Surgical cricothyroidotomy

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• bleeding from neck veins or the cricothyroid artery
• tube placed outside the airway (subcutaneous emphysema)
• pneumothorax
• injury to the back wall of the airway or oesophagus
• vocal cord injury and change in voice
• narrowing below the vocal cords later (subglottic stenosis)
• wound infection
• need for a later tracheostomy or ENT repair

Pre-operative details for this operation

1. Indicationcannot intubate and cannot oxygenate: number and type of intubation attempts, rescue devices tried (supraglottic airway, bag-mask), SpO2 at decision
2. Cause of the airway problemSevere maxillofacial traumaAirway oedemaAirway bleedingNeck haematoma or massOther
3. Cervical spine statusClearedNot cleared: neck kept neutral, manual in-line stabilisation
4. Contraindications checkedsuspected laryngeal or upper tracheal transection (tracheostomy below the injury preferred); child: surgical cricothyroidotomy relatively contraindicated under 8 years (Trauma Atlas) or avoided under 12 years (Neuro ICU Atlas), use needle cricothyroidotomy / jet insufflation or tracheostomy instead
5. ConsentWritten consentEmergency procedure without consent: reason recorded
6. Time of decision for surgical airway

Anaesthesia and position

1. AnaesthesiaNone (patient unresponsive)Local infiltrationSedation (drug and dose given by anaesthetist)
2. Oxygenation during procedure100% oxygen by bag-mask or supraglottic device; oxygen turned down if cautery used near the airway
3. PositionSupine, neck neutralSupine, neck extended over shoulder roll
4. PlaceEmergency departmentOperation theatreICU / ward

Operative findings

1. Landmarksthyroid cartilage, cricoid cartilage and cricothyroid membrane palpable / not palpable; four-finger method used (little finger in the suprasternal notch, index finger tip falls on the membrane in the midline)
2. Neckswelling, haematoma, surgical emphysema, deviation of trachea
3. Airway entryair or blood on entry, bleeding from membrane edges
4. Confirmation of tube positionend-tidal CO2 trace, chest rise, breath sounds both sides, SpO2 after

Procedure (steps)

1. Skin preparationchlorhexidine or povidone-iodine, sterile drape, if time allowed
2. Larynx stabilisedthyroid cartilage held between thumb and middle (or index) finger of the non-dominant hand
3. TechniqueOpen (scalpel)Percutaneous (Seldinger kit)
4. Skin incisionVertical midlineTransverselength in cm; vertical preferred (less anterior jugular bleeding, can be extended)
5. Deep cervical fascia spread, cricothyroid membrane exposedmosquito clamp, retractor used
6. Membrane incisedhorizontal stab, lower half of the membrane along the top of the cricoid
7. Opening held and widenedTracheal hook on thyroid cartilageTracheal hook on cricoidClamp spreadBougiekeep a finger or instrument in the opening until the tube or bougie is in
8. Percutaneous steps (if used)5 mm vertical skin nick; needle on saline syringe directed caudally at 45 degrees, air bubbles; guidewire; dilator with airway cannula over the wire; wire and dilator removed
9. Tube insertedCuffed tracheostomy tubeEndotracheal tubeKit cannulasize (6.0 mm internal diameter tube), passed caudally along the line of the trachea, cuff inflated with 5 to 10 ml of air (write the volume)
10. Position confirmedend-tidal CO2, chest rise, breath sounds both sides, SpO2
11. Suction through tubeblood or secretions cleared
12. Haemostasispressure, ligature or cautery of bleeding veins after the airway is secure
13. Tube securedsutured to skin with 2-0 silk and tied with tape; endotracheal tube depth at skin

Closure, drains and dressing

1. WoundLeft open around tubePartly sutured
2. Dressinggauze around the tube
3. Tube fixationsutures, tapes, ties

Specimens and implants

1. Airway devicetype, size, cuffed / uncuffed, make, batch number
2. SpecimenNoneTracheal aspirate for culture

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Chest X-raynow, to check tube position and exclude pneumothorax
2. Continuous SpO2 and end-tidal CO2call if trace is lost or SpO2 falls
3. Tube caretube type and size written at bedside, cuff pressure checks, suction as needed, spare tube and tracheal hook at bedside
4. Watch for complicationsbleeding from the wound, swelling of the neck or chest wall (surgical emphysema), falling saturation
5. Ventilationventilator settings as per ICU / anaesthesia team
6. Definitive airway plankeep, convert to tracheostomy, or decannulate; ENT review if cricoid or laryngeal injury is suspected
7. Late warning signsany fresh bleeding through the tube in the following weeks to be reported at once (possible tracheo-innominate fistula)

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery