What are the steps for performing a cricothyroidomy?

Surgical Cricothyroidotomy: The 4-Step Technique

The scalpel-bougie-tube technique is the preferred method for emergency front-of-neck airway access, performed as a rapid 4-step procedure that can be completed in under 30 seconds when cannot intubate, cannot oxygenate (CICO) is declared. 1, 2, 3

The 4-Step Technique

Step 1: Identify the Cricothyroid Membrane

• Palpate the thyroid cartilage and move inferiorly to locate the cricothyroid membrane between the thyroid and cricoid cartilages 1, 2, 3
• If time permits before induction, ultrasound guidance may be used to identify and mark the membrane, even with a cervical collar in place 1
• Stabilize the larynx with your non-dominant hand throughout the procedure 3

Step 2: Make a Stab Incision Through Skin and Membrane

• Use a scalpel with a short, rounded blade (typically #20 blade) 2, 3
• Make a horizontal incision through the skin and cricothyroid membrane in one motion 1, 2
• Enlarge the incision using blunt dissection with the scalpel handle, forceps, or dilator 1

Step 3: Apply Caudal Traction on the Cricoid Cartilage

• Insert a tracheal hook with a large radius through the incision 2, 3
• Apply firm caudal (downward) traction on the cricoid cartilage to open the airway 1, 2
• This step stabilizes the airway and creates space for tube insertion, with hand movements similar to orotracheal intubation 3

Step 4: Insert Bougie, Then Tube, and Inflate Cuff

• Insert a bougie through the incision as a guide 2, 3
• Railroad a small cuffed tracheal tube (typically 6.0-7.0 mm) over the bougie into the trachea 1, 2
• Inflate the cuff to protect against aspiration 2

Post-Procedure Verification

• Ventilate with a low-pressure source (standard bag-valve-mask or ventilator) 1, 2
• Verify correct tube position using waveform capnography 2
• Confirm pulmonary ventilation clinically by observing chest rise and auscultation 1, 2

Critical Timing Considerations

The front-of-neck airway set should be brought to bedside after one failed intubation attempt, opened after one failed attempt at facemask or supraglottic airway oxygenation, and used immediately when CICO is declared. 2

• Rapid development of severe hypoxemia, particularly with bradycardia, mandates immediate cricothyroidotomy 1, 2
• The procedure can be completed in less than 30 seconds with proper technique 3
• Delay in performing cricothyroidotomy in CICO situations results in death 1

Common Pitfalls to Avoid

Do Not Delay the Procedure

• Multiple failed intubation or ventilation attempts waste critical time during progressive hypoxemia 2
• Once CICO is declared, proceed immediately to surgical cricothyroidotomy 1, 2, 4

Avoid Needle Cricothyroidotomy as First-Line

• Cannula cricothyroidotomy has documented low success rates in emergency situations 1
• High-pressure ventilation through a cannula carries significant risk of barotrauma, with initial pressures needing to be less than 4 kPa (55 psi) 1
• Needle techniques require special high-pressure equipment that may not deliver sufficient pressure with standard anesthesia machines 1
• If needle cricothyroidotomy is ineffective or causes complications, immediately convert to surgical cricothyroidotomy 1

Do Not Attempt Emergency Tracheostomy

• Emergency tracheostomy is technically difficult with serious complications 1
• Most operators take longer than 3 minutes to complete tracheostomy, causing fatal delays in CICO situations 1
• Cricothyroidotomy is safer and more rapid than emergency tracheostomy 4, 5

Equipment Required

• Scalpel with short, rounded blade (#20) 2, 3
• Bougie 2, 3
• Small cuffed tracheal tube (6.0-7.0 mm) 1, 2
• Tracheal hook with large radius 2, 3

Safety Profile

• Surgical cricothyroidotomy is a relatively safe procedure when performed correctly 4, 5
• Overall complication rate is approximately 6% 6
• Major complications are rare; minor complications include minimal subglottic stenosis (2%), local wound infection (1%), and non-threatening hemorrhage (1%) 5
• Chronic subglottic stenosis does not occur with proper technique 6
• No additional complications occur when performed at bedside versus operating room 6

Definitive Airway Management

• Cricothyroidotomy is a temporary measure to restore oxygenation 1
• Convert to a definitive airway (formal tracheostomy or tracheal intubation under vision with fiberoptic scope) as soon as possible 1, 2
• These techniques should only be used in life-threatening situations 1