Sideline Airway Access
William O. Roberts, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 4 - APRIL 2021
Emergency care of a collapsed athlete begins with the ABC basic: A (airway), B (breathing) and C (circulation). Without an effective airway, all other interventions will fail. Cricothyrotomy is an emergency procedure that sideline providers should know and be ready to perform if airway access cannot be accomplished by positioning, rescue breathing, or endotracheal intubation.
Cricothyrotomy is an incision through the cricothyroid membrane to gain access to the trachea below the level of the thyroid cartilage. It is the procedure of choice in prehospital care when obstruction from a foreign body or facial injury prevents endotracheal intubation or other adjunctive airway techniques. The anatomy is simple, the access is fast, the neck does not have to be extended, and the risk of hemorrhage is low. It is the preferred method for bypassing an upper airway obstruction caused by a foreign body, trauma, edema, or laryngospasm; and for providing an airway when cervical spine injury precludes extending the cervical spine to visualize the trachea.
Cricothyrotomy is contraindicated if a less invasive method can be used or if there is an obvious distal trachea obstruction. Relative contraindications include coagulopathy, overlying tumor or hematoma, age less than 10 years, acute laryngeal disease, indistinct landmarks, and previous intubation longer than 3 days' duration. These relative contraindications would not be a factor for most athletes.
Cricothyrotomy has been used for many years but was not an accepted emergency procedure until Brantigan and Grow (1) documented its relative safety in 1976. The procedure is now taught in advanced trauma life support (ATLS) emergency care courses. Various techniques have been described (2-4); a prepackaged cricothyrotomy kit is a good alternative on the sidelines.
Cricothyrotomy is accomplished by identifying the anatomy and making two incisions, one through the skin and one through the cricothyroid membrane. If the cervical spine is known to be intact, the neck can be extended to better define the anatomy of the anterior surface.
The cricothyroid membrane is located between the thyroid cartilage and the cricoid cartilage (figure 1). The easiest landmark to identify is the thyroid notch on the superior end of the thyroid cartilage (Adam's apple). To locate the cricothyroid membrane, place a finger on the thyroid notch and slide the finger distally to the groove below the thyroid cartilage. If there is time, the neck should be prepped with alcohol or povidone-iodine and the skin anesthetized locally before the first incision is made. The initial 3- to 4-cm incision is made vertically, and if there is difficulty finding the underlying landmarks, the incision can easily be extended.
The next step is to identify the cricothyroid membrane below the thyroid cartilage and make a 1- to 2-cm horizontal incision. With the membrane incised, pull back the thyroid cartilage with a tracheal hook or insert a hemostat to open the cricothyroid space to allow air to pass. Insert a tracheostomy tube or a 5 to 6 mm endotracheal tube (3 mm for a child) and tape the tube in place.
For easy access and use, the components of a "home assembled" sideline cricothyrotomy kit (table 1) can be kept in a separate, labeled bag or box. Prepackaged cricothyrotomy kits are available for either blind percutaneous insertion or insertion through a skin incision—the blind percutaneous methods are more hazardous and are generally not recommended. Several brands of prepackaged kits are available. The kits come with a needle-and-trochar combination that can be inserted through the cricothyroid membrane (figure 2). After the initial vertical skin incision, the trachea is stabilized with one hand and the trochar is inserted into the trachea through the cricothyroid membrane with the other hand.
TABLE 1. Contents of a Sideline Cricothyrotomy Kit
Procedure diagram and flow sheet
Alcohol or povidone-iodine pads
1% or 2% lidocaine
5- to 6-mm endotracheal tube or tracheostomy tube
The trochar either becomes the airway, or the needle is split to allow different sizes of airway and obturator sets to be passed through the needle for enlarging the airway. The airway has tie-down attachments to secure the tube and bag-valve attachments to assist ventilation if necessary.
Potential complications of the procedure must be weighed against the athlete's risk of death. Immediate complications include damage to the thyroid cartilage and vocal cords, subcutaneous emphysema, hemorrhage, extratracheal tube placement, pneumothorax, laceration of the esophagus or trachea, and prolonged procedure time with anoxia. Most of these complications are avoided with proper placement. Late complications include infection, fistula, and voice alteration.
This is not a procedure that is easy to practice for "real life" situations. The first time you do the procedure may be the first chance you will get to practice outside an ATLS course or using a practice mannequin. In emergency situations, when it was the only chance for airway access and survival, physicians have used pocket knives and ball point pen bodies to enter the trachea and make breathing tubes.
The sideline medical kit should have either a prepackaged cricothyrotomy kit or the necessary equipment. Resuscitation begins with a check of the airway and ends rapidly if an airway is not established. If the airway is obstructed, cricothyrotomy may be the only way to create an airway access, and the sideline physician should be prepared to use the procedure in the unlikely event that a cricothyrotomy is needed.
Dr Roberts is a family physician at MinnHealth Family Physicians in White Bear Lake, Minnesota. Address correspondence to William O. Roberts, MD, MinnHealth Family Physicians, 4786 Banning Ave, White Bear Lake, MN 55110.