With all anticipated difficult airways, the initial management plan should include plans for a failed airway, including anticipation of the potential need for a cricothyroidotomy. In our new review on penetrating neck trauma, we describe both the standard technique for this lifesaving procedure and a new bougie-assisted technique.
It is important to remember that a cricothyroidotomy is a reasonable choice unless the larynx and cricoid are clearly disrupted or the injury is below the level of the cricothyroid membrane. To bypass the damaged portion of the trachea and ensure a secure airway, a tracheostomy may need to be performed. Many emergency physicians practice in environments where such an appropriately skilled surgeon is not available, and they should be prepared to perform a tracheostomy if a more familiar technique is not adequate. For a full description of the procedure, please refer to the detailed description in our new penetrating neck trauma review. The essential changes in the bougie-assisted technique, outlined below, make the procedure much less likely to result in misplacement and failure.
As with the standard technique, a skin incision should be extended above and below the level of the cricothyroid membrane and be extended rapidly through the subcutaneous tissue. This large vertical incision allows access to more of the anterior surface of the airway and improves visualization by decreasing the chance of injury to the anterior jugular veins. After the skin and the subcutaneous tissue have been divided, an incision should be made through the cricothyroid membrane. This is most rapidly done with a No. 11 scalpel blade. The posterior wall of the cricoid cartilage should protect the structures behind the airway when making the stab incision through the cricothyroid membrane. After the incision has been made, it can be enlarged by using a tracheostomy hook on the thyroid cartilage or by placing the knife handle in the incision and twisting it 90º. At this point, the bougie-assisted technique diverges from the standard technique in that placement of the endotracheal tube into the trachea is facilitated by first passing the coude tip of a gum elastic bougie into the incision. The tracheal rings can be palpated with the bougie as it is advanced, increasing confidence that the operator is in the airway and not a false lumen. The endotracheal tube can then be passed over the bougie and into the trachea by a Seldinger technique [see Figure]. This facilitates passage and helps ensure that the lumen is not accidentally allowed to close by operators who perform these procedures infrequently.