Airway cut-down

Modified on 2009/07/20 21:09 by Ole Losvik — Categorized as: Airway

Airway cut-down (crico-thyrotomy or emergency tracheotomy) is cutting a hole through the skin and the larynx in order to place an endotracheal tube. An airway cut-down is only done when standard endotracheal intubation is not possible.

When?

If the upper airway is blocked or partly blocked AND you cannot pass the endotracheal tube with the laryngoscope – do an airway cut-down immediately. Remember, after 4-5 minutes without oxygen the patient’s brain is damaged. With the victim lying flat on his back, extend the neck by tilting the head. Or let the head hang over the edge of a table. Or put a roll of clothes under the victim, between his shoulders.

How



The cut-down is done through the membrane between the two main cartilages of the larynx (the thyroid cartilage and the cricoid cartilage) called the crico-thyroid membrane. First identify the cricoid cartilage (c): Find the top of the chest bone in the mid line. Let your finger run up the trachea exactly along the mid line. The first “peak” of cartilage you encounter is the cricoid. Then let your finger run further upward along the mid line: Now you feel another, larger “peak” of cartilage, that’s the thyroid (t). The crico-thyroid membrane is the narrow “hollow” you feel between the cricoid and the thyroid.

Fix the larynx and cut through the skin If you stretch the skin over the larynx to the sides, then the incision will bleed less. Maintain your left-hand grip on the larynx all the time until you have cut through the membrane with your right hand. The patient is close to dying, there is no time for anesthesia or disinfection. Use any sharp knife at hand. Cut through the skin and the subcutaneous fat exactly along the mid line from the peak of the thyroid downward a few cm.

Cut through the membrane Wipe the soft tissues off the larynx with some cloth and use your fingertip to locate the crico-thyroid membrane. The membrane is just 0.5 cm to 1 cm beneath the skin. When you can see the membrane, make a decisive cut transversely through the membrane with the knife. This cut should not be more than 2 cm (one good fingertip) wide. Now you have entered the trachea and can hear air wheezing through the incision. Congratulations, you have saved a life!

Insert a tube if you have one Place one small fingertip or the handle of your scalpel knife inside the cut-down incision to keep it open. Then introduce a 5-mm endotracheal tube through the incision into the trachea, fix the tube with your hand and inflate the tube cuff. If you have no endotracheal tube, use any soft plastic tube about 5 mm in diameter. Or simply hold the cut-down incision open with your fingertip until a tube is found.

If the victim does not breathe: Start rescue breathing – by either mouth-to-tube or bag-to-tube.

If the victim breathes: Clear the upper airways with suction. Pack wounds of the mouth and pharynx with gauze to stop the bleeding. Fix the tube with a band of gauze or cloth tied around the neck of the patient. Close the skin with interrupted sutures if you find time for it. The sutures should be deep and include the soft tissues under the skin, but do not suture the crico-thyroid membrane or the cartilage. If you cannot suture the incision, cover it with some clean gauze or cloth.

Emergency airway in children

In children under 3 years, airway cut-down is difficult to perform without training and practice. Insert three large-bore IV catheters through the crico-thyroid membrane. This will give the child a sufficient airway in an emergency.