Successful cricothyrotomy after thrombolytic therapy for acute myocardial infarction: A report of two cases

Cricothyrotomy is an emergency airway procedure that is generally performed after failure of primary methods for securing the airway. Coagulopathy has traditionally been considered a relative contraindication to cricothyrotomy, but there is little evidence in the literature to support this. There have been no reports of successful cricothyrotomy in a patient who had received systemic thrombolytic therapy. This report, from the National Emergency Airway Registry, is the first to describe successful cricothyrotomy in this context. We describe 2 patients who received thrombolytic therapy and then bad cricothyrotomy performed after failure of other airway measures. The first patient was a 67-year-old man who developed severe pulmonary edema and respiratory failure less than 30 minutes after administration of tissue plasminogen activator using an accelerated regimen. Both intubation and attempts at ventilation using an esophageal/tracheal double-lumen airway (Combitube, Kendall-Sheridan, Argyle, NY) were unsuccessful, and the emergency physician then performed an uneventful cricothyrotomy using a vertical midline incision. There were no complications, and bleeding was minimal. The second patient was a 45-year-old man who developed severe angioedema with respiratory compromise after receiving streptokinase for acute myocardial infarction. Intubation was impossible, and a cricothyrotomy was performed. Significant bleeding was controlled initially with packing and was semielectively explored later in the ICU with ligation of several small bleeding vessels. Prior administration of thrombolytic therapy does not preclude successful cricothyrotomy.