Open Cricothyrotomy

1. Patient Positioning and Preparation

1. Position the patient supine with the neck extended.
2. Gather supplies needed for cricothyrotomy, including a #11 scalpel, tracheal hook, Trousseau dilator, tracheostomy tube (or modified endotracheal tube), 10 cc syringe for inflating the cuff, and chlorhexidine.
3. If a tracheostomy tube is not available, prepare endotracheal tube by removing the bag-valve-mask (BVM) adapter at the distal end and cutting the tube just distal to site where the cuff insufflator enters. Reattach the BVM adapter.
4. If the situation calls for local anesthesia, such as when rapid sequence intubation medications have not been administered, and the patient is awake and alert, then gather a 5 cc syringe, 25-gauge needle, and 5 mL of 1% lidocaine with epinephrine 1:100,000.
5. If full sterile technique is observed, then gather sterile towels, face mask, bonnet, sterile gown, and sterile gloves. As with all truly emergent procedures, complete sterile technique is optional based on the time pressure of the situation.

2. Protocol

1. Test the cuff of the tracheostomy tube or the modified endotracheal tube by inflating and deflating it using the syringe.
2. Clean the anterior neck with chlorhexidine by vigorous scrubbing. Full barrier precautions should be undertaken if clinically possible: don mask, bonnet, sterile gown and gloves, and place sterile towels around the cleaned site to create a complete sterile field.
3. To optimize the access to the site, stand on the patient's right side if you are right-handed, and on the patient's left side if you are left-handed.
4. Locate the cricothyroid membrane by palpating the laryngeal prominence ("Adam's apple") and moving your fingers inferiorly into the depression below. If the palpation is difficult due to body habitus or pathology, the location of the cricothyroid membrane may be estimated as being four fingerbreadths above the sternal notch.
5. Confirm the location of the midline by grabbing the paratracheal structures and moving them around as a unit.
6. Administer local anesthesia by inserting the 25-gauge needle just into the skin, and creating a wheal in the midline of the expected location of the cricothyroid membrane. Extend the wheal superiorly and inferiorly by 3cm in both directions.
7. Make a 3-5 cm vertical incision in the midline through the skin and subcutaneous tissues using the #11 scalpel.
8. Attempt to feel the cricothyroid membrane through the incision with your non-dominant finger, and then extend the incision superiorly or inferiorly to fully expose the cricothyroid membrane.
9. Now make a 1 cm horizontal incision across the cricothyroid membrane at its inferior aspect. This position of the incision prevents lacerating the cricoid arteries.
10. Take the tracheal hook and pull the superior portion of the incision upwards. An assistant can hold the tracheal hook to keep the incision open.
11. Using your non-dominant hand, insert the Trousseau dilator through the opening in the cricothyroid membrane, placing the bills on the superior and inferior portions of the incision. If you are standing on the patient's right side, the handles will also be on the patient's right. If you are standing on the patient's left side, the handles will also be on the left.
12. Open the bills of the Trousseau dilator
13. Rotate the handle of the dilator to 90° so that it is vertically in relation to the patient. The bills of the dilator are now spreading away from the midline.
14. With your dominant hand, place the modified endotracheal tube through the cricothyroid membrane.
15. Remove the Trousseau dilator.
16. If using a tracheostomy tube, remove the obturator, insert the inner cannula of the tube, and inflate the cuff.