Cricothyroidotomy—Standard and Needle

To provide emergent airway access only when a safer, less invasive airway cannot be established or is contraindicated

For children younger than 12 years, needle cricothyroidotomy is the surgical airway of choice

CONTRAINDICATIONS

Absolute

An oral or nasal airway can be established

Significant injury or fracture of the cricoid cartilage or larynx (tracheostomy is the procedure of choice)

Tracheal fracture or transection

Obstruction below the cricothyroid membrane

Patients younger than 12 years (needle cricothyroidotomy is the procedure of choice for this age-group)

Relative

Neck mass, swelling, or cellulitis

Neck hematoma

Coagulopathy

LANDMARKS

The cricothyroid membrane—an elastic membrane located anteriorly and midline in the neck, measuring 9 mm longitudinally and 30 mm transversely. Bordered superiorly by the thyroid cartilage (“Adam’s apple”) and inferiorly by the cricoid cartilage.

In children, the larynx is positioned more superiorly than in adults and is relatively smaller in size (FIGURES 6.1 and 6.2)

STANDARD CRICOTHYROIDOTOMY

Supplies

Antiseptic solution, drapes, towel clips

Lidocaine with epinephrine

No. 11 blade scalpel with handle

Tracheal hook

Trousseau dilator

Tracheostomy tube

Neck tie or sutures

Technique

Preparation

Hyperextend the neck to more readily identify landmarks, unless the patient has a known or suspected cervical spine injury

Preoxygenate the patient by bag-mask ventilation

Test the integrity of the balloon on the tracheostomy tube by injecting with 10 mL of air

If time permits, apply appropriate antiseptic solution and drape the area with sterile towels

If time permits and patient is conscious or responding to pain, infiltrate the skin of anterior neck with 1% lidocaine solution with epinephrine

FIGURE 6.1 Anatomy of the larynx. The cricothyroid membrane (arrow) is bordered above by the thyroid cartilage and below by the cricoid cartilage. (From Walls RM, Murphy MF. Manual of Emergency Airway Management. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:162, with permission.)

FIGURE 6.2 A: Surface anatomy of the airway. B: The thumb and middle finger immobilize the superior cornua of the larynx; the index finger palpates the cricothyroid membrane. (From Walls RM, Murphy MF. Manual of Emergency Airway Management. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:163, with permission.)

General Basic Steps

Identify the landmarks

Stabilize the larynx

Incise the skin

Reidentify the cricothyroid membrane

Incise the cricothyroid membrane

Insert the tracheal hook

Insert the trousseau dilator

Insert the tracheostomy tube

Inflate the cuff and confirm tube position

Secure the tracheostomy tube

Identify the Landmarks (See Earlier “Landmarks” Section)

Stabilize the Larynx

Grasp both sides of the thyroid cartilage with the thumb and middle finger using the nondominant hand

Palpate the depression over the cricothyroid membrane with the index finger

Control the larynx throughout the procedure by stabilizing it in this manner and reidentify the cricothyroid membrane at any time during the procedure

Incise the Skin

Using a no. 11 scalpel blade in the dominant hand, make a vertical midline incision through the skin and subcutaneous tissue approximately 2 to 3 cm in length

Care should be taken to extend the incision down to but not through any of the deep structures of the neck

Reidentify the Cricothyroid Membrane

Using the index finger of the nondominant hand, reidentify the cricothyroid membrane while maintaining immobilization of the larynx with the thumb and middle finger

If the cricothyroid membrane cannot be palpated, extend the initial incision superiorly and inferiorly and try to palpate again

Incise the Cricothyroid Membrane

Using the stabilizing index finger as a guide, incise the cricothyroid membrane at least 1 cm in length in the horizontal direction

Note that the skin incision is vertical and the incision through the membrane is horizontal

Place the index finger into the stoma temporarily while exchanging the scalpel for the tracheal hook

FIGURE 6.3 A: The tracheal hook is oriented transversely during insertion. B and C: After insertion, cephalad traction is applied to the inferior margin of the thyroid cartilage. (From Walls RM, Murphy MF. Manual of Emergency Airway Management. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:166, with permission.)

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