Lund Center for Emergency Medicine (LUCEM)
Lund, Sweden
info@lucem.info

Cricothyrotomy

Clarity in Emergency Medicine

CRICOTHYROTOMY

Indication

  • Can’t oxygenate & can’t intubate

Contraindication

  • Age < 10 years

The method taught during the course is the ”scalpel-bougie-tube” technique based on Dr. Andrew Heard’s video (https://www.youtube.com/watch?v=SbhEyGIf9Y4). The advantages of this technique are that it can be rapidly performed without specialized equipment while avoiding the risk of finger trauma associated with the ”scalpel-finger-bougie-tube” techniques.

  1. Procedure

  • Stabilize the larynx with the non-dominant hand

  • Locate the cricothyroid membrane (palpate the gap between the thyroid cartilage and cricoid cartilage). If the cricothyroid membrane cannot be identified, make a midline longitudinal incision with a scalpel #10 over the cricothyroid membrane with the dominant hand and use the non-dominant index finger to palpate membrane

  • With the scalpel blade in the transverse orientation and the blade towards you, push through the cricothyroid membrane until you feel a pop

  • Apply gentle traction to the scalpel blade towards you, then rotate the blade 90° so that the sharp edge points caudally

  • Keeping the scalpel in the vertical position, pull the scalpel towards you to produce a triangular hole

  • Switch hands, and using the dominant hand, insert the bougie into the hole while maintaining contact between the bougie and the scalpel blade; a pop may be felt

  • Rotate the bougie to align it with the airway

  • Remove the scalpel and advance the bougie into the trachea

  • Thread an endotracheal tube (ETT) #6 over the bougie

  • Stabilise the trachea with the non-dominant hand

  • Insert the ETT into the airway over the bougie using continual 360° rotation

  • Inflate the ETT cuff and pull back until resistance is felt

  • Withdraw the bougie

  1. Post

  • Bag-ventilate, assess chest wall motion

  • Connect the capnometer, assess EtCO2 during 6 breaths

  • Secure the tube

NEEDLE CRICOTHYROTOMY

Indications

  • Can’t oxygenate & can’t intubate

  • Age < 10 years

Contraindications

  • Distal tracheal rupture

  • Age < 10 years

  1. Procedure

  • Stabilize the larynx with the non-dominant hand

  • Locate the cricothyroid membrane (palpate the gap between the thyroid cartilage and cricoid cartilage)

  • Insert at 12-14G catheter attached to a syringe through the membrane until air is aspirated

  • Thread the catheter into the airway and remove the needle

  • Ventilate/oxygenate:

  • if < 5 years: connect the catheter to a bag, e.g. via a 3 ml syringe and the adapter of a ETT #7, and ventilate

  • If > 5 years: connect the catheter to the high-pressure wall-mounted oxygen via a Y connector, occlude the Y connector to administer YEARS L/min oxygen during 1 second, then release the occlusion during 4 seconds, and repeat

  1. Post

  • Assess chest wall motion if ventilating

  • Follow SpO2%

  • Secure the catheter

  • Plan for a definitive airway