REVIEW ARTICLE Conversion of Emergent Cricothyrotomy to Tracheotomy in Trauma Patients Peep Talving, MD, PhD; Joseph DuBose, MD; Kenji Inaba, MD; Demetrios Demetriades, MD, PhD Objectives: To review the literature to determine the patients for whom cricothyrotomy was performed, in- rates of airway stenosis after cricothyrotomy, particu- cluding 368 trauma patients who underwent emergent larly as they compare with previously documented rates cricothyrotomy. The rate of chronic subglottic stenosis of this complication after tracheotomy, and to examine among survivors after cricothyrotomy was 2.2% (11/ the complications associated with conversion. 511) overall and 1.1% (4/368) among trauma patients for follow-up periods with a range from 2 to 60 months. Only Data Sources: We conducted a review of the medical 1 (0.27%) of the 368 trauma patients in whom an emer- literature by the use of PubMed and OVID MEDLINE da- gent cricothyrotomy was performed required surgical tabases. treatment for chronic subglottic stenosis. Although the literature that documents complications of surgical air- Study Selection: We identified all published series that way conversion is scarce, rates of severe complications describe the use of cricothyrotomy, with the inclusion of up to 43% were reported. of the subset of patients who require an emergency air- way after trauma, from January 1, 1978, to January 1, Conclusions: Cricothyrotomy after trauma is safe for ini- 2008. tial airway access among patients who require the estab- lishment of an emergent airway. The prolonged use of a Data Extraction: Only 20 published series of crico- cricothyrotomy tube, however, remains controversial. Al- thyrotomy were identified: 17 retrospective reports and though no study to date has demonstrated any benefit 3 prospective, observational series. of routine conversion to tracheostomy, considerable de- ficiencies in existing studies highlight the need for fur- Data Synthesis: Considerable variance in methods and ther investigations of this practice. follow-up periods were noted between examinations. Pub- lished experiences documented the results of 1134 total Arch Surg. 2010;145(1):87-91 HE EARLY ESTABLISHMENT OF ries that preclude the insertion of an en- a patent and secure air- dotracheal tube. Cricothyrotomy, which way, in either the field set- can be rapidly and successfully per- ting or the emergency de- formed in both field and hospital settings partment, is a basic tenet of by a variety of trained professionals, has Ttrauma care.1 Endotracheal intubation re- been widely advocated as the initial sur- mains the initial airway of choice for gical airway of choice in these emergent trauma patients with a decreased Glasgow situations.1,7-9 Coma Scale score or airway or ventila- Among patients who require a crico- tory compromise and can be achieved with thyrotomy and survive their initial inju- a high degree of success in most cases.2-4 ries, many may require the prolonged use During recent years, the laryngeal mask of a surgically created airway. Tradi- airway and double-lumen tube (Combi- tional surgical teaching has dictated that tube; Tyco-Kendall Healthcare Products, a cricothyrotomy tube placed for emer- Mansfield, Massachusetts) have also gained gency purposes should be converted to a popularity because of their simplicity and tracheotomy tube within 72 hours in these demonstrated effectiveness in both pre- patients primarily because the prolonged hospital and in-hospital settings.5-7 The es- use of this airway access is thought to be Author Affiliations: Division of tablishment of a surgical airway, how- associated with a prohibitive risk of sub- Trauma and Surgical Critical 10 Care, Los Angeles County and ever, remains indicated for those patients glottic stenosis. Although this practice University of Southern in whom these initial adjuncts fail to pro- continues to be advocated by contempo- California Medical Center, vide adequate airway access or for those rary authors,11,12 the literature on which Los Angeles. patients with severe facial or neck inju- this assumption is primarily based is now (REPRINTED) ARCH SURG/ VOL 145 (NO. 1), JAN 2010 WWW.ARCHSURG.COM 87 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table 1. Studies Included in the Review No. of No. of Follow-up No. With No. Level Source Study Design Cricothyrotomies Survivors Time, mo Chronic SGS Operated On of Evidence Boyd et al,13 1979 Retrospective 147 103 6.0 2 1 III Weymuller and Cummings,14 1982 Prospective, observational 15 15 2.0 0 0 II Greisz et al,15 1982 Retrospective 61 31 3.0 0 0 III McGill et al,16 1982 Retrospective 38 12 Not stated 0 0 III Holst et al,17 1985 Retrospective 203 61 6.0 0 0 III Miklus et al,9 1989 Retrospective 20 8 Not stated 0 0 III Spaite and Joseph,18 1990 Retrospective 20 3 Not stated 0 0 III Boyle et al,19 1993 Retrospective 69 5 Not stated 0 0 III Sise et al,20 1984 Prospective, observational 76 30 8.5 2 1 II O´Connor et al,21 1985 Retrospective 49 30 17.0 0 0 III Esses and Jafek,22 1987 Retrospective 78 46 Not stated 3 3 III DeLaurier et al,23 1990 Retrospective 34 20 2.0 0 0 III Salvino et al,25 1993 Retrospective 30 15 Not stated 2 0 III Hawkins et al,24 1995 Retrospective 66 26 60.0 0 0 III Jacobson et al,8 1996 Retrospective 47 10 24.0-60.0 0 0 III Gillespie and Eisele,26 1999 Retrospective 20 11 23.0 1 1 III Isaacs,27 2001 Retrospective 65 27 37.0 0 0 III Rehm et al,28 2002 Retrospective 18 11 12.0-24.0 0 0 III Wright et al,29 2003 Retrospective 46 15 6.0 0 0 III Franc¸ois et al,30 2003 Prospective, observational 32 32 6.0 1 1 II Total No. (%) 1134 (100.0) 511/1134 (45.1) 16.0 11/511 (2.2) 7/11 (63.6) Abbreviation: II indicates prospective clinical study or retrospective analysis of reliable data, including observational, cohort, prevalence, or case-control studies; III, retrospective study, including database or registry reviews, a large series of case reports, and expert opinion; SGS, subglottic stenosis. older than 80 years. A growing body of more contem- 3 were prospective, observational series. Considerable porary literature has suggested that the risk associated variance in methods and follow-up among these inves- with the prolonged use of a cricothyrotomy tube, par- tigations was noted. In these reports, 1134 total crico- ticularly that of airway stenosis, may be much lower than thyrotomies were documented, with 511 survivors avail- previously believed.8,9,13-30 The risk of conversion, al- able for follow-up (Table 1). Follow-up periods ranged though less well examined, may also be associated with overall from 2 to 60 months, with a mean of 16 months. underappreciated risk.29,31 The aims of the present re- Chronic subglottic stenosis was documented in 11 of 511 view are to review the literature to determine the rates overall survivors (2.2%). Surgical intervention to cor- of airway stenosis after cricothyrotomy, particularly as rect stenosis was required in 7 of the 511 survivors (1.4%). they compare with previously documented rates of this Among trauma patients, 452 cricothyrotomies were complication after tracheotomy, and to examine the com- performed. Adequate documentation that these proce- plications associated with conversion. dures were performed for emergent airway access was available in 368. The overall rate of chronic subglottic METHODS stenosis in this setting was 0.9% (4/452) and 1.1% (4/368) when cricothyrotomy was used to establish We conducted a search of the medical literature using the key- emergent airway access. Only 1 of 368 trauma patients word cricothyrotomy in PubMed (http://www.pubmed.gov; ac- (0.27%) required surgical treatment for chronic sub- cessed May 6, 2008), a service of the National Library of Medi- glottic stenosis after emergent cricothyrotomy for cine of the National Institutes of Health and OVID MEDLINE trauma (Table 2). databases. A total of 153 publications that pertain to cricothy- The examination of complications directly related to rotomy performed from January 1, 1978, to January 1, 2008, conversion to tracheotomy was limited to only 2 iden- were identified. A consensus panel of 3 reviewers (P.T., J.D., tified case series consisting of 15 total patients.29,31 The and K.I.) reviewed each study and their references to extract overall complication rate from these 2 reports was 53.3% all studies that addressed open cricothyrotomy in human pa- (8/15), with a mortality rate of 28.6% in 1 series.31 tients who require airway access (Table 1). Twenty studies were identified and analyzed to abstract the following data: pa- tient population type, nature of cricothyrotomy tube place- COMMENT ment, clinical outcomes, and follow-up. An additional sub- group of trauma patients was also identified for examination In the late 19th century, Chevalier Jackson began to es- (Table 2). tablish surgical airway operative techniques as standard- ized procedures. During his investigations, he con- RESULTS ducted extensive examinations of the complications associated with the performance of these interventions. Twenty published series and studies were identified. Sev- In a 1921 publication,10 he reported on a series of 200 enteen of these consisted of retrospective reports, and cases of subglottic stenosis after the surgical creation of (REPRINTED) ARCH SURG/ VOL 145 (NO. 1), JAN 2010 WWW.ARCHSURG.COM 88 ©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Table 2. Studies With Available Data That Pertain to Trauma Patients No. of No.