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For all procedures, ask yourself, 'does this need to be done 'now vs later'? And should this be done by 'me vs someone else?' Very often the answers will be 'now' and 'me' - so read on!

Cricothryroidotomy - "finger - scalpel - bougie" technique

Description

Emergency cricothyroidotomy is emergency airway access via the cricothyroid membrane. Although intimidating, it is a life-saving procedure and can be quite simple to perform.
The finger-scalpel-bougie technique is simple and therefore has increased chance of success.

Indications

"Can’t intubate, can’t ventilate" situation, not responding to other airway rescue procedures, during an endotracheal intubation (Rapid Sequence Intubation/Delayed Sequence I) attempt.

Upper airway obstruction (foreign body, oedema, trauma) not amenable to other measures.

Contraindications

This is an emergent, 'last resort' procedure, thus contraindications are of limited relevance.

Inability to identify the anatomy.

Children under 10 years old - the narrow cricothyroid membrane increases risk of causing damage to nearby structures. This is a very difficult situation, needle cricothyroidotomy is recommended as the safer alternative to surgical cricothyroidotomy although there is evidence of high failure rate and significant rates of barotrauma. It is hard to draw a conclusion as to what to do.

Equipment

Scalpel

Bougie

6.0 ETT with syringe attached and cuff completely deflated

Syringe to inflate tube cuff

Procedure

Call for help - but don't delay in "can't intubate, can't ventilate, can't oxygenate" situation.

Then 'incision to bougie in the trachea' is the critical piece - so have everything ready and to hand before cutting skin.

It is easiest to stand at the head, on the side of the patient that is your dominant side.

Grasp the thyroid cartilage with your non-dominant hand middle finger and thumb.

Use the tip of your index finger to locate the cricothryoid membrane (the depression just below the thyroid cartilage, and just above the 'wedding band' type feel of the cricoid cartilage).

Stretch the skin tight over this area using your middle finger and thumb and hold the structures firmly - this is more of a 'by palpation' than visual procedure.

Clean the skin with chlorhexidine.

If conscious and if there is time, infiltrate a small amount of lidocaine with epinephrine (reduces bleedin) local anaesthetic - take care not to add so much as to distort the anatomy.

With the tip of your index finger in/on the cricothryroid membrane depression, and firm resolve not to let go or move, make a stab incision horizontally through the skin and cricothyroid membrane into the airway, make it a little wider to fit the tube by tuning the if you can do this quickly - keep the tip of your index finger in this depression/incision.

[If the landmarks are not easily palpated, start with a vertical midline incision over the area and quickly blunt dissect through the subcutaneous tissue with your fingers to properly identify the cricothyroid membrane. Once it has been identified in this manner, proceed with the horizontal incision]

Ignore the bleeding - it will distract you.

Without moving your hand/finger on the anatomy - do not let the skin move over the deeper structures - insert a bougie initially posteriorly, but then directing towards the feet. Insertion should be at least 10cm to avoid accidental removal. There is no advantage to over-insertion and no need to insert until the bougie stops or meets resistance.

Enlarge the incision horizontally if necessary, to 1.5-2.0 cm to allow the ET tube to enter (do not cut or dislodge the bougie - keep hold of it at the skin!).

Slide a size 6.0 ET tube over the bougie, into the trachea and inflate the cuff.

Now, and only now, address any bleeding and secure the tube - whilst initiating ventilation and checking lung expansion and end-tidal CO₂

Potential pitfalls

Moving your hand and thus 'losing' the anatomy or creating a false passage.

Not having everything to hand so that you work 'one handed' (the other hand holding the anatomy in place.

Stopping because of bleeding - bleeding is common - work quickly, this procedure is done by palpation not direct vision

Trying to use an ET tube smaller than 6.0 (it won't fit over the bougie)

"Plan B"

The emergency cricothyroidotomy is your plan B. Other help may arrive. Re-attempt endotracheal intubation.

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References:

https://litfl.com/surgical-cricothyroidotomy/

http://emcrit.org/procedures/bougie-aided-cric/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3982374/

Credits: This Critical Procedure was contributed by Paula Sneath, edited by The CARE Course.

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