We do a lot of life-saving procedures and interventions on a daily basis in the emergency room. However, there are some much less frequent but equally as important life-saving procedures we need to know how to do. Today we will review how to do an emergency cricothyrotomy.

This procedure is indicated for those patients you cannot intubate and cannot ventilate. This should not be done if you are able to secure the airway with less invasive means or if there is trauma to cricothyroid membrane. Also of note, patients under the age of 10 should receive a needle cricothyrotomy.

There are a number of different techniques, but we will go over the knife- finger- bougie technique. Most places have cric kits, but in a hurry you will need a scalpel (11 blade), forceps (optional), bougie and a tracheostomy tube (or size 6-0 ETT). If possible this should be done under sterile technique and if you have enough time, analgesia or sedation should be given.

You should position yourself on the same side of the patient as your dominant hand. Stabilize thyroid cartilage with non-dominant hand and hold scalpel in dominant hand. Make a 4cm vertical incision through skin over the cricothyroid membrane.

1stincision

Perform a blunt dissection to cricothyroid membrane, then a horizontal incision through cricothyroid membrane, flip the scalpel 180degrees and extend to the other side where you started the incision.

horizontal

With your gloved finger, dilate and palpate tracheal lumen.

Pass bougie alongside finger into trachea, confirm bougie passage with finger in trachea.

Pass tracheostomy tube (or ETT) over bougie and into trachea. If using ETT only advance until the deflated balloon is no longer visible and then stop. Remove bougie, secure placement and confirm tracheostomy tube (or ETT) placement with ETCO2, bilateral breath sounds, CXR.

Here is a video by Scott Weingart going over this knife-finger-bougie technique: https://vimeo.com/123573243

Special thanks to Dr. Scott and Dr. Taub for the inspiration for this pearl.

Sources:

EMCrit Podcast