Cricothyrotomy is performed when airway control is not possible by other methods
(orotracheal or nasotracheal intubation).
Equipment
materials for skin sterilization
materials for sterile technique (cap, mask, gloves, gown)
lidocaine, 1% with 10 ml syringe and 25-gauge needle
sponges
drapes and rolled bath towel
No. I I scalpel blade, mounted
2 mosquito clamps
2 Kelly clamps
Adhesive tape and tincture of benzoin
Low-pressure, high-flow tracheostomy tube sized to the patient 6-8 mm diameter
in adults
Syringe, 10 ml to inflate the balloon on the tracheostomy tube
Bag-valve unit
End tidal CO2detector
Procedure
Position the patient. The patient should be supine,
with a rolled bath towel under the shoulders, and
the neck hyperextended.
The cricothyroid membrane is the small depression just
below the thyroid cartilage or Adam's apple.
Sterilize the skin of the neck from the chin to the sternal notch and laterally
to the base of the neck.
Observe sterile technique if time permits.
Check the tracheostomy tube for cuff leaks by inflating the tube with air from
a syringe.
Identify the cricothyroid membrane. If complete airway obstruction is present
or if patient is comatose, skip the following step. Using the 10 ml syringe
with the 25 gauge-needle, infiltrate the skin and underlying cricothyroid membrane
with the 1% lidocaine in a line across the membrane while steadying the thyroid
cartilage with the left hand.
Using the No. 1 1 blade, make a vertical incision of
the skin over the membrane, and then a horizontal incision through the membrane.
Bluntly dissect the subcutaneous tissue and membrane for approximately I cm
on each side of the midline.
Using a mosquito or Kelly clamp in the left hand with the points downward,
insert the clamp into the incision and spread it. This maneuver alone is
sufficient to provide an airway for a patient with supraglottic airway obstruction.
Grasp the endotracheal tube or tracheostomy tube with the right hand, and insert
the tube through the incision into the trachea, directing it caudally.
Connect the bag-valve unit to the tube, and immediately ventilate the patient
with 100% oxygen. Check for respiratory movement of the chest and the presence
of bilateral breath sounds.
Inflate the balloon just enough to stop any audible air leak during the inspiratory
phase of positive pressure ventilation.
Cut a 4X4 gauze sponge halfway down the middle, and wrap it around the tube.
Secure tube in place with sutures and cloth ties.
Suction the trachea.
Obtain a chest x-ray immediately to check ETT placement.
