CRICOTHYROTOMY (NEEDLE, WITH JET INSUFFLATION)

INDICATIONS:

• Inability to establish or maintain airway patency, oxygenation, and/or ventilation by BVM, by supra-glottic airway, or by orotracheal or nasotracheal intubation, e.g. a patient with massive facial trauma.

LIMITATIONS:

• Provides short-term (less than 30 minutes) oxygenation, but very little ventilation.  Hypercarbia will develop quickly.  As such, this may be a life-saving procedure, but it is not a substitute for definitive airway management.  Intermittent ventilation with high-flow oxygen is required.

CONTRAINDICATIONS:

• Ability to oxygenate and ventilate the patient by BVM, supra-glottic airway or endotracheal intubation.

• Oxygen tubing, with a hole cut near one end, and the other end connected to a high-flow, 50 psi oxygen source
• Iodine skin cleanser
• 12-gauge or 14-gauge IV catheter, connected to a 10 mL syringe
• ET Tube adapter from a 3 Fr. or 3.5 Fr ET Tube, to fit the end of the IV catheter

PROCEDURE:

1. Place the patient supine and cleanse the skin with iodine.
2. Continuously monitor ECG, SpO2 and ETCO2.
3. Palpate the cricothyroid membrane on the midline, between the thyroid cartilage and the cricoid cartilage.
4. Stabilize the trachea with the non-dominant thumb and finger.
5. Puncture the skin/syringe on the midline, directly over the cricothyroid membrane.
6. With a 45-degree angle towards the patient’s feet, insert the needle through the cricothyroid membrane into the trachea while continuously, gently aspirating the syringe.
7. Aspiration of air confirms entry into the tracheal lumen.
8. Remove the syringe and withdraw the stylet/needle, while simultaneously advancing the catheter downward into position.
9. Take care not to puncture the posterior tracheal wall and not to inadvertently withdraw the catheter itself.
10. Secure the oxygen tubing to the catheter, using the 3 Fr. or 3.5 Fr. EET adapter, if needed.
11. Secure the catheter to the patient’s neck.
12. Provide intermittent ventilation:
1. Occlude the open hole cut into the oxygen tubing for 1 second, then release for 4 seconds.
1. Upon release of the tubing hole, passive exhalation will occur.
2. Repeat: 1 second “on”, followed by 4 seconds “off”, and so on.
2. Adequate oxygenation can be provided for no more than 30 to 45 minutes; CO2 accumulation will be even more rapid.
13. Monitor the patient for lung inflation, breath sounds, heart rate, blood pressure, SpO2 and ETCO2.

COMPLICATIONS:

• Inadequate ventilation and/or oxygenation, leading to hypoxia and death
• Aspiration of blood
• Esophageal laceration
• Hematoma
• Posterior tracheal laceration
• Subcutaneous and/ or mediastinal emphysema
• Thyroid perforation
• Pneumothorax