Purpose
• Failed airway (can’t intubate/can’t ventilate); severe facial trauma, trismus, upper airway obstruction
Equipment
• Scalpel (11 blade), Trousseau dilator, tracheal hook, Bougie, tracheostomy tube (ET tube if none immediately available)
Positioning
• Pt supine, hyperextend neck if no CI
Procedure
• Sterile technique if time allows; see RSI for preparation & postintubation management
• Open Technique:
• Hold larynx w/ nondominant hand
• Make vertical incision w/ dominant hand from thyroid cartilage to cricoid membrane (2–3 cm), through skin & soft tissue
• Palpate cricothyroid membrane through incision using nondominant index finger, not visualization
• Make horizontal incision <1 cm through cricothyroid membrane
• Place finger into stoma, then replace w/ tracheal hook-pointed caudad, then rotate cephalad. Alternatively, place Bougie (instead of tracheal hook) deep into stoma then slide ETT over Bougie & into place.
• Place Trousseau dilator in stoma w/ handle perpendicular to neck & dilate vertically
• Rotate dilator parallel to neck, then place tracheostomy tube w/ obturator in place, thumb over the obturator or ET tube
• Remove obturator (if tracheostomy tube), inflate cuff
Complications
• Bleeding, misplaced tube, vocal cord damage
Pearl
• The hardest part of performing cricothyrotomy is deciding to do it → therefore, always consider this procedure in your airway algorithm