A coniotomy (cricothyroidotomy) – colloquially known as a tracheotomy – is an emergency airway protection through a skin incision below the larynx at the level of the cricothyroid ligament (ligament between the cricoid and thyroid cartilages).
An emergency coniotomy (emergency coniotomy) for airway protection occurs only in extremely rare cases (< 1/1,000). It is an acutely life-threatening complication of airway protection called a cannot-ventilate-cannot-intubate situation.
Indications
- Emergencies involving impossible endotracheal intubation and impending death by asphyxiation.
The surgical procedure
Surgical technique: in this procedure, with the head hyperextended, the skin is cut longitudinally and the underlying cricothyroid ligament (conicum) between the thyroid and cricoid cartilages (Latin cartilago cricoidea) is cut transversely. A blade is then inserted and spread by means of scissors in order to be able to insert a tracheal cannula or an endotracheal tube (called tube for short; it is the ventilation tube, a hollow probe made of plastic, which is inserted into the trachea (windpipe)). The tube is then fixed in place.
Puncture technique: commercially available ready-made sets are available for emergency coniotomy.Procedure: The operator stands or kneels behind the patient’s head and works overhead, as this facilitates puncture in a caudal (“downward” oriented) fashion. The first step is to identify the cricothyroid membrane and stabilize the thyroid cartilage with the non-dominant hand. The skin and the membrana cricothyroidea are then punctured using a metal cannula. A trocar is used or the Seldinger technique, in which the membrana is punctured with a thin cannula over which a guide wire is then inserted. After removal of the cannula, the tracheal cannula (breathing tube) can be inserted into the trachea (windpipe) via the guide wire, through which the patient can then be ventilated.
The coniotomy represents the ultima ratio of airway protection and is only a temporary provisional measure for airway protection. It should be followed immediately by endotracheal intubation or tracheostomy (tracheotomy).
Possible complications
- Acute bleeding
- Pressure ulcers (pressure sores)
- Paratracheal malpositions (“next to the trachea”).
- Stenosis (narrowing) of the trachea
- Tracheoesophageal fistulas – fistula connections between the trachea (windpipe) and esophagus (esophagus).
- Obstruction of the stoma (gr. στόμα stóma “mouth“, also “mouth”, “opening”) by secretion (wound water).
- Injury to vessels, nerves, skin or soft tissues.
- Wound infection
