The LSUHSC New Orleans
Emergency Medicine Interest Group


The Student Procedure Manual


by Nicole Charbonnet
with Patrick Hymel





  1. Position the patient. The patient should be supine,
    with a rolled bath towel under the shoulders, and
    the neck hyperextended.
  2. The cricothyroid membrane is the small depression just
    below the thyroid cartilage or Adam's apple.
  3. Sterilize the skin of the neck from the chin to the sternal notch and laterally to the base of the neck.
  4. Observe sterile technique if time permits.
  5. Check the tracheostomy tube for cuff leaks by inflating the tube with air from a syringe.
  6. 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.
  7. Using the No. 1 1 blade, make a vertical incision of
    the skin over the membrane, and then a horizontal incision through the membrane.
  8. Bluntly dissect the subcutaneous tissue and membrane for approximately I cm on each side of the midline.
  9. 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.
  10. Grasp the endotracheal tube or tracheostomy tube with the right hand, and insert the tube through the incision into the trachea, directing it caudally.
  11. 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.
  12. Inflate the balloon just enough to stop any audible air leak during the inspiratory phase of positive pressure ventilation.
  13. Cut a 4X4 gauze sponge halfway down the middle, and wrap it around the tube. Secure tube in place with sutures and cloth ties.
  14. Suction the trachea.
  15. Obtain a chest x-ray immediately to check ETT placement.



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