Specific Issues That Affect Evaluation And Treatment

Needle cricothyroidotomy is the preferred emergency surgical airway in children under the age of approximately 12 years who cannot be intubated orotracheally or nasotracheally. A 12- or 14-gauge catheter over a needle will support ventilation and oxygenation in a child until a tracheostomy can be performed in the operating room by a surgeon familiar with the anatomy of a child's neck. Surgical cricothyroidotomy should not be considered. The larynx is easily damaged by surgical cricothyroidotomy, and younger individuals have a higher incidence of late airway complications. 2

Associated Injuries

The standard indications for an airway in emergency patients are mentioned below; however, some specific types of trauma usually have a greater need for a surgical airway.

Penetrating trauma to the neck (gunshot or stab wound) that injures a major artery (carotid, vertebral, or thyroid) demonstrates an expanding hematoma around the injured artery and may cause obstruction of the airway by pressure. The need for a surgical airway should be anticipated. Infrequently, free blood from concomitant vascular and pharyngeal or tracheal injuries spills into the oro- or hypopharynx and causes severe aspiration of blood; in such cases a cuffed tube (surgical cricothyroidotomy, not needle cricothyroidotomy) is needed. Difficulty in establishing an airway occurs in approximately 10 percent of penetrating cervical trauma cases.3

Blunt trauma to the neck or face may cause hemorrhage of the soft tissues or injury to the trachea or larynx itself. The trachea may become detached from the larynx at the level of the first tracheal ring, and the larynx or the trachea itself may become ruptured. In either of these rare circumstances, an emergency tracheostomy is required. This procedure should be performed by someone with experience in surgery of the neck. It is difficult to perform as an emergency tracheostomy, especially with an awake patient who is becoming hypoxic and combative. Severe edema of the larynx or, rarely, fracture of the cartilages of the larynx may obstruct the airway.

In blunt facial trauma, the principal cause of death is obstruction of the airway. This occurs for several reasons. In patients with mandibular fractures, the loss of supporting structure for the tongue allows the base of the tongue to fall back into the hypopharynx and obstruct the airway. Also, these patients, placed supine and with major facial bleeding, will aspirate blood continuously.

Type of Emergency Airway and Tube Selection

Surgical cricothyroidotomy is always preferred over needle cricothyroidotomy (except for children under 12 years of age, as noted above) simply because of the larger diameter of the 6-mm (internal diameter) endotracheal or tracheostomy tube compared to the needle cricothyroidotomy catheter. Adequate ventilation is crucial in the early prevention of cerebral edema after brain injury. Ventilation is practically impossible through a 14- or 12-gauge catheter. Emergency tracheostomy is rarely indicated and extremely difficult to perform. This procedure should be performed only by physicians who are familiar with surgical anatomy and skilled with the procedure.

A tracheostomy tube is preferred to an endotracheal tube for several reasons. A tracheostomy tube has an obturator, which makes entry through the narrow cricothyroid membrane easier. The tracheostomy tube is shorter and therefore easier to suction through. Most important, it has phalanges on each side that allow it to be sutured to the neck and secured with a cloth ribbon around the neck (Fig 16-1). The endotracheal tube (when used for cricothyroidotomy) is very difficult to affix to the neck and moves easily no matter how well secured with adhesive tape. Unfortunately, many emergency departments are not stocked with tracheostomy tubes because of their infrequent need, or when they are stocked, they may not be readily available. Therefore, an endotracheal tube is most commonly used and is readily available. When a tracheostomy tube becomes available, a tube change can be made using the Seldinger technique; a suction catheter with the suction vent cut off at one end is readily available and easy to use.

The diameter of the tube inserted is crucial. A 6-mm tracheostomy or 6-mm endotracheal tube is preferred (never larger than 7 mm in either case). Tubes with diameters larger than 7 mm are difficult to insert in the narrow space between the cricoid and thyroid cartilages. If airway pressures are high with the small-diameter tube, the cricothyroidotomy tube may be changed to a tracheostomy or endotracheal tube with a larger diameter at a later, convenient time.

Conversion from Cricothyroidotomy to Tracheostomy

The question frequently arises as to how long to leave a cricothyroidotomy tube in place in the larynx. A tube left in the narrow space between the cricoid and thyroid cartilages can erode both cartilages, and a bacterial chondritis may occur. The cartilages will be destroyed and eventually scar, leading to stenosis and loss of the function of the larynx. Because cricothyroidotomy has a higher incidence of airway stenosis, a cricothyroidotomy should be converted to a tracheostomy. 4 As a rule of thumb, if the airway will be needed for more than 2 to 3 days, the cricothyroidotomy should be changed to a tracheostomy. Otherwise, the cricothyroid tube may stay in place.

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