# Needle Cricothyroidotomy

## Overview

This module describes how to perform a needle cricothyroidotomy for oxygenation. This procedure is an interim life-saving technique and must be replaced with a more definitive strategy, such as surgical cricothyroidotomy, tracheostomy or endotracheal intubation, as soon as possible.

## Indications

1. “Can’t intubate, can’t oxygenate” — patients with airway compromise in whom other airway management has failed

2. In children, an alternative preferred to surgical cricothyroidotomy

## Contraindications

1. None for emergency cricothyroidotomy

2. Consider increased difficulty of procedure in patients with laryngeal fractures, previous laryngeal surgery or other laryngeal abnormalities

## Patient information and consent

This procedure is usually done as an emergency measure with an unconscious patient. However, it may be explained to family members afterwards.

### How do I explain this procedure?

“The patient was unable to breathe because their airway was blocked and air was not getting into their lungs. I had to put a thin tube below the blockage through the skin of their neck into their windpipe so that I could deliver oxygen. This is a temporary measure.”

## Preparation

###

### Documentation

1. Patient notes

### Equipment

Asepsis: do not delay the procedure unnecessarily

1. Alcohol-based hand rub

2. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

3. Sterile or non-sterile gloves

4. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another. Caution: chlorhexidine solutions may be associated with burns and skin breakdown in infants < 2 months old.

   or alcohol swabs

5. Sterile pack with sterile drapes

## Procedure

1. Largest available IV cannula

2. 5 ml syringe and either a 2 ml or 3 ml or 10 ml syringe

3. Normal saline

4. Size 3 or 7.5 ET tube

5. Self-inflating bag system
   Self-inflating bag system

   Although jet insufflation is frequently advocated, serious complications such as bilateral pneumothoraces occur commonly when performed by inexperienced operators.

   such as a bag-valve mask reservoir

6. Zinc oxide or similar tape for securing

## Site & Positioning

Place the patient in a supine position with in-line immobilization of the neck, and hyperextend the neck by placing a 1L IV fluid bag behind the shoulders. Stand at the head, facing caudally.

Identify the landmarks of the cricothyroid membrane. The Adam's apple is the thyroid prominence formed by the thyroid notch. Moving inferiorly, the next solid prominence is the cricoid cartilage. Immediately above the cricoid cartilage the finger slips into the depression of the cricothyroid membrane.

## Procedure

Follow medical asepsis as far as possible. Since this is an emergency procedure, non-sterile gloves and an alcohol swab may be the only aseptic preparations available.

1. Remove the cap of the cannula and attach the syringe. You may choose to

   draw up saline
   draw up saline

   Having saline in the syringe makes bubbles of air visible when you enter the trachea. However, it may delay the procedure. The practitioner must use clinical discretion.

   in the syringe.

2. Stabilise the larynx and tighten the skin over the cricothyroid membrane between your non-dominant thumb and index finger.

3. Hold the cannula between the thumb and index finger of your dominant hand, supported on the underside of the mandible.

4. Hold the cannula with the bevel facing upwards and place the cannula tip in the midline of the cricothyroid membrane.

5. Enter the skin at a 45° caudal angle and advance, withdrawing the plunger until air is aspirated. You will likely feel a ‘pop’ as the needle enters the trachea.

6. Holding the needle still, advance the cannula over the needle into the trachea. Withdraw the needle and syringe. Confirm air aspiration with syringe once cannula is snug in place.

7. Connect the cannula to a bag-valve mask reservoir (BVMR) or ventilator. The cannula can be attached to an BVMR or ventilator in two ways:

   1. Disconnect the adaptor of the size 3 ET tube and connect it to the cannula.
   2. Fit a 2 ml or 3 ml syringe (with plunger removed) to the cannula, and connect the adaptor of a size 7.5 ET tube to the back/barrel of the syringe.

8. Keep hold of the cannula to prevent dislodgement and secure the cannula in place.

9. Oxygenate for up to 40 minutes, after which a definitive airway should be secured. You may or may not see chest rise with ventilation. Use sats monitoring to guide success.

10. Dispose of medical waste safely.

11. Afterwards, record the indication for the procedure and how long the patient was oxygenated in this way in patient notes.

## Troubleshooting

There is significant resistance to ventilation.

Do not expect to see chest rise reliably. The small bore of the catheter provides more resistance to ventilation than you may be accustomed to. Check that the catheter is not kinked or dislodged. If you are unable to oxygenate the patient, consider converting to a surgical cricothyrotomy.

Surgical emphysema or growing mass around cannula insertion site.

You are probably not in the trachea and are insufflating air into the surrounding tissues. Surgical emphysema feels like small cracking pockets of air when you touch the skin. Remove the cannula & re-attempt insertion, and prepare for a more definitive airway such as a surgical cricothyroidotomy.

I don’t have a size 3 or 7.5 ETT.

Fit a 10 ml syringe (plunger removed) to the cannula, insert a cuffed ETT tube into the barrel of the syringe and inflate the cuff.

## Risks

1. Inadequate ventilation: hypoxia and death

2. Aspiration

3. Injury to oesophagus, thyroid, or larynx

4. Haematoma or uncontrollable bleeding

5. Creation of a false passage into the tissue of the neck

6. Sharps injury to healthcare provider

## References

1. Chung PH. How To Do a Percutaneous Cricothyrotomy. In: MSD Manual. 2020. Available from: https://www.msdmanuals.com/professional/critical-care-medicine/how-to-do-other-airway-procedures/how-to-do-a-percutaneous-cricothyrotomy

2. Fagan J. Open Access Atlas of Otolaryngology, Head & Neck Operative Surgery. Available from:

   https://vula.uct.ac.za/access/content/group/ba5fb1bd-be95-48e5-81be-586fbaeba29d/Cricothyroidotomy%20and%20needle%20cricothyrotomy.pdf

3. Engelbrecht D. How To Do a Cricothyrotomy. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 319-320.

4. McKenna P, Desai NM, Morley EJ. Cricothyrotomy. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537350/

5. Nicol A, Steyn E. Emergency Procedures. Chapter 6. Handbook of Trauma for Southern Africa. 2009. 4th ed. 66-67

6. https://youtu.be/4WbsLe27F0Q