What is the role for cricothyrotomy in this era of many devices and better oxygenation and ventilation techniques? Crics should be considered a first-line approach in situations of the “surgically inevitable airway.” These are cases in which mask ventilation, supraglottic airways (LMA/King LT), and passive oxygenation will not work. Surgically inevitable airways are trauma cases in which a surgical airway will be required as part of the patient’s near-term management. The prototypical example is a severe blast injury to the lower face. Distorted anatomy coupled with blood/vomit is a serious problem—it is bad for laryngoscopy, mask ventilation, LMA, and King LT use, as well as passive oxygenation via mouth or nose. Rapid sequence intubation (RSI) must be avoided in these cases; an awake surgical airway (with or without ketamine) is the safest option. Not all instances of distorted anatomy require an immediate surgical airway; without bleeding or vomit, an awake, fiber-optic, or other non-RSI technique may be worth trying in angioedema and other oral-pathology circumstances. Because there is no guarantee of being able to rescue ventilate, a surgical approach may be emergently needed if the patient deteriorates. Instances involving massive fluids (blood/vomit) even without distorted anatomy may trigger a surgical airway when epiglottoscopy and other landmark identification are impossible along with the inability to oxygenate and/or ventilate. If intubation fails in cases with intrinsic laryngeal pathology (eg, laryngeal tumor, high-grade laryngeal fracture), a surgical airway is necessary below the level of the pathology (ie, tracheotomy instead of a cricothyrotomy).
Once the operator has crossed the decision point, a surgical airway is inevitable; patient outcome hinges on speed. To ensure success, one must be able to reliably identify landmarks and have a methodical, step-by-step approach.
Instead of using the tip of the index finger to feel for landmarks, palpate the laryngeal framework using the whole hand with what I call the “laryngeal handshake.”