Cricothyrotomy

When endotracheal intubation or a tracheotomy can't be performed quickly to establish an airway, an emergency cricothyrotomy may be necessary. Performed rarely, this procedure involves puncturing the trachea through the cricothyroid membrane.

Usually, your role will be to assist a doctor with this procedure, but if you have received special training, you may have to perform the procedure in an emergency. Ideally, cricothyrotomy is performed using sterile technique but, in an emergency, this may not be possible.


EQUIPMENT

Have one person stay with the patient while another collects the necessary equipment.

For scalpel or needle cricothyrotomy:

• Sterile gloves
• goggles
• povidone-iodine solution
• sterile 4" × 4" gauze pads
• dilator
• tape
• oxygen source

For scalpel cricothyrotomy:

• Scalpel
• #6 or smaller tracheostomy tube (if available)
• handheld resuscitation bag or T tube and wide-bore oxygen tubing

For needle cricothyrotomy:

• 14G (or larger) through-the-needle or over-the-needle catheter
• 10-ml syringe
• tape
• I.V. extension tubing
• hand-operated release valve or pressure-regulating adjustment valve

IMPLEMENTATION

• Put on sterile gloves and personal protective equipment.
• Hyperextend the patient's neck to expose the area of the incision site.
• Have someone hold the patient's head in the correct position while you perform the procedure.

PERFORMING AN EMERGENCY CRICOTHYROTOMY
To perform this procedure, first put on sterile gloves and clean the patient's neck with a gauze pad soaked in povidone-iodine solution. To reduce the risk of contamination, use a circular motion, working outward from the incision site.

• Locate the precise insertion site by sliding your thumb and fingers down to the thyroid gland. You'll know you've located its outer borders when the space between your fingers and thumb widens.

• Move your fingers across the center of the gland, over the anterior edge of the cricoid ring.

Using a scalpel

• Make a horizontal incision, less than 1/2" (1.3 cm) long, in the cricothyroid membrane just above the cricoid ring.
• Insert a dilator to prevent tissue from closing around the incision. If a dilator isn't available, insert the handle of the scalpel and rotate it 90 degrees (as shown below).

• If a small tracheostomy tube (#6 or smaller) is available, insert it into the opening and secure it to help maintain a patent airway. If a tracheostomy tube isn't available, tape the dilator or scalpel handle in place until a tracheostomy tube is available.
• If the patient can breathe spontaneously, attach a humidified oxygen source to the tracheostomy tube with a T tube; if he can't, attach a handheld resuscitation bag. You'll need to inflate the cuff of the tracheostomy tube with a syringe to provide positive-pressure ventilation.
• Auscultate bilaterally for breath sounds, and take the patient's vital signs.
• Dispose of the gloves properly and wash your hands.

Using a needle

• Attach a 10-ml syringe to a 14G (or larger) through-the-needle or over-the-needle catheter. Then insert the catheter into the cricothyroid membrane just above the cricoid ring.
• Direct the catheter downward at a 45-degree angle to the trachea to avoid damaging the vocal cords. Maintain negative pressure by pulling back the syringe plunger as you advance the catheter. You'll know the catheter has entered the trachea when air enters the syringe.

• When the catheter reaches the trachea, advance it and remove the needle and syringe. Tape the catheter in place.
• Attach the catheter hub to one end of the I.V. extension tubing. At the other end, attach a hand-operated release valve or a pressure-regulating adjustment valve. Connect the entire assembly to an oxygen source.
• Press the release valve to introduce oxygen into the trachea and inflate the lungs. When you can see that they're inflated, release the valve to allow passive exhalation. Adjust the pressure-regulating valve to the minimum pressure needed for adequate lung inflation.
• Auscultate bilaterally for breath sounds, and take the patient's vital signs.
• Dispose of the gloves properly and wash your hands.

SPECIAL CONSIDERATIONS

• Immediately after the procedure, check for bleeding at the insertion site, subcutaneous emphysema or inadequate ventilation, and tracheal or vocal cord damage.
• Pediatric alert: Scalpel cricothyrotomy isn't recommended for children under age 12 because it could damage the cricoid cartilage — the only circumferential support to the upper trachea.

COMPLICATIONS

Hemorrhage, perforation of the thyroid or esophagus, and subcutaneous or mediastinal emphysema may occur from this procedure. Infection may also occur several days after the procedure.

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