The primary indication for performing a cricothyroidotomy has already been mentioned – an unsuccessful attempt to maintain a patent airway using positioning techniques often in casualties with facial and oral trauma.

Thermal or toxic gas injuries are also important considerations in certain tactical situations and may result in airway edema that can cause an immediate or delayed airway obstruction. Thermal injuries should be suspected if the casualty is exposed to fire in a confined space or if they have facial burns, singeing of the nasal hairs, or carbonaceous sputum. In these cases, cricothyroidotomy is the airway intervention of choice.

Therefore, If the less invasive measures previously discussed are unsuccessful, a surgical airway by cricothyroidotomy is recommended. Cricothyroidotomy has been reported as safe and effective in trauma patients, albeit with occasional complications.

One large study of military prehospital surgical airways showed a 33% procedure failure rate for medics and a 15% failure rate for physicians and physician assistants. Some of that is likely due to the tactical situation where the procedure was performed, but it highlights the need for medics to consistently train and refresh their skills.

The only absolute contraindication to cricothyrotomy is the ability to secure an airway with less invasive means, but this is not always an option in austere environments. Airway trauma that renders cricothyrotomy a hopeless procedure, such as tracheal transection in which the distal end retracts into the mediastinum or a significant cricoid cartilage or laryngeal fracture, can also be absolute contraindications.

Relative contraindications to surgical cricothyrotomy include massive swelling or obesity with loss of landmarks. Age younger than 10 to 12 years is a contraindication because anatomical considerations make surgical cricothyrotomy extremely difficult, children are prone to laryngeal trauma, and they have a higher incidence of postoperative complications from surgical cricothyrotomy than adults. Therefore, children should undergo needle cricothyrotomy if no other airway can be obtained.