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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 4 – Practical procedures > Chapter 62 – Cricothyroidotomy Chapter 62 Cricothyroidotomy P.664
Call for anaesthetic and ENT help. In some situations of upper airway obstruction or facial trauma, ventilation and tracheal intubation of a patient is impossible. It may therefore be necessary to create an immediate surgical airway below the level of obstruction.

  • Extend the head, with the patient lying flat. Place a pillow under the patient’s shoulders, not their head
  • Identify cricothyroid membrane: soft triangular area above cricoid ring and below the thyroid cartilage. (Put your fingers on the larynx and move them down to the soft area below, where you are aiming for.) Clean with antiseptic swab
  • Puncture the membrane in the midline with a large-bore cannula (18G or larger). Remove the needle, attach a syringe, and aspirate air to confirm correct position. Specific cricothyroidotomy kits are available
  • Angle the cannula downwards at 45 degrees and advance. Ensure air can still be aspirated and then connect to high-pressure oxygen supply, with a Y connector if possible
  • Occlude one limb of Y connector with a finger until chest rises and then release to allow exhalation, ideally via larynx. Inflate for 1 second and deflate for 4 seconds. Must allow air to be exhaled. If there is no Y connector, a hole is cut in the oxygen tubing, which can be intermittently occluded
  • Secure the cannula
  • Perform a formal surgical cricothyroidotomy with ENT help, as needle method does not allow adequate ventilation as the tube is too small and the larynx is blocked. Vertical skin incision, press lateral edges outwards to minimize bleeding. Transverse cricothyroid membrane incision, care not to damage cricoid cartilage. Dilate tract with tracheal spreader or scalpel handle and insert a cuffed tube.
Diagram of needle cricothyroidotomy.

Further information Advanced Life Support Provider Manual, 4th edition 2000. Resuscitation Council UK

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