Cricothyroidotomy—Standard and Needle

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

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



   imagesAn oral or nasal airway can be established

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

   imagesTracheal fracture or transection

   imagesObstruction below the cricothyroid membrane

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


   imagesNeck mass, swelling, or cellulitis

   imagesNeck hematoma



imagesThe 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.

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



   imagesAntiseptic solution, drapes, towel clips

   imagesLidocaine with epinephrine

   imagesNo. 11 blade scalpel with handle

   imagesTracheal hook

   imagesTrousseau dilator

   imagesTracheostomy tube

   imagesNeck tie or sutures



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

      imagesPreoxygenate the patient by bag-mask ventilation

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

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

      imagesIf 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.)

imagesGeneral Basic Steps

   imagesIdentify the landmarks

   imagesStabilize the larynx

   imagesIncise the skin

   imagesReidentify the cricothyroid membrane

   imagesIncise the cricothyroid membrane

   imagesInsert the tracheal hook

   imagesInsert the trousseau dilator

   imagesInsert the tracheostomy tube

   imagesInflate the cuff and confirm tube position

   imagesSecure the tracheostomy tube

imagesIdentify the Landmarks (See Earlier “Landmarks” Section)

imagesStabilize the Larynx

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

   imagesPalpate the depression over the cricothyroid membrane with the index finger

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

imagesIncise the Skin

   imagesUsing 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

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

imagesReidentify the Cricothyroid Membrane

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

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

imagesIncise the Cricothyroid Membrane

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

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

   imagesPlace 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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Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Cricothyroidotomy—Standard and Needle
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