No situation in medicine is as stressful as the management of a patient with an unstable airway after multiple failed attempts at endotracheal intubation. Cricothyroidotomy can save the day if performed correctly. The indication for cricothyroidotomy is simple: the inability to obtain an airway by any other means. The maneuver is theoretically simple to perform. However, the stressful situation surrounding a compromised airway requires full understanding of the technique of cricothyroidotomy and a steady hand.

If a prepackaged cricothyroidotomy kit is available, the operator may request it. Otherwise, an antiseptic, a scalpel, and an airway device are all that will be required. Chlorhexidine is a better antiseptic than is an iodine-based solution, but this is of secondary concern. The airway device may either be a small-caliber tracheostomy tube or an endotracheal tube. The anatomical landmarks used to identify the cricothyroid membrane are the thyroid cartilage (Adam’s apple) above and the cricoid ring below. The thyroid cartilage is grasped in the operator’s nondominant hand while the other hand is used to make a generous vertical incision through the skin and subcutaneous tissue. A vertical incision avoids the anterior jugular veins to minimize bleeding. Making a generous incision will allow the necessary exposure. Once the cricoid membrane is located, it is perforated with the tip of the scalpel, which can be moved caudally to expose the airway opening and allow for easy placement of the tube. Once the tube has been placed in the airway, the operator or assistant should maintain control of the airway by keeping at least one hand on it to secure it in place. Tube placement should be confirmed by verifying breath sounds and checking end-tidal carbon dioxide. It should now be easy to oxygenate and ventilate the patient. It is controversial whether a cricothyroidotomy must be converted to a tracheostomy if needed long term.