22.10c Open Cricothyrotomy

An open, or surgical, cricothyrotomy involves placing an endotracheal or tracheostomy tube directly into the trachea through a surgical incision at the cricothyroid membrane.

Open cricothyrotomy is preferred to needle cricothyrotomy in older pediatric patients and adult patients because it allows for enhanced oxygenation and ventilation and protects the airway against aspiration.

However, the increased potential for complications with open cricothyrotomy mandates even more training and skills monitoring than for the needle method.

Indications are the same as for needle cricothyrotomy.

Contraindications are the same as for needle cricothyrotomy with the addition that open cricothyrotomy is contraindicated in children under the age of 8 because the cricothyroid membrane is small and underdeveloped.

The potential complications of open cricothyrotomy with jet ventilation include: incorrect tube placement; cartilage, nerve, vocal cord, or gland damage; severe bleeding; subcutaneous emphysema; infection.

With the rapid four step technique, a single incision is made horizontally through the skin and cricoid membrane and then a tracheal hook is held in the left hand and traction is applied against the cricoid membrane, directed toward the feet, and the tube is inserted with the right hand, mimicking endotracheal intubation.

In some studies, this technique has been associated with more complications than the traditional technique.

An endotracheal tube introducer (bougie) can be used with either the traditional or the rapid four-step technique to minimize the risk of placement in a false passage, to allow the operator to let go without losing critical landmarks, and to ease threading of the tube.

In the simplest version of this technique, an adult bougie is passed into the trachea through the incision in the cricothyroid membrane directed distally, and intratracheal placement is confirmed with palpation of clicks as the bougie passes over the cartilage rings and/or palpation of resistance (hold-up) within 20 cm.

Note that the distance to hold-up is much shorter than when using the introducer/bougie through the mouth.

Once placement is confirmed, the endotracheal or tracheostomy tube is threaded over the bougie into the trachea.