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Clinically Correlated Anatomical Basis of Cricothyrotomy and Tracheostomy

  • Gulsen, Salih (Department of Neurosurgery, Faculty of Medicine, Baskent University Medical Faculty) ;
  • Unal, Melih (State Institute of Forensic Medicine, Ministry of Justice, Morque Department) ;
  • Dinc, Ahmet Hakan (State Institute of Forensic Medicine, Ministry of Justice, Morque Department) ;
  • Altinors, Nur (Department of Neurosurgery, Faculty of Medicine, Baskent University Medical Faculty)
  • Received : 2008.11.04
  • Accepted : 2010.01.31
  • Published : 2010.03.28

Abstract

Objective : Cricothyrotomy and tracheostomy are performed by physicians in various disciplines. It is important to know the comprehensive anatomy of the laryngotracheal region. Hemorrhage, esophageal injury, recurrent laryngeal nerve injury, pneumothorax, hemothorax, false passage of the tube and tracheal stenosis after decannulation are well known complications of the cricothyrotomy and tracheostomy. Cricothyrotomy and tracheostomy should be performed without complications and as quickly as possible with regards the patients' clinical condition. Methods : A total of 40 cadaver necks were dissected in this study. The trachea and larynx and the relationship between the trachea and larynx and the surrounding structures was investigated. The tracheal cartilages and annular ligaments were counted and the relationship between tracheal cartilages and the thyroid gland and vascular structures was investigated. We performed cricothyrotomy and tracheostomy in eleven cadavers while simulating intensive care unit conditions to determine the duration of those procedures. Results : There were 11 tracheal cartilages and 10 annular ligaments between the cricoid cartilage and sternal notch. The average length of trachea between the cricoid cartilage and the suprasternal notch was 6.9 to 8.2 cm. The cricothyroid muscle and cricothyroid ligament were observed and dissected and no vital anatomic structure detected. The average length and width of the cricothyroid ligament was 8 to 12 mm and 8 to 10 mm, respectively. There was a statistically significant difference between the surgical time required for cricothyrotomy and tracheostomy (p < 0.0001). Conclusion : Tracheostomy and cricothyrotomy have a low complication rate if the person performing the procedure has thorough knowledge of the neck anatomy. The choice of tracheostomy or cricothyrotomy to establish an airway depends on the patients' clinical condition, for instance; cricothyrotomy should be preferred in patients with cervicothoracal injury or dislocation who suffer from respiratory dysfunction. Furthermore; if a patient is under risk of hypoxia or anoxia due to a difficult airway, cricothyrotomy should be preferred rather than tracheostomy.

Keywords

References

  1. Ahmed N, Kuo YH : Early versus late tracheostomy in patients with severe traumatic head injury. Surg Infect (Larchmt) 8 : 343-347, 2007 https://doi.org/10.1089/sur.2006.065
  2. American Society of Anesthesiologists Task Force on Management of the Difficult Airway : Practice guidelines for management of the difficult airway : an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 98 : 1269-1277, 2003 https://doi.org/10.1097/00000542-200305000-00032
  3. Bair AE, Filbin MR, Kulkarni RG, Walls RM : The failed intubation attempt in the emergency department : analysis of prevalence, rescue techniques, and personnel. J Emerg Med 23 : 131-140, 2002 https://doi.org/10.1016/S0736-4679(02)00501-2
  4. Bonanno FG : Techniques for emergency tracheostomy. Injury 39 : 375-378, 2008 https://doi.org/10.1016/j.injury.2007.09.025
  5. Bulger EM, Copass MK, Maier RV, Larsen J, Knowles J, Jurkovich GJ : An analysis of advanced prehospital airway management. J Emerg Med 23 : 183-189, 2002 https://doi.org/10.1016/S0736-4679(02)00490-0
  6. De Leyn P, Bedert L, Delcroix M, Depuydt P, Lauwers G, Sokolov Y, et al. : Tracheotomy : clinical review and guidelines. Eur J Cardiothorac Surg 32 : 412-421, 2007 https://doi.org/10.1016/j.ejcts.2007.05.018
  7. Dob DP, McLure HA, Soni N : Failed intubation and emergency percutaneous tracheostomy. Anaesthesia 53 : 72-74, 1998
  8. Dunford JV, Davis DP, Ochs M, Doney M, Hoyt DB : Incidence of transient hypoxia and pulse rate reactivity during paramedic rapid sequence intubation. Ann Emerg Med 42 : 721-728, 2003 https://doi.org/10.1016/S0196-0644(03)00660-7
  9. Ellis H : Applied anatomy of cricothyrotomy and tracheostomy. Br J Hosp Med (Lond) 67 : M168-M169, 2006
  10. Freeman BD : Is there a hidden benefit associated with early tracheostomy? Crit Care Med 36 : 2688-2689, 2008 https://doi.org/10.1097/CCM.0b013e3181843e04
  11. Goldenberg D, Ari EG, Golz A, Danino J, Netzer A, Joachims HZ : Tracheotomy complications : a retrospective study of 1130 cases. Otolaryngol Head Neck Surg 123 : 495-500, 2000 https://doi.org/10.1067/mhn.2000.105714
  12. Heffner JE, Miller KS, Sahn SA : Tracheostomy in the intensive care unit. Part 1 : Indications, technique, management. Chest 90 : 269-274, 1986 https://doi.org/10.1378/chest.90.2.269
  13. Jaeger K, Ruschulte H, Osthaus A, Sheinichen D, Heine J : Tracheal injury as a sequence of multiple attempts of endotracheal intubation in the course of reclinical cardiopulmonary resuscitation. Resuscitation 43 : 147-150, 2000 https://doi.org/10.1016/S0300-9572(99)00124-0
  14. Kane TD, Rodriguez JL, Luchette FA : Early versus late tracheostomy in the trauma patient. Respir Care Clin N Am 3 : 1-20, 1997
  15. Lewis RJ : Tracheostomies. Indications, timing, and complications. Clin Chest Med 13 : 137-149, 1992
  16. Libert N, Leclerc T, De Rudnicki S : Cricothyroidotomy. N Engl J Med 359 : 1073-1074, 2008 https://doi.org/10.1056/NEJMc081375
  17. McWhorter AJ : Tracheotomy : timing and techniques. Curr Opin Otolaryngol Head Neck Surg 11 : 473-479, 2003 https://doi.org/10.1097/00020840-200312000-00012
  18. Mort TC : Emergency tracheal intubation : complications associated with repeated laryngoscopic attempts. Anesth Analg 99 : 607-613, 2004
  19. Mort TC : The incidence and risk factors for cardiac arrest during emergency tracheal intubation : a justification for incorporating the ASA Guidelines in the remote location. J Clin Anesth 16 : 508-516, 2004 https://doi.org/10.1016/j.jclinane.2004.01.007
  20. Myers EN, Carrau RL : Early complications of tracheotomy. Incidence and management. Clin Chest Med 12 : 589-595, 1991
  21. Schlossmacher P, Martinet O, Testud R, Agesilas F, Benhamou L, Gauzere BA : Emergency percutaneous tracheostomy in a severely burned patient with upper airway obstruction and circulatory arrest. Resuscitation 68 : 301-305, 2006 https://doi.org/10.1016/j.resuscitation.2005.06.021
  22. Scurry WC Jr, McGinn JD : Operative Techniques in Otolaryngology. Tech Head Neck Surg 18 : 85-89, 2007 https://doi.org/10.1016/j.otot.2007.05.003
  23. Stock MC, Woodward CG, Shapiro BA, Cane RD, Lewis V, Pecaro B : Perioperative complications of elective tracheostomy in critically ill patients. Crit Care Med 14 : 861-863, 1986 https://doi.org/10.1097/00003246-198610000-00005
  24. Wang HE, Yealy DM : How many attempts are required to accomplish out-of-hospital endotracheal intubation? Acad Emerg Med 13 : 372-377, 2006

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