What is the preferred method for emergency surgical cricothyrotomy?

Emergency Surgical Cricothyroidotomy: Preferred Method

The scalpel-bougie-tube technique (open surgical cricothyroidotomy) is the preferred method for emergency front-of-neck airway access in cannot intubate, cannot oxygenate (CICO) situations. 1

Why Open Surgical Technique is Superior

The most recent high-quality guideline evidence from the British Journal of Anaesthesia (2018) explicitly recommends scalpel cricothyroidotomy as the default technique for CICO situations, based on multiple advantages over alternative approaches 1:

• Fast and reliable with high success rates in emergency situations 1
• Provides a definitive airway with cuff protection against aspiration 1
• Enables confirmation of correct placement via waveform capnography 1
• Facilitates adequate ventilation including exhalation and PEEP application 1
• Uses familiar standard equipment (scalpel, bougie, small cuffed tube) 1

The Recommended Technique: Scalpel-Bougie-Tube Method

This is a 4-step approach that should be performed immediately when CICO is declared 1:

1. Identify the cricothyroid membrane with maximum neck extension 1
2. Make a horizontal incision with a wide scalpel blade (size 10 or 20) through skin and membrane if the membrane is palpable; use a large vertical midline skin incision first if the membrane is impalpable 1
3. Apply caudal traction on the cricoid cartilage with a tracheal hook 1
4. Insert a bougie as a guide, then railroad a 5.0-6.0 mm cuffed tracheal tube over it and inflate the cuff 1

Why NOT to Use Needle/Cannula Techniques

Transtracheal jet ventilation (TTJV) via narrow-bore cannula is increasingly recognized as high-risk and should be avoided 1:

• High failure rates for both device insertion and subsequent ventilation 1
• Extremely poor outcomes documented in closed claims analysis 1
• Prone to barotrauma and complications including subcutaneous emphysema that hinders later open approaches 1
• Poorly suited for critically ill patients who require PEEP and have poorly compliant lungs 1
• Non-definitive airway requiring urgent conversion to more reliable devices 1

Research evidence supports this guideline recommendation, showing anatomical-surgical techniques have higher success rates (94-100%) compared to puncture techniques (71-82%), faster insertion times, and fewer complications 2.

Equipment Required

Keep immediately available 1:

• Scalpel with short, rounded blade (size 10 or 20) 1
• Bougie (ensure your tube size fits over your unit's bougie type) 1
• Small cuffed tracheal tube (5.0-6.0 mm or 6-7 mm) 1
• Tracheal hook for cricoid traction 1

Critical Timing Considerations

"Priming for FONA" (Front of Neck Airway) prevents delayed progression 1:

• Get the FONA set to bedside after one failed intubation attempt 1
• Open the FONA set after one failed attempt at facemask or supraglottic airway oxygenation 1
• Immediately use the FONA set at CICO declaration 1

This staged approach facilitates psychological and operational preparation, expediting performance when seconds matter 1.

Post-Procedure Verification

After tube placement 1:

• Confirm position with waveform capnography 1
• Ventilate with low-pressure source 1
• Verify pulmonary ventilation clinically 1
• Convert to definitive airway as soon as possible 1

Common Pitfalls to Avoid

• Delaying the procedure while attempting multiple failed intubation or ventilation attempts—rapid hypoxemia with bradycardia mandates immediate action 1
• Choosing needle cricothyroidotomy as first-line approach—this has unacceptably high failure rates in emergencies 1
• Attempting emergency tracheostomy instead—this is very difficult, takes longer (most operators exceed 3 minutes), and has serious complications 1
• Using percutaneous tracheostomy kits—these involve multiple steps and take excessive time in CICO situations 1

If Surgical Cricothyroidotomy Fails

This is a desperate situation with cardiac arrest being usual 1:

• Attempt FONA lower in the trachea if cricothyroid membrane approach fails 1
• An experienced operator may attempt percutaneous or surgical tracheostomy at this point 1
• These are last-resort maneuvers in an already catastrophic situation 1