PREPARE PATIENT

1. Pre-oxygenate patient if possible.
2. Inspect/assemble/test equipment for cricothyroidotomy.
3. Prepare site with alcohol and betadine -or- Chlorhexadine (Chlora-prep).
4. Follow SOAP ME and for induction, use ketamine (1mg/kg IV/IO or 3-4mg/kg IM) if time permits and the medication is available. SOAP ME: Suction, Oxygen, Airway Assessment, Pharmacy, Plan, Monitor, and Equipment

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

1. Stabilize thyroid cartilage with nondominant hand. Maintain control with hand until the membrane incision is secured (step 8 below).
2. Locate cricothyroid membrane with index finger (commonly located approximately three to four finger widths above the sternal notch in adults).
3. Make vertical incision through the skin over cricothyroid membrane.
4. Make horizontal incision through cricothyroid membrane, then immediately:
5. Open and maintain membrane incision with tracheal hook (or curved hemostat, bougie or blunt end of scalpel).
6. Insert endotracheal/tracheostomy tube into opening and direct tube caudad into trachea until the balloon is just inside the airway.
7. Inflate cuff and detach syringe (palpate bulb to ensure it’s not under-inflated or over-inflated).
8. Maintain control of tube at all times to prevent dislodgement.
9. Attach waveform capnography, or capnometry, or colorimetric device to confirm proper placement of tube.
10. Being careful not to dislodge the tube, attach BVM with positive end-expiratory pressure and further check placement (epigastric and bilateral chest) and adequacy of bilateral insufflation of lungs.
11. Remove BVM (if sufficient respiratory effort), assess respirations for adequacy (rate, rhythm, and quality), assist ventilations if needed.
12. 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.
13. Consider placing a nasogastric/orogastric tube if available.