Needle cricothyrotomy

Indications

External views of the larynx: (a) anterior aspect; (b) anterolateral aspect with the thyroid gland and cricothyroid ligament removed.

The cartilages and ligaments of the larynx seen posteriorly.

• Failed airway in adults or children
  • Preferred method of rescue airway in infants and children (cutoff 5-12 years of age, depending on source)
• Temporizing measure until definitive airway management
  • Will provide adequate oxygenation, but will NOT provide adequate ventilation
• Obstruction above the level of the cricothryoid membrane

Contraindications

When used as a rescue airway, no absolute contraindications.

• Relative Contraindications
  • Inability to identify landmarks
  • Tracheal transection or severe trauma
  • Underlying tumor, abscess/infection, or other known abnormality

Equipment

• Povidone iodine
• Sterile drapes, gloves, gown, gauze
• 12-14 G angiocath
• 3mL syringe x 2
• Adapter to 7-0 ETT or adapter to 3-0 ETT
• BVM appropriate for size of patient
  • Can also use jet vet ventilation setup in adults
    • High flow O2 source, 50 PSI
    • O2 tubing
    • Valve-3 way stop cock or cut holes in O2 tubing
    • Depending on O2 source, calculate time valve must be open for tidal volume
    • BVM setup does not allow adequate exhalation in adults

Procedure

(1) Thyroid cartilage (2) Cricothyroid ligament (3) Cricoid cartilage (4) Trachea (A) Cricothyrotomy site (B) Tracheotomy site

1. Prep and drape
2. Locate cricothyroid membrane
3. Pierce membrane with angiocath directed 30-45 deg caudal
   • Attach 3mL syringe with saline, aspirate as you enter
   • Advance until air is aspirated in syringe
4. Advance catheter over needle, hub to skin
   • Remove needle
5. Attach 3-0 ETT adapter directly to angiocath (best option)
   • OR attach 3 mL syringe to catheter, then attach 7-0 ETT adapter to syringe
   • OR attach 10 mL syringe to catheter, then insert actual 7-0 ETT (works best with cut down ETT) into syringe and blow up balloon so that ETT does not move
6. Attach BVM to ETT adapter
7. Secure system
8. Ventilate with BVM or high flow O2 setup
9. OBTAIN DEFINITIVE AIRWAY
   • Should be used for < 45 minutes

Complications

• Hemorrhage
• Infection
• Tracheal stenosis
• Subcutaneous emphysema
• Posterior tracheal perforation

See Also

• Intubation
• Surgical airways

External Links

• EMCrit: Needle vs Knife: Part I

Videos

• EMCrit (0:50) https://www.youtube.com/watch?v=Q0RVlgwC9rs&feature=emb_logo
• EMCrit (0:58) https://www.youtube.com/watch?v=WnTBm5f_ihQ&feature=emb_logo
• Henneman (6:59) https://www.youtube.com/watch?v=bIbl6zgWBjg&feature=emb_logo

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