Despite advanced airway management options like mask ventilation supraglottic airways, there is still a role for cricothyrotomy in the ED. Here are some tips on when to use cricothyrotomy and tricks on performing the surgery

Crics should be considered a first-line approach in situations of the “surgically inevitable airway.” These are cases in which mask ventilation, supraglottic airways (LMA/King LT), and passive oxygenation will not work.

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ACEP Now: Vol 33 – No 02 – February 2014

Part one of a two-part series.

Thirty years ago, when airway management options only included direct laryngoscopy and mask ventilation, cricothyrotomy was used routinely if laryngoscopy and mask ventilation failed. Now, the laryngeal mask airway (LMA) and other supraglottic airways allow us to rescue ventilate in 95 percent of mask-ventilation failures. Video laryngoscopes (and fiber optics via LMA) now allow intubation in many instances of difficult or impossible direct laryngoscopy. New techniques of pre-oxygenation, positioning, and apneic oxygenation (ie, nasal oxygen during efforts securing a tube, or NO DESAT) can markedly prolong safe apnea. Better ventilation strategies (low volume, low pressure, positive end-expiratory pressure [PEEP] valves, nasal cannula with bag-valve-mask [BVM] use) improve oxygenation and also reduce the risk of regurgitation. We are no longer bound to one attempt at intubation before hypoxemia leads to desperate bagging and a surgical airway.

What is the role for cricothyrotomy in this era of many devices and better oxygenation and ventilation techniques? Crics should be considered a first-line approach in situations of the “surgically inevitable airway.” These are cases in which mask ventilation, supraglottic airways (LMA/King LT), and passive oxygenation will not work. Surgically inevitable airways are trauma cases in which a surgical airway will be required as part of the patient’s near-term management. The prototypical example is a severe blast injury to the lower face. Distorted anatomy coupled with blood/vomit is a serious problem—it is bad for laryngoscopy, mask ventilation, LMA, and King LT use, as well as passive oxygenation via mouth or nose. Rapid sequence intubation (RSI) must be avoided in these cases; an awake surgical airway (with or without ketamine) is the safest option. Not all instances of distorted anatomy require an immediate surgical airway; without bleeding or vomit, an awake, fiber-optic, or other non-RSI technique may be worth trying in angioedema and other oral-pathology circumstances. Because there is no guarantee of being able to rescue ventilate, a surgical approach may be emergently needed if the patient deteriorates. Instances involving massive fluids (blood/vomit) even without distorted anatomy may trigger a surgical airway when epiglottoscopy and other landmark identification are impossible along with the inability to oxygenate and/or ventilate. If intubation fails in cases with intrinsic laryngeal pathology (eg, laryngeal tumor, high-grade laryngeal fracture), a surgical airway is necessary below the level of the pathology (ie, tracheotomy instead of a cricothyrotomy).