertical incision measuring approximately 4 cm through the skin above the CTM (or from mandible to sternum if anatomy not readily visible; others recommend use other measurements to increase their chances of success, for example by using the 4-finger technique or cutting at the neck crease and using your non-dominant index finger to re-orientate yourself to the anatomy)
  5. Palpate the CTM and dissect bluntly with fingers through the subcutaneous tissues until you can clearly identify the membrane
    1. Note: There will be a decent amount of bleeding after this is done. Ignore it until the airway is secured, as the ETT tamponades most of the bleeders once inserted
  6. Next, make a horizontal incision through the membrane by pulling the scalpel from one to the other and then rotating it 180 degrees to extend the other aspect of the CTM – stop when you feel the resistance of the cartilaginous cage of the CTM
  7. Use your pinky finger to dilate the incision and to palpate through the cricothyrotomy to identify the solid back wall of the cricoid cartilage
  8. Insert the bougie along the little finger into the trachea approximately 10 cm until you feel the resistance of the carina
    1. Note: do not force the bougie past this point as you may perforate the carina
  9. Use your little finger to then ensure the bougie passes through the membrane
  10. While stabilizing the bougie with your non-dominant hand, pass a size 6 ETT (with the ballon deflated) over the bougie and into the trachea, using a gentle twisting motion to pass it through the skin
    1. Ensure the ETT is advanced until the balloon is within the airway and no longer visible 
  11. Secure the ETT, then remove bougie
  12. Connect ETT to BVM or ventilator and use ETCO/other adjuncts to confirm tube placement
  13. Get a CXR to determine depth of the ETT

Video Tutorial

Several video tutorials exist in the FOAM realm. Check out the following videos to solidify your approach to the surgical airway:

Needle Cricothyroidotomy 

Preparation

As described in above section

Materials

  1. 14G IV with Cathlon
  2. 5 cc syringe
  3. 3 cc syringe
  4. 1-2 cc 0.9% NS
  5. Size 7 ETT connector

Steps

  1. Connect the 14G IV with Cathlon to the 5 cc syringe and draw up 1-2 cc NS into the syringe itself
  2. Extend patient’s neck to ensure access to the relevant structures is optimized 
  3. Stabilize cartilage using the non-dominant hand, using the laryngeal handshake maneuver (i.e., palpate the CTM with the index finger and stabilise the trachea with the thumb and middle finger) to identify the CTM
  4. Using your dominant hand, insert the 14G needle into the skin at a 45 degree angle caudally, ensuring you aspirate continuously until you are in the airway
  5. Once you see bubbling in the syringe, stop inserting
    1. Note: Do not aspirate when not advancing, as you may cause false atmospheric air aspiration
  6. Use your non-dominant hand to stabilize the IV cannula hub and release the plunger of the syringe – if it sucks back into the syringe barrel, you are not in the tracheal lumen. If it stays in position, the IV cannula is in place, you are in the clear!
  7. Use your dominant hand now to stabilize the needle/IV cannula, using the chin or neck 
  8. Advance the cannula over the needle into the trachea and remove the trochar
    1. Note: Ensure the plastic cannula is inserted before you remove the needle, as it will easily bend and kink
  9. Re-check cannula placement by using the syringe to once again aspirate, using bubbling and plunger movement to determine accuracy of location
    1. If initial aspiration fails, gently withdraw the catheter while aspirating – free air aspiration thereafter likely suggests the cannula tip was impacted against the posterior wall of the trachea
  10.  Remove the 5 cc syringe and attach a 3 cc syringe with the connector tip from a size 7 ETT to the cannula
  11. Secure set up, ensuring the cannula is not dislodged
  12. Attach BVM or ventilator

Video Tutorial

Several video tutorials exist in the FOAM realm. Check out the following videos to solidify your approach to the surgical airway:

Needle Cricothyroidotomy step-by-step video

Surgical Airway Clinical Pearls

1) While knowing this content is foundational, be cognizant of the fact that it is exceedingly rare to perform either of these critical airway procedures in the ED. If you are working in a tertiary care centre with specialist support and are considering the need for placement of a surgical airway, consult early.

2) There are multiple techniques that will allow you to place a surgical airway. Learn one for surgical cricothyroidotomy and one for needle cricothyroidotomy and practice regularly.

3) If time permits, take the time to thoroughly prepare for a surgical airway. This involves some forethought when developing your airway plan and the following: prebriefing your team that you may need to perform emergent cricothyroidotomy and that when the decision is made, complete buy-in and synchrony is needed; landmarking appropriately and noting the location of the CTM with indelible ink; and having a double set-up in cases where there a reasonable suspicion that a surgical airway may need to be placed.

This post was copyedited by Emily Stoneham

Staff reviewer: Dr. Phil Davis

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Dillan Radomske

Dillan Radomske

Dillan Radomske is an Emergency Medicine resident at the University of Saskatchewan. He is passionate about technology-enhanced medical education, podcast creation and production, and Indigenous advocacy. He is one of the new CRACKCast hosts, and aspires to continue to contribute to the field of FOAMed in the future.
Dillan Radomske
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Owen Scheirer

Owen Scheirer

Owen is a resident in the FRCPC Emergency Medicine program at the University of Saskatchewan. When he's not running around the emergency department, he's hanging out with his wife, new baby girl, and dog. Spare time = climbing and cycling!
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