The Sphincter Series: Emergent Cricothyrotomy

Author: Francesca Civitarese, DO (EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital)

Editors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

Cricothyrotomy (CT) as a Primary Airway maneuver vs. an Airway Salvage Technique

What is a failed airway?

There are many definitions of a “failed airway,” and there have been many attempts to simplify emergency airway management with algorithms, whether they originate from the anesthesia or the emergency medicine literature. It can help to evaluate the airway in stepwise fashion, and Walls, et al.1 describes the basic airway algorithm as a response to 5 basic questions reviewed below:

  1. Is this a crash airway?
  2. Is this a difficult airway?
  3. If not #1 or #2, after an attempt at rapid sequence intubation (RSI), was it successful?
  4. Can the patient’s oxygenation be maintained if it was not successful?
  5. Have 3 attempts been made at orotracheal intubation by an experienced operator?

It is this final question in the basic airway algorithm that addresses the “failed airway.” Walls defines three essential definitions of “failed airway” scenario, with one being the “Can’t intubate, Can’t Oxygenate (CICO),” the second being 3 failed attempts by an experienced clinician, and the final being a failed intubation in the “single best attempt” forced-to-act scenario, where oxygenation may be possible with BVM but was not initially attempted due to acuity/urgency of situation.

Who is an experienced clinician? Typically, an attending. So, if a resident made three failed attempts and the patient can still be oxygenated adequately, 3 subsequent attempts by the supervising physician can be made before it is considered failed. There are always caveats to every guideline, and at any point, the airway can be considered failed if the anatomy is deemed unfavorable, oxygenation/ventilation is not possible, or if further attempts/adjustments are unlikely to be successful, in which case the “failed airway algorithm” should take over immediately.

In the failed airway scenario, step I should be always to call for help, whether that be in the form of another ED doc, advanced airway equipment such as video laryngoscope or fiberoptics, or additional back up in the form of more personnel, like additional nurses, medics, anesthesia, surgery, etc.

The critical step in this algorithm is to identify if oxygenation is adequate with BVM. If not, cricothyrotomy is indicated. If oxygenation is possible, you may be able to achieve orotracheal intubation with fiberoptics or video laryngoscopy, but the end point for a failed airway if these maneuvers are unsuccessful is cutting the neck.1

Studies that were reviewed for this article describing emergency airway management by ED physicians report cricothyrotomy rates ranging from 0.4% to 1.2%.2-9

What about pediatric patients?

The pediatric larynx is more compliant and funnel-shaped. Because of these anatomical differences, it is contraindicated (in most pediatric literature) to perform a cric in children < age 8 years. There are several other textbook sources that give possible cric age ranges from 5-10 years. ACLS and PALS define the infant airways as up to 1 year, and the child airway from age 1 to age 8 years. The pediatric alternative to cricothyrotomy is trans-tracheal jet ventilation.1,10

Why is a Cric a scary airway?

Usually, when emergency medicine docs think of cricothyrotomy (CT), it is in the “failed airway” scenario…the dreaded “can’t intubate, can’t oxygenate,” or the CICO. However, there are some primary indications for cricothyrotomy, in which a surgical airway can be attempted under more “controlled” circumstances as a primary maneuver, but most of these typically fall into the “scary airway” category as well.

Although the primary indication for CT is inability to secure the airway with noninvasive techniques, there are several additional scenarios to consider CT. We will review the most common scenarios below.

Indications:
Cannot intubate/cannot oxygenate
No oral access
Masseter spasm, clenched teeth, or trismus
Structural upper airway deformities (acquired, traumatic, or congenital)
Laryngospasm
Massive upper airway hemorrhage or emesis obscuring airway from orotracheal or nasotracheal approach
History of upper airway stenosis or history of previous failed airways
Mass effect or displacement of trachea from cancer, tumor, polyps, webs, or hematoma, etc
Airway swelling (angioedema, Deep space neck infections, hematomas, etc)
Massive facial trauma
Awake intubation is desired but not achievable
Foreign bodies in airway that cannot be easily or safely removed
No viable connection between upper airway and lower airway that would allow passage of an ETT

Cricothyrotomy: When should I consider it as a Primary Airway Maneuver?

Massive Upper Airway/Facial Trauma

In an emergent trauma airway scenario, often a surgical airway can be a viable primary maneuver for airway management. The most frequent indication for emergent Cric is often trauma related, particularly head/facial trauma.

A CT can be particularly helpful in the patient who is in cervical spine precaution immobilization, has embedded facial foreign bodies, and if the patient has massive upper facial/oral trauma that could potentially prevent successful first pass oral laryngoscopy.

Why should you potentially consider cricothyrotomy as a primary maneuver?

In severe facial trauma, there can be immediate AND delayed airway compromise, often in the form of tissue displacement, significant soft tissue swelling (even in the absence of facial fractures, often in those patients on anticoagulants or those with clotting abnormalities), or bleeding/hematoma formation, particularly in the retropharyngeal spaces in high velocity injuries.

Additionally, polytrauma patients can suffer from embedded or intraoral/airway foreign bodies (glass, tree branches, weapons, etc), traumatic brain injury (TBI), agitation either from pain/hypoxia/intoxication, vomiting (either from TBI, or because they didn’t think to not eat for 6 hours prior to their car accident and showed up with a full stomach of Cheetos and cheeseburger), or difficult to control oral/facial bleeding. To complicate matters, they are often in cervical spine precautions (supine, in a hard collar), which inevitably makes your job as an airway clinician more difficult and places the patient at high risk for aspiration.

If a difficult airway is anticipated, and orotracheal intubation is unlikely to be successful, cricothyrotomy in these cases may provide a more secure airway with fewer risks to the patient that may be induced by multiple oral airway attempts, such as provocation of vomiting/aspiration, increased intracranial pressure/blood pressure, increased intraocular pressures, etc.11

Angioedema

Angioedema is another great reason to consider CT a primary surgical strategy. Patients with angioedema often have very tenuous airways and classically present with asymmetrical swelling of the lips, face, tongue, oro- or hypopharynx, or larynx. 

Why should you potentially consider cricothyrotomy as a primary maneuver?

The patient with angioedema may have profound oral swelling/tongue swelling, which can progress to total occlusion of the airway unpredictably or as a result of attempts to manipulate the airway with the laryngoscope. The swelling in the oropharynx can progress rapidly and ultimately may totally prevent orotracheal attempts secondary to obstruction and result in a “heroic measures” scenario.

Some studies have attempted to identify high risk locations of swelling as indicators of when you should take over the airway (either surgically or via orotracheal intubation), but ultimately, definitive airway management in angioedema is still a case-by-case scenario. Some “danger zone” swelling areas that have been identified are the anterior aspect or base of the tongue, hypopharynx, and larynx. Patients who had vocal changes, stridor, or sensation of throat swelling, stridor, associated rash, and dyspnea were more often dispositioned to the ICU and required definitive airway management more often.12-16

The cric is a great option as a primary airway maneuver for achieving a definitive airway for angioedema patients, whose airways are notoriously precarious and can rapidly worsen.

Deep Space Neck Infections

Deep space oral/neck infections can, like angioedema airways, progress rapidly and ultimately occlude a patient’s airway, using the superhighway of fascial planes that run from the oropharynx to the mediastinum. A few of the commonly reviewed deep space neck infections include necrotizing cervical fasciitis, Lemierre Syndrome, and Ludwig’s Angina, the name of which is derived from the Latin term “angere,” or “to strangle.” 17 With a name like that, one should be uber-prepared to manage a potentially difficult airway.

Why should you potentially consider cricothyrotomy as a primary maneuver?

Patients with deep space neck infections are often toxic appearing, hypoxic, panicked, and can have severe trismus, which may severely limit oral access to the airway. Additionally, patients may be VERY reluctant to lie flat, as it can precipitate closure of an already narrowed and distorted airway, and have limited neck mobility. Standard orotracheal intubation would obviously be complicated by all of the above, in addition to the patient having relatively difficult to manipulate soft tissues due to indurated and swollen submandibular spaces. Endotracheal intubation, on top of the above complications, can precipitate rupture of a pharyngeal wall abscess and subsequent aspiration of pus. These airways are similar to angioedema patients in that they are often rapidly progressive, unpredictable, and can be compromised easily with excessive manipulation.18,19

In select cases, orotracheal intubation can be attempted; however, these airways often require more delicate management. You can obviously consider awake fiberoptics for direct airway visualization and intubation. If this is not available at your facility or you do not feel particularly comfortable with this strategy, the scalpel is your friend and cricothyrotomy may be your primary maneuver. Additionally, another option is awake tracheostomy under local anesthesia, which in much of the reviewed literature remains the “gold standard” for airway management in deep space neck infections, but this may require consultation with a subspecialist if you are not trained in this technique.20-21

In a retrospective analysis of 85 patients undergoing airway intervention for deep space infections evaluating tracheostomy versus endotracheal intubation, it was found that those who had primary tracheostomy for airway management in deep space neck infections had lower rates of complications and airway loss, shorter overall hospital stay, less time in the ICU, and lower average hospital stay costs. Granted, this involves tracheostomy, but it does provide some interesting points.22 

Other Potential Indications for Primary Cricothyrotomy7

  • In patients with structural deformities of the upper airway (masses, congenital, hematoma, etc) or scenarios with limited/no oral access: trismus, masseter spasms, clenched teeth, surgical mandible wiring in place.
  • Patients who have a known history of upper airway stenosis/multiple prior failed airways. Remember though, if these patients have required a tracheostomy or cricothyrotomy in the past, you may run into significant scar tissue or distorted anatomy from the prior surgical interventions.
  • Foreign bodies/copious matter occluding access to the oral airway.
  • Crashing patient, with no IV access. 

What Do I Need?

EQUIPMENT: (the bare essentials)

-11 blade scalpel

-Trousseau dilator

-Tracheal hook (or a bent 18G needle)

-Trach or ETT (cuffed, 6-0)

-Shiley #4 (has outer diameter of 9.4mm)

**A note on Tube Size: “Since the average size of the cricothyroid membrane in the adult is about 22 to 30 mm wide and 9 to 10 mm high, the tube ideally should have an outer diameter no greater than 8.5 mm.”23

The MacGyver Version:

-11 blade scalpel

-Bent 18G needle, or towel clamps  (both optional, meant to allow improvement in exposure)

-Bougie

-Trach or ETT

 The Fancy Equipment: a brief walk-through the different types of Cric kits24,25

Three Different Seldinger kits:

  • Arndt emergency cricothyrotomy catheter set (Arnd) (Cook, Bloomington, IL, USA

Arndt

  • Melker emergency cricothyrotomy (Mlkr) (Cook, Bloomington, IL, USA)

Melker1

Melker2

  • Minitrach II (Mini) (Smiths Medical Ltd, Hythe, UK)26

MinitrachII

The common thread with the above kits is the performance of an initial skin incision before incising the cricothyroid membrane with either a needle attached to a syringe with saline or a scalpel. Some of these kits utilize a guidewire inserted through the needle, after which the needle is removed and a specially designed endotracheal tube is threaded over the guidewire/obturator, or the ETT is fashioned connected to the obturator/dilator. After the ETT is placed, the guidewire/obturator is removed, and the patient can be ventilated. 24-26

Non Seldinger Kits Across-the-World

  • The Airfree coniotomy set (Airf) (FRC Medizintechnik, Holzheim a.F., Deutschland)
  • Patil’s airway (Pati) (Cook, Bloomington, IL, USA)
  • Portex cricothyrotomy kit (PCK) (Smiths Medical Ltd, Hythe, UK)
  • QuickTrach1 kit (QT1)
  • QuickTrach2 kit (QT2) (VBM Medizintechnik GmbH, Sulz, Germany)
  • TracheoQuick emergency coniotomy set (Trqu) (Tele- flex Medical GmbH, Kernen, Deutschland)
  • Pertrach kit (Pert) (Pulmodyne, Indianapolis, IN, USA)

These kits provide custom-made cutting devices for the cricothyroid membrane, and no guidewires are used. After dilation of the wound, a specially designed endotracheal tube can be introduced into the lumen, and then the patient can be ventilated.

Open Techniques

Setting up your patient:

Ideally, you should be sterile for this procedure. You should have at least one assistant and an RT, with a BVM ready.

  1. Locate your Space: A game of feel

Cricothyroid localization is less about LOOKING for the membrane as it is about FEELING it. Try to feel EVERY neck of EVERY patient that you see to get used to what the cricothyroid membrane feels like in every size patient.

The patient’s neck should be palpated, feeling for the thyroid cartilage (superior structure to the cricothyroid membrane) and the cricoid cartilage (inferior structure). If you can hyperextend the patient’s neck, this makes palpation of the landmarks easier. Remember, sometimes the patient’s neck may be so swollen, or have such distorted tissues, that palpation may be difficult.

The cricothyroid membrane is approx. 9mm longitudinally and 30mm in the transverse axis. If soft tissue swelling or obesity is obscuring your landmarks, you can estimate the location of the membrane as being about 2-3cm inferior to the laryngeal prominence and by measuring 4 fingerbreadths above the sternal notch.

If you have a surgical marking pen, mark the neck.

  1. Collect your Supplies:

Familiarize yourself with the kits at your shop. Often, these are crash scenarios, so if you are in a hurry, grab a full Cric kit if you have it. If not, you’ll need an 11 blade scalpel, a 4-0 Shiley (cuffed) or a 6-0 or 6.5 cuffed ETT, and something to secure the trachea with while you dilate/insert the ETT or Shiley. You can use a tracheal hook if you have it, use a bent 18g needle instead, a bougie, or in the worst case scenario, needle drivers. I’d recommend a bougie at beside. This can help dilate and insure that you are in the trachea.

Test your balloon.

  1. Make the Ideal Situation out of a non-ideal scenario: Position the patient as best you can and preoxygenate if you can.

Preoxygenation: self explanatory.

Positioning: Ideally, the patient will be lying flat. Place several towel or blanket rolls under the shoulders and hyperextend at the neck. Some patients may not initially be able to lie flat, or hyperextend, because it can occlude an already narrowed airway.

  1. Use sterile technique if you can: sterile gloves, cleanse the neck, sterile drapes.
  1. Anesthetize if your patient is awake.

Ketamine can be an excellent adjunct to the semi-awake cric attempt, as it maintains respiratory drive and protective laryngeal reflexes but induces relaxation during an emergent airway scenario.

Additionally, if you have time, it’s nice to give a little subcutaneous lidocaine (use epi) and also some trans-tracheal lidocaine. Fill up a 5cc or 10 cc syringe and anesthetize where you have marked. Then, with the needle directed caudally, attempt to puncture the cricothyroid membrane and aspirate until you see bubbles in the syringe. You can then squirt a little lidocaine trans-tracheally as well for a local anesthetic.

  1. Hook up suction. Cricothyrotomies are usually bloody.
  1. Pick your Technique and Go.

Techniques:

There are several techniques for accessing the cricothyroid membrane. There has been much debate in the literature as to the fastest technique, as well as to the technique with the fewest complications.

Some of the most commonly used and researched techniques are the traditional open surgical technique, the rapid four step technique (RFST), the Bair Technique, the Bougie Assisted Cricothyrotomy (BACT), and the Melker Percutaneous Cricothyrotomy Technique.

The single hook RFST technique, Bougie Assisted Cricothyrotomy, and the Bair Technique were found to be significantly faster than the traditional open technique, with fewer complications such as cricoid cartilage fractures. Success rates across techniques seem to be similar in much of the data reviewed for this article, and is estimated to be anywhere from 89% – 100% across various studies reviewed (Roberts and Hedges). When the rapid four step technique was compared to the bougie assisted technique, it was found that the bougie assisted technique was superior with regards to time-to-secure-airway. 25, 27-31

Traditional Open Steps:32

  1. Stand on the patient’s Right side (if R hand dominant).
  2. Stabilize the larynx with the non-dominant hand.
  3. Palpate the cricothyroid membrane depression with your index finger.

(Cheater’s tip: if you have time, you can use a 5cc syringe with some saline in it and an 18g needle, and use this as a “finder”. Insert the needle caudally at 30-45 degrees, where you think the cricothyroid membrane is, aspirating as you advance. When you see bubbles in the syringe, disconnect and leave the needle in place as a guide.)

  1. With the dominant hand, make a vertical 2-3cm incision over the midline of the membrane. Expect blood: they aren’t always pretty.
  2. Re-palpate the membrane through your incision.
  3. Make a horizontal incision with the 11 blade scalpel of no more than 1cm in length, leave the scalpel in place.
  4. Put your finger in the stoma created until you can exchange the scalpel for the tracheal hook.
  5. Place the tracheal hook on the inferior portion of the thyroid cartilage and provide upward traction.
  6. Place the Trousseau dilator into the opening of the membrane and spread in the longitudinal/vertical plane.
  7. After you’ve dilated vertically, rotate the Trousseau so it is parallel to the neck in the vertical plane.
  8. Remove the inner cannula from the trach and insert the solid white obturator.
  9. Insert this whole contraption between the blades of the dilator with your thumb on the back of the obturator the entire time until it is flush with the neck. If you are using an ETT, insert only 5cm from the tip to avoid R main stem intubation.
  10. Remove the dilator, remove the obturator.
  11. Insert the inner cannula.
  12. Inflate the balloon.
  13. Carefully remove the tracheal hook (watch this step carefully, as the tracheal hook is often referred to as the “balloon popper,” upon removal you may inadvertently rupture your trach/ETT balloon).
  14. Secure in place.32

RAPID FOUR STEP TECHNIQUE:33,34

  1. Stand on the patient’s left (if you are right hand dominant).
  2. Palpate your landmarks.
  3. Using your dominant hand, make a stab incision horizontally with a #20 blade approx. 1.5cm in length through the skin, soft tissue, and the membrane.
  4. Using the scalpel as a guide, place the tracheal hook on the cricoid cartilage (and apply caudal traction).
  5. Place a #4 Shiley Cuffed tube or a 6-0 ETT through the opening (this will be a tight squeeze due to the decreased size of the hole).

BOUGIE ASSISTED CRICOTHYROTOMY:29,34

Essentially, you can either do steps 1-4 of the rapid four step technique, and then you can try to advance a bougie first, before the Shiley or the ETT.

Alternatively, and often the more preferred route is below:

  1. Palpate membrane with your non-dominant index finger, securing larynx with other fingers.
  2. Make a vertical incision of approx. 2-3cm over membrane with 11 blade.
  3. Repalpate the membrane through the initial incision.
  4. Make a horizontal stab incision through the cricothyroid membrane.
  5. Pass a bougie through the horizontal stab incision site.
  6. Pass the ETT or shiley over the bougie.
  7. Secure in place.

For a great FOAM blog with videos, go here: http://emcrit.org/procedures/bougie-aided-cric/

Bougie assisted techniques may be helpful to confirm placement in the trachea and not the soft tissues of the neck. It secures the lumen of the trachea and allows you to pass the ETT or the Shiley over the bougie.29,34

Remember, advance the bougie until you feel it stop, which can help confirm tracheal (and not soft tissue) placement. Also of note, you don’t have to bury the ETT. If you felt the bougie make a hard stop, passed your ETT, and aren’t able to bag the patient easily, you may have advanced the ETT too far. Try to retract slowly and bag to evaluate for improvement on the way backwards.

THE BAIR TECHNIQUE:

Very similar to the rapid four step technique, but instead of using a single tracheal hook, it uses a “bair claw” device. This is essentially a double hook used to spread the opening. It looks similar to a towel clamp.

Additionally, the Bair technique advocates for you standing at the head of the bed as opposed to the side of the patient.35

THE MELKER TECHNIQUE:36

This is a kit that can be typically found in emergency departments across the country. The difference with this technique is that it doesn’t use a skin incision, so you MUST be able to clearly palpate the landmarks.

The process is very similar to Seldinger technique central line placement.

  1. Palpate the membrane with your non-dominant hand.
  2. Attach the needle with the flexible catheter to a syringe with saline and insert through the membrane caudally at a 45 degree angle, aspirating as you advance until you see bubbles.
  3. Advance the catheter, remove the needle and the syringe.
  4. Thread the guidewire through the catheter.
  5. Remove the catheter.
  6. With the provided #15 scalpel, make a small incision at the skin.
  7. Thread the trach kit with the grey tipped dilator over the guidewire and into the trachea and advance the airway catheter to the hub until it is flush with the skin
  8. Remove the guidewire and dilator.
  9. Secure the kit with “trach tape.”36

The Scalpel-Finger-Tube Technique:

In a small study of 24 emergent surgical airway cases, the scalpel-finger-tube technique was used successfully in majority of both the field (13 cases) and the ED (9 cases), as well as a few in the ICU and operating theater. The authors advocated for the use of a “little finger” as the dilator to confirm placement because it was readily available in a time-critical situation and could simultaneously confirm placement and dilate the wound to a sufficient size to allow passage of the tube. They also cited tactility and sensation of the finger as an advantage to this method, and critical in field situations, when in darkness or patient entrapment scenarios direct visualization is difficult or impossible.37

  1. Secure larynx with non-dominant hand at the thyroid cartilage.
  2. Identify the cricothyroid membrane with palpation.
  3. Make a single horizontal incision through skin, soft tissue, and membrane (approx. 15mm).
  4. Stick your pinky finger through the membrane to dilate and insure that it is large enough for cuffed tube passage.
  5. Insert cuffed tube.

ERRORS and COMPLICATIONS: A Few Bullet Points on The Ways We Screw This Up38,39

-Failure to secure airway.

-Prolonged attempt (>2min), most studies reviewed for this article identify an “upper limit” between 180 and 300 seconds, but 40 seconds more realistic in a “can’t intubate/can’t ventilate scenario.”38,39

-Incorrect initial incision.

-Misplacement of ETT (pretracheal, with insufflation).

-Hemorrhage… the inability to control it, that we didn’t expect it, or it just plain freaks us out.

-Cartilaginous injury.

-Injury to posterior airway/esophagus.

-Initial incision requiring revision.

-Misplacement of tube without insufflation.

-First operator failure (procedure has to be taken over by 2nd operator).

-Alternatives/devices, surgical alternatives to cric in a failed airway (nasotracheal, percutaneous jet insufflation).7,40

Can I use Sono for Doing A Cric?

A few articles and podcasts/FOAM resources have started to push for the use of ultrasound, which could be particularly helpful in identifying the cricothyroid membrane in the “primary cric for the distorted airway/swollen airway/obese patient” population. Below are some resources for your perusing pleasure:

  • Curtis K, Dawson M, Mallin M. Episode 19: ultrasound guided cricothyrotomy. Available at: www.ultrasoundpodcast.com/2012/01/episode-19-full-cric/.
  • Weingart S, Curtis K, Dawson M, Mallin M. Episode 20: EMCRIT Cric, commentary. Available at: www.ultrasoundpodcast/2012/01/episode-20-emcrit-cric- commentary/.
  • Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark identification for cannula cricothyroidotomy. Anaesthesia 2010;65(9): 889–94.
  • Curtis K, Ahern M, Dawson M, Mallin M. Ultrasound-guided, Bougie-assisted Cricothyroidotomy: A Description of a Novel Technique in Cadaveric Models. Academic Emergency Medicine. 2012;19(7):876-879.
  • Sofka C. Bedside Sonography by Emergency Physicians for the Rapid Identification of Landmarks Relevant to Cricothyrotomy. Ultrasound Quarterly. 2009;25(1):25.
  • Nicholls S, Sweeney T, Ferre R, Strout T. Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy. The American Journal of Emergency Medicine. 2008;26(8):852-856.
  • Mallin M, Curtis K, Dawson M, Ockerse P, Ahern M. Accuracy of ultrasound-guided marking of the cricothyroid membrane before simulated failed intubation. The American Journal of Emergency Medicine. 2014;32(1):61-63.

References / Further Reading:

  1. Walls R, Murphy M. Manual of Emergency Airway Management. 4th ed. Philadelphia, PA: Lippincott Williams; 2012.
  2. Calderon Y, Gennis P, Marinex C. Intubations in an emergency medicine residency: the selection and performance of intubators. Academic Emergency Medicine. 1995;(2):411-412.
  3. Sakles J, Laurin E, Rantapaa A, Panacek E. Airway Management in the Emergency Department: A One-Year Study of 610 Tracheal Intubations. Annals of Emergency Medicine. 1998;31(3):325-332.
  4. Tayal V, Riggs R, Marx J, Tomaszewski C, Schneider R. Rapid-sequence Intubation at an Emergency Medicine Residency: Success Rate and Adverse Events during a Two-year Period. Acad Emergency Med. 1999;6(1): 31-37.
  5. SAGARIN M, CHIANG V, SAKLES J, BARTON E, WOLFE R, VISSERS R et al. Rapid sequence intubation for pediatric emergency airway management. Pediatric Emergency Care. 2002;18(6):417-423.
  6. Levitan R. Alternating Day Emergency Medicine and Anesthesia Resident Responsibility for Management of the Trauma Airway: A Study of Laryngoscopy Performance and Intubation Success. Academic Emergency Medicine. 2003;10(5):484-c-485.
  7. Bair A, Panacek E, Wisner D, Bales R, Sakles J. Cricothyrotomy: a 5-year experience at one institution. The Journal of Emergency Medicine. 2003;24(2):151-156.
  8. Walls R, Brown C, Bair A, Pallin D. Emergency Airway Management: A Multi- Center Report of 8937 Emergency Department Intubations. The Journal of Emergency Medicine. 2011;41(4):347-354.
  9. Bair A, Filbin M, Kulkarni R, Walls R. The failed intubation attempt in the Emergency Department: analysis of prevalence, rescue techniques, and personnel. The Journal of Emergency Medicine. 2002;23(2):131-140.
  10. Custalow C, Roberts J, Thomsen T, Hedges J. Roberts and Hedges’ clinical procedures in emergency medicine. Philadelphia, PA: Elsevier/Saunders; 2013.
  11. Perry M, Morris C. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all?. International Journal of Oral and Maxillofacial Surgery. 2008;37(4):309-320.
  12. McCormick M, Folbe A, Lin H, Hooten J, Yoo G, Krouse J. Site involvement as a predictor of airway intervention in angioedema. The Laryngoscope. 2011;121(2):262-266.
  13. GRANT N, DEEB Z, CHIA S. Clinical experience with angiotensin-converting enzyme inhibitor induced angioedema. Otolaryngology – Head and Neck Surgery. 2007;137(6):931-935.
  14. Al-Khudari S, Loochtan M, Peterson E, Yaremchuk K. Management of angiotensin-converting enzyme inhibitor-induced angioedema. The Laryngoscope. 2011;121(11):2327-2334.
  15. Brook C, Devaiah A, Davis E. Angioedema of the upper aerodigestive tract: risk factors associated with airway intervention and management algorithm. International Forum of Allergy & Rhinology. 2014;4(3):239-245.
  16. ISHOO E, SHAH U, GRILLONE G, STRAM J, FULEIHAN N. Predicting airway risk in angioedema: Staging system based on presentation Otolaryngology – Head and Neck Surgery. 1999;121(3):263-268.
  17. Wasson J, Hopkins C, Bowdler D. Did Ludwig’s angina kill Ludwig?. The Journal of Laryngology & Otology. 2006;120(05).
  18. Neff S, Merry A, Anderson B. Airway management in Ludwigs angina. Anaesth Intensive Care. 1999;(27):659-661.
  19. Visvanathan T. Crisis management during anaesthesia: obstruction of the natural airway. Quality and Safety in Health Care. 2005;14(3):e2-e2.
  20. Karkos P, Leong S, Beer H, Apostolidou M, Panarese A. Challenging airways in deep neck space infections. American Journal of Otolaryngology. 2007;28(6):415-418.
  21. Vieira F, Allen S, Stocks R, Thompson J. Deep Neck Infection. Otolaryngologic Clinics of North America. 2008;41(3):459-483.
  22. Potter J, Herford A, Ellis E. Tracheotomy versus endotracheal intubation for airway management in deep neck space infections. Journal of Oral and Maxillofacial Surgery. 2002;60(4):349-354.
  23. Milner S, Bennett J. Emergency cricothyrotomy. The Journal of Laryngology & Otology. 1991;105(11):883-885.
  24. Ivar Seldinger S. CATHETER REPLACEMENT OF THE NEEDLE IN PERCUTANEOUS ARTERIOGRAPHY. Acta Radiol. 2008;49(s434):47-52.
  25. Bair A, Sakles J. A Comparison of a Novel Cricothyrotomy Device with a Standard Surgical Cricothyrotomy Technique. Acad Emergency Med. 1999;6(11):1172-1174.
  26. Dimitriadis J, Paoloni R. Emergency cricothyroidotomy: a randomised crossover study of four methods. Anaesthesia. 2008;63(11):1204-1208.
  27. Langvad S, Hyldmo P, Nakstad A, Vist G, Sandberg M. Emergency cricothyrotomy: a systematic review. Scand J Trauma Resusc Emerg Med. 2013;21(1):43.
  28. Holmes J, Panacek E, Sakles J, Brofeldt B. Comparison of 2 Cricothyrotomy Techniques: Standard Method Versus Rapid 4-Step Technique. Annals of Emergency Medicine. 1998;32(4):442-446.
  29. Hill C, Reardon R, Joing S, Falvey D, Miner J. Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab. Academic Emergency Medicine. 2010;17(6):666-669.
  30. Armstrong L. Emergency Cricothyrotomy: A Comparative Study of Different Techniques in Human Cadavers: Prospective Review. The Journal of Emergency Medicine. 2009;37(1):111.
  31. Davis D, Bramwell K, Hamilton R, Chan T, Vilke G. Safety and efficacy of the rapid four-step technique for cricothyrotomy using a Bair Claw. The Journal of Emergency Medicine. 2000;19(2):125-129.
  32. American College of Surgeons: Committee on Trauma. Cricothyrotomy. Advanced Trauma Life Support. 2012;:58-61.
  33. Brofeldt B, Panacek E, Richards J. An Easy Cricothyrotomy Approach: The Rapid Four-step Technique. Academic Emergency Medicine. 1996;3(11): 1060-1063.
  34. MacIntyre A, Markarian M, Carrison D, Coates J, Kuhls D, Fildes J. Three- Step Emergency Cricothyroidotomy. Military Medicine. 2007;172(12): 1228-1230.
  35. Bair A, Sakles J. A Comparison of a Novel Cricothyrotomy Device with a Standard Surgical Cricothyrotomy Technique. Acad Emergency Med. 1999;6(11):1172-1174.
  36. Armstrong L. Emergency Cricothyrotomy: A Comparative Study of Different Techniques in Human Cadavers: Prospective Review. The Journal of Emergency Medicine. 2009;37(1):111.
  37. Paix B, Griggs W. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple scalpel-finger-tube method. Emergency Medicine Australasia. 2011;24(1):23-30.
  38. Salah N, Mhuircheartaigh R, Hayes N, McCaul C. A Comparison of Four Techniques of Emergency Transcricoid Oxygenation in a Manikin. Anesthesia & Analgesia. 2010;:1.
  39. Langvad S, Hyldmo P, Nakstad A, Vist G, Sandberg M. Emergency cricothyrotomy: a systematic review. Scand J Trauma Resusc Emerg Med. 2013;21(1):43.
  40. LEVITAN R, KUSH S, HOLLANDER J. Devices for Difficult Airway Management in Academic Emergency Departments: Results of a National Survey: Annals of Emergency Medicine. 1999;33(6): 694-698.
  41. Curtis K, Ahern M, Dawson M, Mallin M. Ultrasound-guided, Bougie-assisted Cricothyroidotomy: A Description of a Novel Technique in Cadaveric Models. Academic Emergency Medicine. 2012;19(7):876-879.
  42. Sofka C. Bedside Sonography by Emergency Physicians for the Rapid Identification of Landmarks Relevant to Cricothyrotomy. Ultrasound Quarterly. 2009;25(1):25.
  43. Nicholls S, Sweeney T, Ferre R, Strout T. Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy. The American Journal of Emergency Medicine. 2008;26(8):852-856.
  44. Mallin M, Curtis K, Dawson M, Ockerse P, Ahern M. Accuracy of ultrasound-guided marking of the cricothyroid membrane before simulated failed intubation. The American Journal of Emergency Medicine. 2014;32(1):61-63.

2 thoughts on “The Sphincter Series: Emergent Cricothyrotomy”

Leave a Reply

Your email address will not be published.