Prepare patient
- Pre-oxygenate patient if possible.
- Inspect/assemble/test equipment for cricothyroidotomy.
- Prepare site with alcohol and betadine -or- Chlorhexadine (Chlora-prep).
- Follow MSMAID and for induction, use ketamine (1mg/kg IV/IO or 3-4mg/kg IM) if time permits and the medication is available.
For awake cricothyrotomy: Explain procedure to patient; *Use local anesthesia: lidocaine (1% or 2%), bupivacaine (0.25%, 0.5% or 1%); local through planned incision area AND approx. 1-2mL through cricothyroid membrane
Perform procedure
- Stabilize thyroid cartilage and keep overlying skin taught. Maintain control with hand until the membrane incision is secured (step 8 below).
- Locate cricothyroid membrane (Palpate for hyoid and tracheal rings. If unsure or difficult landmarks, then measure three finger widths above sternal notch for adults).
- Make vertical incision through the skin over cricothyroid membrane.
- Make horizontal incision through cricothyroid membrane, then immediately:
- Open and maintain membrane incision with tracheal hook (or curved hemostat, bougie or blunt end of scalpel).
- Insert endotracheal/tracheostomy tube into opening and direct tube caudad into trachea until the balloon is just inside the airway.
- Inflate cuff and detach syringe (palpate bulb to ensure it’s not under-inflated or over-inflated).
- Maintain control of tube at all times to prevent dislodgement.
- Attach waveform capnography, or capnometry, or colorimetric device to confirm proper placement of tube.
- Being careful not to dislodge the tube, attach BVM with PEEP and further check placement (epigastric and bilateral chest) and adequacy of bilateral insufflation of lungs.
- Remove BVM (if sufficient respiratory effort), assess respirations for adequacy (rate, rhythm, and quality), assist ventilations if needed.
- Secure with sutures and tie with girth hitch passed around the neck if time permits. As a stopgap, may use chest seal or secure around the neck with tie, ensuring inflation bulb does not get caught.
- Consider placing NG/OG tube if available.