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 cricothyrotom y, but there is little evidence in the literature to support this. There ha ve been no reports of successful cricothyrotomy in a patient who had receiv ed 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 f irst patient was a 67-year-old man who developed severe pulmonary edema and respiratory failure less than 30 minutes after administration of tissue pl asminogen activator using an accelerated regimen. Both intubation and attem pts at ventilation using an esophageal/tracheal double-lumen airway (Combit ube, Kendall-Sheridan, Argyle, NY) were unsuccessful, and the emergency phy sician then performed an uneventful cricothyrotomy using a vertical midline incision. There were no complications, and bleeding was minimal. The secon d patient was a 45-year-old man who developed severe angioedema with respir atory compromise after receiving streptokinase for acute myocardial infarct ion. Intubation was impossible, and a cricothyrotomy was performed. Signifi cant 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 c ricothyrotomy.