Page 192 - 2023 SMOG Digital

CRICOTHYROIDOTOMY

CLINICAL INDICATIONS:
• DIFFICULT AIRWAY- Airway can receive one (1) RSI attempt before calling it a failed airway. Two
exceptions exist:
o Inability to maintain proper O 2 saturation above 90% or major trauma or obstruction
• NON-DIFFICULT AIRWAY- Airway can receive two (2) attempts so long as O₂ saturation is >90%.
• Inability to place / ventilate with blind insertion airway device (BIAD) or inability to provide ventilation with
Bag-Valve mask.
• Massive facial trauma or neck trauma precluding the use of orotracheal intubation/BIAD.
CONTRAINDICATIONS:
• Age <12yo, abnormal anatomy. (See Needle Cricothyroidotomy)
PROCEDURE:
• Maintain patient in sniffing position or place them into
sniffing position. Utilize inline stabilization if indicated.
• Oxygenate the patient with 100% O2. Identify and
cleanse the cricoid area with betadine / alcohol while
oxygenating if possible.
• Before incising place static non-dominant hand using
the middle and thumb to hold either side of the thyroid cartilage
with the palm towards the head leaving and area between the
fingers inferiorly to make the incision. This hand will not move
until bougie is confirmed in the trachea.
• Using a scalpel, make an adequate (2-3cm) vertical
incision over the cricothyroid membrane. Then, using
hemostats, bluntly dissect until membrane fully visualized.
• Make an adequate horizontal incision through the cricothyroid membrane into the trachea. Spread incision
with either hemostats or scalpel handle.
• At this point the index finger of the hand gripping the thyroid cartilage can be placed within the opening and
the posterior aspect of the trachea can be palpated. The index finger maintains the tract should the airway
be extremely bloody as this procedure is prone to be. The bougie/stylet is then placed along the index finger
ensuring tracheal guidance and not subcutaneous plane dissection or posterior tracheal perforation into the
esophagus.
• Once the bougie/stylet is inserted, pass a cricothyroid tube or 6-0 ETT into the trachea (if ETT used, only
insert until just past the cuff, then inflate the cuff). Secure tube in place and begin to ventilate with BVM /
100% O2.
• Confirm placement with capnography, capnometer, bilateral chest rise / breath sounds, good PO2, EtCO2,
lack of increasing SQ air (a small amount is normal).
• Document procedure, results, and vital signs.

192