Cricothyrotomy

Last updated: January 5, 2023

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Cricothyrotomy is the creation of an opening in the cricothyroid membrane (CTM) to establish an effective airway. The primary indication is a cannot intubate-cannot ventilate scenario with actual or impending airway compromise and respiratory failure. Cricothyrotomy may be performed by passing a large bore cannula or needle through the CTM into the trachea (needle cricothyrotomy) or creating an opening through the CTM and passing an endotracheal tube or tracheostomy tube into the trachea (surgical cricothyrotomy). A needle cricothyrotomy is typically paired with jet ventilation to maintain oxygenation and is a temporizing measure because ventilation is often inadequate. Surgical cricothyrotomy is a definitive airway that allows the usage of conventional modes of mechanical ventilation. Contraindications to cricothyrotomy include tracheal transection, tracheal or laryngeal trauma, and/or anatomic distortion. Surgical cricothyrotomy is also contraindicated in infants and young children. Complications include bleeding, airway trauma, and/or incorrect placement.

See also “Surgical airway management.”

The most common indication is a cannot intubate-cannot ventilate (CICV) scenario (e.g., after failed intubation), however, emergency surgical airways can be considered early in difficult airway management in select situations.

Needle cricothyrotomy [2]

Surgical cricothyrotomy [1][3][4]

  • Absolute
  • Relative
    • Infection at the site
    • Distorted anatomy

The ability to perform safe and timely endotracheal intubation is a contraindication to cricothyrotomy.

Tracheostomy is preferred for patients who need a permanent surgical airway without imminent signs of airway compromise, or if surgical cricothyrotomy is absolutely contraindicated.

We list the most important contraindications. The selection is not exhaustive.

The following applies to surgical cricothyrotomy: [1][5]

The following applies to surgical cricothyrotomy: [1][6][7]

  • Position the patient supine with their neck extended.
  • Provide oxygen to the mouth and nose.
  • Identify the CTM landmarks: the depression between the thyroid cartilage and cricoid cartilage
  • Don PPE and sterile gloves.
  • Perform skin preparation.
  • Apply sterile drape (if time permits).
  • Administer local anesthesia (if the patient is conscious and time permits).
  • Apply a small amount of lubricant to the inside of the tube.

The following applies to surgical cricothyrotomy:

Techniques [1][5][8]

Bougie-assisted rapid cricothyrotomy [1][3][6][7][8]

  1. Grasp the cricoid cartilage between the middle finger and thumb of the nondominant hand.
  2. Locate the CTM with the index finger.
  3. Make an ∼ 1.5 cm-wide transverse incision through the skin, subcutaneous tissue, and CTM.
  4. Turn the scalpel 90° to open the incision.
  5. Insert the bougie (angled end first) directed toward the patient's feet.
  6. Advance the bougie 10–15 cm.
  7. Withdraw the scalpel.
  8. Thread the lubricated tube over the bougie.
  9. Advance the tube just until the cuff is no longer visible.
  10. Inflate the tracheal tube cuff.
  11. Remove the bougie and attach a self-inflating bag.
  12. Verify intratracheal placement with positive ETCO2.

Common pitfalls and challenges of cricothyrotomy [1][3][9]
Suggestive features Management
Unable to identify landmarks [1]
  • Distorted anatomy, e.g., edema, scar tissue, overlying masses

Mainstem intubation

(occurs when using ET tubes)

  • Deflate the cuff, pull the ET tube back a short distance, and reassess
Incorrect tube placement
  • Remove the tube and restart the procedure.
Distal airway pathology
  • Consider alternative oxygenation strategies, e.g., ECMO.
Bleeding [3][9]
  • Minor: e.g., oozing
  • Major: e.g., copious and/or pulsatile bleeding
  • Minor: Compress the area with iodoform gauze; consider topical hemostatic agents.
  • Major: Consult the surgical team, as vessel ligation may be required.

Assessment of breath sounds, peak airway pressures, and capnography will help differentiate between common causes of hypoxia and/or inadequate ventilation after a cricothyrotomy.

We list the most important complications. The selection is not exhaustive.

  1. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  2. Mace SE, Khan N. Needle Cricothyrotomy. Emerg Med Clin North Am. 2008; 26 (4): p.1085-1101. doi: 10.1016/j.emc.2008.09.004 . | Open in Read by QxMD
  3. Reichman E. Emergency Medicine Procedures. McGraw-Hill ; 2013
  4. Carretta A, Ciriaco P, Bandiera A, et al. Veno-venous extracorporeal membrane oxygenation in the surgical management of post-traumatic intrathoracic tracheal transection. J Thorac Dis. 2018; 10 (12): p.7045-7051. doi: 10.21037/jtd.2018.11.117 . | Open in Read by QxMD
  5. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015; 115 (6): p.827-848. doi: 10.1093/bja/aev371 . | Open in Read by QxMD
  6. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  7. Yiannakis CP, Hilmi OJ. Evaluation and management of acute upper airway obstruction. Surgery. 2021; 39 (9): p.598-606. doi: 10.1016/j.mpsur.2021.07.006 . | Open in Read by QxMD
  8. Hill C, Reardon R, Joing S, Falvey D, Miner J. Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab. Acad Emerg Med. 2010; 17 (6): p.666-669. doi: 10.1111/j.1553-2712.2010.00753.x . | Open in Read by QxMD
  9. Kristensen MS, McGuire B. Managing and securing the bleeding upper airway: a narrative review. Can J Anaesth. 2019; 67 (1): p.128-140. doi: 10.1007/s12630-019-01479-5 . | Open in Read by QxMD

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