Cricothyroidotomy for elective airway management in critically ill trauma patients

Objective

To assess the value of elective cricothyroidotomy for airway management in critically ill trauma patients with technically challenging neck anatomy.

Design and setting

A retrospective chart review of patients admitted to the Trauma Service at a Level I Trauma Center who underwent cricothyroidotomy for elective airway management over a 40 month period from January 1997 to April 2000. Comparison was made to a cohort of Trauma Service patients who received a tracheostomy. Selection was based on a list generated chronologically and selecting each tracheostomy procedure immediately prior to the cricothyroidotomy.

Results

Eighteen patients met study criteria and unpaired t-test revealed significance (P < 0.05) for age only. There was no difference with Injury Severity Score, ICU days, number of days requiring ventilation post procedure or number of days intubated prior to procedure. The major difference was the more technically challenging neck anatomy in the patients undergoing cricothyroidotomy. Five of 18 patients undergoing cricothyroidotomy died prior to discharge and 2/18 after discharge from complications unrelated to their airway. Two of 18 patients undergoing tracheostomy died prior to discharge from complications unrelated to their airway. For a period of 1 week to 15 months, average 5.5 months, notes in subsequent clinic appointments were reviewed for subjective assessment of wound healing, breathing and swallowing difficulties, and voice changes. One patient with a cricothyroidotomy required silver nitrate to treat some granulation tissue otherwise no complications were identified. Telephone interviews were conducted from 12 to 46 months, average 30 months, with 8 of the 11 surviving cricothyroidotomy patients and 9 of the 16 surviving tracheostomy patients. One tracheostomy patient required surgical closure 3 months after discharge; otherwise, the only noted change was minor voice changes in 3 patients in each group. All six patients denied this compromised them in any way.

Conclusion

Elective cricothyroidotomy has a low complication rate and is a reasonable, technically less demanding option in critically ill patients with challenging neck anatomy requiring a surgical airway.