Surgical cricothyroidotomy in trauma patients. (Original Article).

Background: Surgical airway intervention is occasionally necessary due to contraindicated or failed endotracheal intubation. In cricothyroidotomy patients, a choice exists between continued long-term ventilation via the cricothyroidotomy portal or conversion to tracheostomy. We examined whether conversion to tracheostomy reduces the risk of acute complications.

Methods: We retrospectively identified 46 patients with cricothyroidotomies performed at our level I trauma center over a 63-month period. We reviewed the success rate, indications, etiology, and complications.

Results: An airway was obtained in all cases. The most common indicator for surgical airway intervention was unsuccessful endotracheal intubation. The cause of death among nonsurvivors was not due to au-way complications. Of the 15 surviving patients, 8 had conversions to tracheostomy and 7 patients did not have conversions but had decannulations. The converted group had a greater percentage of acute complications than the nonconverted group.

Conclusion: Rate of acute complications with prolonged ventilation via cricothyroidotomy portal is equal to, if not lower than, via converted tracheostomy. Cricothyroidotomy in trauma patients may be used long term without any increase in acute complications.

Key Words: airway, cricothyroidotomy, resuscitation, tracheostomy, wounds and injuries

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Key Points

* Complications in patients after cricothyroidotomy included pneumonia and retropharyngeal abscess.

* No patients were noted to have evidence of subglottic stenosis or other tracheal injuries in either group.

* Acute complications are equal, if not lower, with prolonged ventilation via cricothyroidotomy portal compared with via converted tracheostomy.

* Cricothyroidotomy in trauma patients can be used long term without any increase in complications.

A patent airway is of the utmost importance in the injured patient. Initial efforts in obtaining a secure airway are necessary before continuing with other resuscitation efforts. When intubation via nasal or oral route proves to be unsuccessful or contraindicated, a surgical airway provides a rapid means of access to ventilating the critically injured patient.

Chevalier Jackson's 1921 landmark article (1) condemned the use of "high tracheostomies" secondary to a high rate of complications, particularly subglottic stenosis. Although some of these complications may have been caused by airways obtained through the thyroid cartilage instead of the cricothyroid membrane, more than 50 years passed before publication of the seminal work of Brantigan and Grow in 1976 (2) that contradicted Jackson's negative view. Their series demonstrated a low complication rate (6.1%) in 655 patients undergoing elective cricothyroidotomy, which prompted renewed interest in the procedure on both an elective and an emergent basis. (2-13)

As general acceptance of cricothyroidotomy has grown, so too has the controversy between leaving the cricothyroid portal until decannulation versus conversion to a tracheostomy for continued airway access following stabilization of the trauma patient. (11-14) The purpose of our study was to examine the indications, etiology, and complications within two groups of long-term surviving trauma victims: those who were ventilated via their cricothyroid portal until decannulation and those who had their cricothyroidotomy converted to a tracheostomy.

Patients and Methods

During a 63-month period beginning August 1993 and ending in November 1998, 46 emergent cricothyroidotomies were performed among 16,669 acute trauma admissions at the Medical Center of Louisiana at New Orleans, the only level I trauma center in southeast Louisiana verified by the American College of Surgeons. We retrospectively reviewed prospectively collected data to identify all patients who underwent surgical airway intervention in the emergency department. Charts were reviewed to ensure that a true cricothyroidotomy was performed. In addition, data on patient age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, mechanism of injury, indication for cricothyroidotomy, days until decannulation or conversion to tracheostomy, complications, length of stay, and disposition were collected for each patient in the series. Nonparametric Mann-Whitney 2-sample tests and Fisher's exact tests were performed when appropriate to compare patients with converted cricothyroidotomies with those not undergoi ng conversion. Statistical analysis was performed using GraphPAD InStat, version 1.12a (GraphPad Software, Inc., San Diego, CA). The resident physicians and attending staff in the accident room at the Medical Center of Louisiana managed patients requiring cricothyroidotomy. The emergency medicine resident physician conducted initial airway evaluation with supervision from the emergency medicine attending physician. When needed, the chief surgical resident performed the cricothyroidotomy. The attending trauma surgeon supervised the procedures and provided assistance. The technique used at our institution is the one outlined in the American College of Surgeons Advanced Trauma Life Support Course manual. (15)

Results

Of the 825 critically injured patients presenting to the emergency department in need of an emergent airway, 46 (5.6%) underwent cricothyroidotomies. Patients ranged in age from 16 to 83 years (mean, 32 years). A majority (84.8%) of the patients were male. In all 46 patients undergoing cricothyroidotomy, a patent airway was secured. No deaths were associated with failure to obtain or maintain the airway. Fifteen (32.6%) of the total 46 patients were discharged from the hospital and considered long-term survivors. The mechanism of injury in patients who survived were: motor vehicle collision (n = 5); gunshot wound to the face (n = 5), chest (n = 5), or neck (n = 1); pedestrian versus motor vehicle accident (n = 1); and cyclist versus motor vehicle accident (n = 1). Patients received cricothyroidotomy as their initial airway stabilization for blood in the oropharynx, unsuccessful endotracheal intubation, expanding neck hematoma, facial trauma, or inability to open the airway.

Of the long-term survivors, 8 (53.3%) underwent conversion to tracheostomy. The converted group averaged 6.1 days (range, 1-17 days) until conversion of their cricothyroidotomy to a tracheostomy. Seven (46.7%) of the 15 long-term survivors never had conversion to tracheostomy. Cricothyroidotomy portal was used for tracheal access until decannulation for a mean of 14.1 days (range, 2-41 days) (Table 1). Both groups were evenly matched for age, ISS, and Glasgow Coma Scale score. No statistically significant differences were seen. The converted group, however, had a longer length of stay compared with the nonconverted group (21.5 versus 14.4 d; P < 0.036).

In all cases, a patent airway was secured as the initial step of the resuscitation effort. None of the patients died as a result of asphyxia during or following the cricothyroidotomy procedure. Except for one case of retropharyngeal abscess, pneumonia was the only acute complication in both the converted and the nonconverted subsets. No patient demonstrated evidence of subglottic stenosis or other tracheal injuries during long-term follow-up (minimum follow-up time, 6 months). The cricothyroidotomy group with conversion to tracheostomy experienced four (50%) cases of pneumonia postconversion. One case of retropharyngeal abscess was also reported in this group. This patient had sustained a gunshot wound to the neck with a combined tracheal and esophageal injury. In the nonconverted group, the only acute complication was pneumonia, which occurred in two patients (28.6%). Overall, complications occurred in 7 of the 15 long-term survivors, for an overall complication rate of 46.7%.

We chose to look at patients who were ventilated via their cricothyroid portal for more than 10 days. There were three of these patients in the converted group and four patients in the nonconverted group. Of the patients in the converted group who were ventilated via the cricothyroid portal for longer than 10 days (n = 3), none experienced any complications. In contrast, the patients who were ventilated via the cricothyroid portal for fewer than 10 days and then underwent conversion had an 80% (4/5) complication rate. Of those who retained their cricothyroidotomy until decannulation at 10 or more days, 50% (2/4) of patients experienced pneumonia as a complication. Interestingly, these were the only patients in the nonconverted group who experienced a complication. There were no differences in complications seen between patients who were ventilated via their cricothyroidotomy portal after more than 10 days and not undergoing conversion (50%) versus all other patients (45%). For all patients who sustained cric othyroid intubation for more than 10 days, the total complication rate was 28.6%.

Discussion

Emergency resuscitations often take place under less than optimal conditions and, occasionally, endotracheal intubation is unsuccessful or contraindicated in trauma patients. A rapid means of securing tracheal access for patient oxygenation/ventilation is crucial. As Brantigan and Grow demonstrated, cricothyroidotomy is a rapid and safe form of surgical airway intervention. (2) Others have shown its successful use during emergent situations and have cited its absolute contraindications: prolonged intubation, airway obstruction following previous intubation, and laryngeal pathology of any kind.

Previous studies have indicated complication rates for cricothyroidotomy ranging up to approximately 40% when used under emergent conditions. (2,5,6,8,9) Of note, there were no complications directly related to the actual performance of cricothyroidotomy. Our complication rate among trauma patients who did not have conversion to tracheostomy (28.6%) is well within the reported ranges. Among the converted group, we experienced a complication rate of 62.5%, much higher than expected. Although this did not reach statistical significance, a trend toward higher complications was seen in the converted group. This may, however, just be a reflection of sicker patients in the converted group, although the ISS scores were equal in both groups.

Postoperative complications associated with tracheostomy include secondary hemorrhage, atelectasis, pneumonia, diminution of the tracheal lumen, and wound infections. (16,17) Within our series, we found that four patients (50%) experienced a case of pneumonia following conversion of their cricothyroidotomy to a tracheostomy. Only one other complication, a retropharyngeal abscess, was detected in this limited population. Two of the seven patients (28.6%) in the nonconverted group developed pneumonia, but no other complications were noted in this group. Pneumonia has been previously reported as a complication of cricothyroidotomy in Sise's (13) findings, in which six cases of transient aspiration resulted in two cases of pneumonia.

Our series has shown that a properly performed cricothyroidotomy is a viable and effective means of rapidly securing a patent airway in the critically injured patient. Our data also have shown that, compared with those patients undergoing conversions, patients not having conversions to tracheostomy had a lower percentage of acute complications (28.6 versus 62.5%), although due to the small sample size this did not reach statistical significance. It is possible that early conversion of cricothyroidotomy to a tracheostomy (before 10 days) actually increases the rate of pneumonia. Due to limited numbers of patients in our study, however, it is premature to suggest that early conversion may actually be contraindicated. In the group of patients with cricothyroid intubation lasting from 10 to 41 days (mean, 18.4 d) until conversion to tracheostomy or decannulation, two patients developed pneumonia, for a complication rate of 28.6%. While this study admittedly has a low sample size, we feel this indicates that vent ilation via the cricothyroid portal instead of via a tracheostomy is acceptable and provides minimal risk of complications. Without larger number of patients and longer follow-up times, however, it is difficult to make any definite conclusions regarding long-term complications. None of the patients in our study, including those with longterm cannulation of cricothyroidotomy, had long-term complications. There were no cases of subglottic stenosis, but since no imaging on endoscopic evaluations were performed, mild subglottic stenosis could have occurred without our knowledge. Conversion to a tracheostomy after emergent surgical cricothyroidotomy may not always be necessary. Due to the limited number of patients requiring cricothyroidotomy seen by any single trauma center, a multicenter study may be useful in evaluating emergent surgical cricothyroidotomy and in addressing the need for conversion to formal tracheostomy.

Table 1

Survivor data (a)

                               Converted          Nonconverted
Parameter                      patients             patients

No. of patients (%)             8 (53.3%)          7 (46.7%)
Mean days until conversion      6.1 (range, 1-17
Mean days until decannulation                     14.1 (range, 2-41)
Mean age (b)                   31 yr              34 yr
Mean ISS score (b)             21                 17
Mean GCS score (b)              7                  9
Length of stay (c)             21.5 d             14.4 d
Subglottic stenosis (b)         0 (0%)             0 (0%)
Complications (b)               5 (62.5%)          2 (28.6%)

(a)ISS, Injury Severity Scale; GCS, Glasgow Coma Scale.

(b)P = NS.

(c)P < 0.036.

Accepted March 15, 2002.

Acknowledgments

We thank the staff at the Trauma Registry of the Medical Center of Louisiana at New Orleans (Charity Hospital) for their assistance in identifying cases to be included in the study and Patricia Kirsch-Duboue for her assistance in preparing the manuscript.

References

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(2.) Brantigan CO, Grow JB Sr. Cricothyroidotomy: Elective use in respiratory problems requiring tracheotomy. J Thorac Cardiovasc Surg 1976;71:72-80.

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(11.) Burkey B, Esclamado R, Morganroth M. The role of cricothyroidotomy in airway management. Clin Chest Med 1991;12:561-571.

(12.) Cole RR, Aguilar EA III. Cricothyroidotomy versus tracheotomy: An otolaryngologist's perspective. Laryngoscope 1988;98:131-135.

(13.) Sise MJ, Shackford SR, Cruickshank JC, Murphy G, Fridlund PH. Cricothyroidotomy for long-term tracheal access: A prospective analysis of morbidity and mortality in 76 patients. Ann Surg 1984;200;13-17.

(14.) Brantigan CO, Grow JB Sr. Subglottic stenosis after cricothyroidotomy. Surgery 1982;91:217-221.

(15.) Alexander RH, Proctor HJ (eds). Advanced Trauma Life Support Program for Physicians: ATLS. Chicago, American College of Surgeons, 1993, ed 5.

(16.) Rogers LA. Complications of tracheostomy. South Med J 1969;62:1496-1500.

(17.) Davis HS, Kretchmcr HE, Bryce-Smith R. Advantages and complications of tracheostomy. JAMA 1953;153:1156-1159.

From the Department of Surgery, Tulanc University School of Medicine, and the Department of Surgery, Louisiana State University, New Orleans, LA.

Presented at the 13th annual meeting of the Eastern Association for the Surgery of Trauma, Fort Myers, FL, January 2000.

Reprint requests to Mary Hi Wright, MD, Department of Surgery, Tulane Medical School, 1430 Tulane Avenue, SL 22, New Orleans, LA 70112.

Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9605-0465