Name: emergency airway access with cricothyrotomy
Uploaded: 2023-04-30T06:48:06.000Z
Duration: 8 min 20 s
Channel: JoVE

K12 Standards

new-york-state-science-learning-standards

New York State Science Learning Standards

High School

Life Science

Structure and Function

HS-LS1-3.

Percutaneous Cricothyrotomy

1. Patient positioning and preparation for the procedure
<ol>
	<li>The patient in this situation has likely undergone attempted endotracheal intubation and should already be lying supine.</li>
	<li>Extend the patient&#39;s neck to better assess anatomic landmarks.</li>
	<li>The cricothyroid membrane is located below the laryngeal prominence (&#34;Adam&#39;s apple&#34;) and is palpated as a soft indentation in the midline on the anterior neck. The superior thyroid arteries anastomose in the midline inferior to the cricothyroid membrane. The thyroid gland is located inferior to the superior thyroid arteries</li>
	<li>Gather supplies, including chlorhexidine, a needle cricothyrotomy kit, and airway management supplies (bag-valve-mask device, supplemental oxygen, and suction).</li>
	<li>There are several pre-packaged percutaneous cricothyrotomy kits available. Standard kits include an introducer needle, a 5mL syringe, a scalpel, a guide wire, a dilator, and an airway catheter, which may be cuffed or uncuffed.</li>
	<li>Open the needle cricothyrotomy kit and attach the introducer needle to the syringe. Assemble the airway catheter/dilator, prepare the guide wire, and lay out the scalpel for easy access</li>
</ol>
2. Protocol
The context of this procedure is often the truly emergent situation. In this event, there may not be time for local anesthesia (if the patient is awake) or skin preparation with chlorhexidine. As with all emergent procedures, true sterile technique is sacrificed for rapidity. For example, it is unlikely that the situation that calls for an emergent cricothyrotomy would allow for sterile gowning and gloving.
<ol>
	<li>Stand at the head of the bed and identify the patient&#39;s anatomy by palpating the laryngeal prominence and moving your fingers inferiorly into the depression below, the cricothyroid membrane.</li>
	<li>Grab the paratracheal structures and move them around to be certain you can identify the midline. They will move as a unit. It is in the midline of this depression that the practitioner will make the incision and insert the needle.</li>
	<li>If time allows, the area should be cleaned with chlorhexidine. Ideally, the exam gloves that the practitioner is wearing should be traded for sterile gloves.</li>
	<li>Make a small (5mm) vertical incision with the scalpel in the midline previously identified.</li>
	<li>Advance the introducer needle into the neck through the skin incision and through the cricothyroid membrane at a 45&#176; angle toward the patient&#39;s feet, withdrawing on the plunger as you advance.</li>
	<li>When the needle enters into the airway, you will be able to aspirate air. Note that some practitioners prefer to have 2-3 cc saline in the syringe prior to attaching the needle, to aid in identifying the aspiration of air by creating bubbles when the plunger is withdrawn.</li>
	<li>Remove the syringe from the needle, taking care to keep the needle within the air-filled lumen identified. This is best done by bracing the hand against the patient&#39;s neck, so that there is no migration of the needle tip.</li>
	<li>Advance the guide wire through the needle approximately 15 cm, so that the guide wire is well within the airway.</li>
	<li>Remove the needle, keeping the guide wire in place</li>
	<li>Thread the catheter/dilator assembly over the distal end of the guide wire, and advance along the wire</li>
	<li>Push the catheter/dilator assembly through the skin, anatomically oriented with the airway such that the curve of the catheter matches the curve needed from its entry point into the trachea. Keep pushing until the catheter is fully in place, which means the plastic flange is against the neck.</li>
	<li>If the catheter is cuffed, fill cuff with air by injecting several milliliters of air into it. Typically 10 mL of air is required. Check the pilot balloon to be sure the cuff is inflated.</li>
	<li>Remove the dilator and wire from the assembly</li>
	<li>Attach the catheter to the bag-valve manual resuscitator; auscultate for breath sounds, monitor end-tidal CO2, and obtain chest X-ray</li>
	<li>Secure airway catheter with appropriate necktie.</li>
</ol>
3. Alternative approach for percutaneous cricothyrotomy using Seldinger technique if pre-assembled kit is unavailable
<ol>
	<li>Place the patient in supine position as above, with the neck extended.</li>
	<li>Open central venous catheter tray. Separate out the 5 mL syringe, the introducer needle, the guide wire, and the scalpel.</li>
	<li>Gather a tracheostomy tube.</li>
	<li>Attach the introducer needle to an empty 5mL syringe (again, adding water to the syringe first is unnecessary and not advocated by this author).</li>
	<li>Prepare the guide wire by retracting it in its sheath and straightening out the J tip.</li>
	<li>Prepare the neck with chlorhexidine if time allows</li>
	<li>Identify the laryngeal prominence and palpate the depression just caudal to this, the cricothyroid membrane.</li>
	<li>Grab the laryngeal structures as a unit to be certain the midline is identified.</li>
	<li>From your position at the head of the bed, advance the introducer needle into the patient&#39;s neck, at the point just identified as the cricothyroid membrane. The needle is directed at a 45&#176; angle from the horizontal, in a caudal direction, applying gentle pressure to the plunger of the syringe.</li>
	<li>Once air is easily aspirated into the syringe, the airway has been identified.</li>
	<li>Holding the needle steady with your non-dominant hand, remove the syringe with your dominant hand.</li>
	<li>Advance the guide wire through the introducer needle, to a depth of 15 cm</li>
	<li>With a #11 scalpel blade, make a 2 cm horizontal incision at the level of the needle. This incision is a complete incision, through both skin and cricothyroid membrane, a depth of approximately 2 cm.</li>
	<li>The needle is removed with the guide wire left in place</li>
	<li>Prior to advancing the tracheostomy tube through the neck, it will help if the incision made by the scalpel is dilated open. This can be facilitated with the handle of the scalpel.</li>
	<li>Retract the blade of the scalpel and advance the handle of the scalpel through the incision</li>
	<li>With the handle firmly in the incision, rotate the handle 90&#176; so the handle is oriented parallel with the patient&#39;s neck and perpendicular to the horizontal incision. This will hold the incision aperture open and allow for easier passage of the tracheostomy tube.</li>
	<li>Advance the tracheostomy tube over the guide wire. This will assure that the tube follows the correct tract into the airway previously identified by the syringe with air aspiration.</li>
	<li>Advance the tracheostomy tube into position.</li>
	<li>Remove the guide wire.</li>
	<li>Inflate cuff of tracheostomy tube (if cuffed).</li>
	<li>Attach to appropriate ventilator device as above and secure with neckties.</li>
</ol>

Percutaneous cricothyrotomy using Seldinger technique is a critical and life saving procedure. It was first described by Melker and is also referred to as "Melker technique." The decision to place a surgical airway must be made quickly. The procedure itself should be completed in less than a minute. Percutaneous cricothyrotomy with needle and guide wire has been advocated over open cricothyrotomy because the potential complications in an open cricothyrotomy can prove disastrous for the patient. 
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percutaneous cricothyrotomy

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
A surgical airway procedure is indicated when other forms of endotracheal intubation have failed and ventilation is worsening or not possible. This is the feared &#34;can&#39;t intubate, can&#39;t ventilate&#34; scenario, and in the emergency setting, cricothyrotomy is the surgical procedure of choice.
Cricothyrotomy is preferred over tracheotomy because of the lower risk of complications, the predictable anatomy of the cricothyroid membrane, and the comparative rapidity with which the procedure can be performed&#8212;even by less experienced practitioners. Cricothyrotomy traditionally has been done in an &#34;open&#34; form; however, percutaneous cricothyrotomy using standard Seldinger technique has been advanced as a more successful approach when identification of the relevant anatomic landmarks is more difficult. Seldinger technique involves the introduction of a device into the body through the use of an introducer needle and a guide wire. The needle is used to locate the target; a guide wire is then fed through the thin-walled needle into the target, acting as a &#34;placeholder&#34; for the device, which is fed over the guide wire and into the target.
In the case of percutaneous cricothyrotomy, the practitioner first identifies the cricothyroid membrane by physical landmarks and makes a small vertical skin incision. A thin-walled 18-gauge needle (attached to a syringe) pierces the membrane, and the airway is positively identified when air is aspirated in the syringe. A guide wire is then fed through the needle. Standard cricothyrotomy sets include an airway catheter (similar to a tracheostomy tube) with a stiff dilator within its lumen. The catheter/dilator combination is fed onto the guide wire and the catheter/dilator is placed within the airway. The dilator and guide wire are subsequently removed, and the catheter is attached to a bag-valve device for ventilation.

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
A surgical airway procedure is indicated when other ...

Cricothyrotomy is a surgical airway procedure indicated when other forms of endotracheal intubation have failed and patient ventilation is declining or not possible. The two forms of this procedure are open or surgical cricothyrotomy - discussed in a different video - and percutaneous cricothyrotomy, which will be discussed here. The latter is the method of choice for many practitioners especially when identification of the relevant anatomic landmarks is more difficult, such as in the patients with short neck and excessive soft tissue. In this presentation, we will outline how to conduct the percutaneous cricothyrotomy procedure using a pre-packaged kit and when kit is not available. Start by gathering the necessary supplies for the procedure including: chlorhexadine, a bag valve mask device, suction and oxygen supply equipment, and the pre-packaged percutaneous cricothyrotomy kit. A standard pre-packaged kit should include: a 18 gauge introducer needle, a 5 milliliter syringe, scalpel, guide wire, a dilator, an airway catheter and a neck-tie. After opening the kit, attach the introducer needle to the syringe, make sure that the catheter and dilator are assembled, and lay out the guidewire and scalpel for easy access. The patient in this situation has likely undergone attempted endotracheal intubation and should already be lying supine. Stand at the patient's head, extend the neck (2.4.2) and palpate to locate the cricothyroid membrane. This membrane is located below the laryngeal prominence -- the "Adam's Apple". After locating the membrane, grab the paratracheal structures and move them around. They will move as a unit and create a depression. The needle insertion landmark is in the midline of this depression. If time allows, the area should be cleaned with chlorhexadine, and ideally, the exam gloves should be traded for sterile gloves. However, as with all emergent procedures, true sterile technique may be sacrificed for rapidity.Make a small 5-millimeter vertical incision with the scalpel at the identified midline. Then, advance the introducer needle at a 45? angle into the incision and through the cricothyroid membrane toward the patient's feet. Withdraw on the plunger while advancing the needle. When the needle enters into the airway, you will be able to aspirate air easily. Next, brace your hand against the patient's neck and remove the syringe from the needle. Be sure to keep the needle opening within the air filled lumen. Now, advance the guidewire through the needle approximately 15 centimeters to assure the wire is well within the airway. Then, remove the needle, keeping the guidewire in place. Next, thread the catheter-dilator assembly over the wire and push it through the patient's skin. While doing so, anatomically orient the device with the airway such the curve of the catheter matches the curve needed from its entry point into the trachea. Keep pushing until the catheter is fully in place -- that is till the plastic flange is against the patient's neck. Next, remove the dilator and the wire from the assembly and attach the catheter to the bag-valve manual resuscitator. Confirm correct placement by auscultating for breath sounds, and monitoring the end tidal CO2 -- the normal range for which is 35-45 mmHg. Finally, secure the airway catheter with appropriate necktie. Now let's review how to conduct the percutaneous cricothyrotomy procedure without a kit, which is not ideal, but may be the most preferable option in an emergency situation.For supplies, open the central venous catheter tray and remove the following items : a 5-milliliter syringe, an introducer needle, a guidewire, and a scalpel. In addition, obtain a tracheostomy tube . Attach the introducer needle to the empty 5-milliliter syringe. Then, prepare the guidewire by retracting it in its sheath and straightening out the J tip. Locate the cricothyroid membrane by palpating as shown previously and prep the neck with chlorhexadine if time allows. Grab the laryngeal structures as a unit to be certain that the midline is identified. Next, while applying gentle pressure to the plunger, advance the introducer needle at a 45? angle in caudal direction. Once the needle tip reaches the trachea, air can be easily aspirated into the syringe. Now, with your non-dominant hand, hold the needle steady and remove the syringe with your dominant hand. Then advance the guide wire 15 centimeters through the introducer needle. Next, with a number 11-scalpel blade make a horizontal incision at the level of the needle -- approximately 2 centimeter in length and 2 cm deep --, cutting through the skin and cricothyroid membrane. Now, remove the needle and leave the guidewire in place and load the tracheostomy tube onto the guidewire. Next, to dilate the incision open, retract the scalpel blade and advance the handle of the scalpel through the incision. With the handle is firmly inside the incision, rotate it by 90? so that it is oriented parallel with the patient's neck and perpendicular to the horizontal incision. This will hold the aperture open and allow for easier passage of the tracheostomy tube. Advance the tube over the guidewire and through the opening created by the scalpel handle. This will assure that the tube follows the correct tract into the airway. After the tube is in position, remove the guide wire, attach the tube to the ventilator device and secure it in place with neckties. Cricothyrotomy is a critical and life saving procedure. The decision to place a surgical airway must be made quickly, and the procedure itself should be completed in less than a minute. The procedure shown in this video on percutaneous cricothyrotomy using the Seldinger technique has been advocated over open cricothyrotomy, because of the potential for bleeding with open cricothyrotomy.A major advantage of using a needle to locate the airway is that if the cricothyroid membrane is not encountered with the first needle insertion, the location may be re-adjusted and there is less likely to be a life threatening complication. On the contrary, the open cricothyrotomy procedure relies on identification of the cricothyroid membrane and airway by visual inspection after a vertical incision is made with a scalpel. If there is a hemorrhage, visualization can become impossible. Furthermore, in the obese and in those with otherwise poor anatomic landmarks, identifying midline can be a challenge. You have just watched a JoVE video demonstrating the percutaneous cricothyrotomy procedure, with and without a pre-packaged kit. As always, thanks for watching!

Education

JoVE Science Education

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Emergency Medicine and Critical Care

emergency airway access with cricothyrotomy

Emergency cricothyrotomy provides airway access when endotracheal intubation has failed and ventilation is getting worse or is not possible. This is the feared &quot;can’t intubate, can’t ventilate&quot; situation. In that setting, cricothyrotomy is the surgical airway procedure of choice.

Cricothyrotomy is often chosen over tracheotomy because it has a lower risk of complications. It also uses the cricothyroid membrane, whose anatomy is more predictable. The procedure can be performed more quickly, even by less experienced practitioners.

Cricothyrotomy has traditionally been done in an open form. A percutaneous cricothyrotomy uses the standard Seldinger technique, which places a device into the body with an introducer needle and a guide wire. This approach can be especially useful when the landmarks are harder to identify.

The procedure begins by locating the cricothyroid membrane using physical landmarks and making a small vertical skin incision. A thin-walled 18-gauge needle attached to a syringe is used to pierce the membrane. Air in the syringe confirms that the airway has been entered.

Next, a guide wire is passed through the needle. Standard cricothyrotomy sets include an airway catheter, similar to a tracheostomy tube, with a stiff dilator inside it. The catheter and dilator are advanced over the guide wire into the airway, then the dilator and guide wire are removed, and the catheter is connected to a bag-valve device for ventilation.

Emergency Airway Access with Cricothyrotomy

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Emergency cricothyrotomy provides airway access when endotracheal intubation has failed and ventilation is getting worse or is not possible. This is the feared "can’t intubate, can’t ventilate" situation. In that setting, cricothyrotomy is the surgical airway procedure of choice. Cricothyrotomy is often chosen over tracheotomy because it has a lower risk of complications. It also uses the cricothyroid membrane, whose anatomy is more predictable. The procedure can be performed more quickly,...

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emergency medicine and critical care

This collection delves into a wide range of procedures employed in emergency and intensive care settings, ranging from basic life support methods such as CPR and rescue breathing to other common procedures performed during emergency situations.

Learn how percutaneous cricothyrotomy uses a needle, guide wire, and catheter to create emergency airway access when intubation fails.

Emergency Airway Access with Cricothyrotomy | JoVE K12

James Bonz

Overview

Percutaneous Cricothyrotomy Procedure with a Kit

Percutaneous Cricothyrotomy Procedure without a Kit

Summary

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In molecular biology, ligation refers to the joining of two DNA fragments through the formation of a phosphodiester bond.  An enzyme known as a ligase ...

explant-culture-for-developmental-studies

Explant Culture for Developmental Studies

Explant culture is a technique in which living cells or tissues are removed from an embryo for continued development outside of the organism. This ex vivo ...

DNA Methylation Analysis

Methylation at CpG dinucleotides is a chemical modification of DNA hypothesized to play important roles in regulating gene expression. In particular, the ...

Expression Profiling with Microarrays

Microarrays are important tools for profiling gene expression, and are based on complementary binding between probes that are attached to glass chips and ...

Density Gradient Ultracentrifugation

Density gradient ultracentrifugation is a common technique used to isolate and purify biomolecules and cell structures. This technique exploits the fact ...

F&#246;rster Resonance Energy Transfer (FRET)

F&#246;rster resonance energy transfer (FRET) is a phenomenon used to investigate close-range biochemical interactions. In FRET, a donor photoluminescent ...

detecting-environmental-microorganisms-with-polymerase-chain-reaction

Detecting Environmental Microorganisms with the Polymerase Chain Reaction and Gel Electrophoresis

Source: Laboratories of Dr. Ian Pepper and Dr. Charles Gerba - Arizona University
Demonstrating Author: Bradley Schmitz
Polymerase chain reaction (PCR) is ...

Gel Purification

Gel purification is used to recover DNA fragments after electrophoretic separation. DNA recovery from an agarose gel includes three basic steps: binding, ...

Detecting Reactive Oxygen Species

Reactive oxygen species are chemically active, oxygen-derived molecules capable of oxidizing other molecules. Because of their reactive nature, there are ...

Gene Silencing with Morpholinos

Morpholino-mediated gene silencing is a common technique used to study roles of specific genes during development. Morpholinos inhibit gene expression by ...

development-and-reproduction-of-the-laboratory-mouse

Development and Reproduction of the Laboratory Mouse

Successful breeding of the laboratory mouse (Mus musculus) is critical to the establishment and maintenance of a productive animal colony. Additionally, ...

Genetic Crosses

To dissect genetic processes or create organisms with novel suites of traits, scientists can perform genetic crosses, or the purposeful mating of two ...

Construct an explanation based on evidence for how the structure of DNA determines the structure of proteins which carry out the essential functions of life through systems of specialized cells.

HS-LS1-1.

Emergency Airway Access with Cricothyrotomy

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