How To Do a Percutaneous Needle Cricothyrotomy

Apnea, severe respiratory failure, or impending respiratory arrest requiring endotracheal intubation and either:

• A situation in which the patient cannot be intubated or given oxygen, described as failed attempts at orotracheal or nasotracheal intubation with the inability to oxygenate or ventilate via alternate methods (eg, bag-valve-mask or supraglottic airway device)

• Contraindications to orotracheal or nasotracheal intubation such as massive oral hemorrhage, severe facial trauma, or mass effect due to tumor

Age < 8 to 12 years (varying age cutoffs based on the patient's physical size and anatomy without definitive expert consensus)

Absolute contraindications:

• None

Relative contraindications:

• Inability to identify landmarks due to significant injury to the larynx, thyroid cartilage, or cricoid cartilage

• Partial or complete transection of the distal trachea

Early complications, recognized immediately or within hours after cricothyrotomy, include the following:

• Bleeding, sometimes uncontrollable

• Injury to or perforation of the posterior aspect of the trachea

• Larynx, vocal fold, or thyroid injury

Late complications, recognized weeks or months after cricothyrotomy, include the following:

• Progressive airway obstruction due to subglottic stenosis and stomal granulation tissue

• Voice changes, which are chronic but may resolve with time

• Wound infection

• Antiseptic solution (eg, chlorhexidine, povidone-iodine) and sterile gauzeAntiseptic solution (eg, chlorhexidine, povidone-iodine) and sterile gauze

• Sterile drapes

• Sterile gloves and gowns along with eye and face protection (ie, universal precautions)

• Local anesthetic (eg, 1% or 2% lidocaine with epinephrine, 25-gauge needle, 3-mL syringe)Local anesthetic (eg, 1% or 2% lidocaine with epinephrine, 25-gauge needle, 3-mL syringe)

• 12- to 14-gauge angiocatheter over needle attached to a 3-mL syringe half-filled with saline

• Adapter from 7.0 endotracheal tube

• Bag-valve-mask and oxygen source

• Patient monitoring equipment, including cardiac monitor, pulse oximeter, blood pressure monitor (noninvasive)

• Capnometer (end-tidal carbon dioxide monitor)

• The cricothyroid membrane should be readily identifiable as no skin incision is typically made with the guidewire technique. Anatomic distortions will make the cricothyroid membrane less identifiable.

• Sterile technique is necessary to prevent local microbial contamination during the procedure.

• The cricothyroid membrane lies between the thyroid cartilage and the cricoid cartilage. Tracheal cartilages extend caudally from the cricoid cartilage to the sternal notch.

• The area around the cricothyroid membrane is rich with blood vessels (superior thyroid arteries and the relatively uncommon variant thyroid ima arteries).

• Position the patient supine, and, if cervical spinal injury is not a concern, hyperextend the neck. The sniffing position is not necessary for cricothyrotomy.

• To the extent possible, ensure adequate oxygenation and ventilation throughout this procedure, using a bag-valve-mask or laryngeal mask airway and supplemental oxygen (high-flow if readily available).

• Identify the cricothyroid membrane. Move your finger caudally from the laryngeal prominence (the most prominent part of the anterior thyroid cartilage) until you feel the cricothyroid membrane, palpable as a step-off between the caudal end of the thyroid cartilage and the cricoid cartilage.

• Prepare the anterior neck with a skin cleansing agent such as chlorhexidine or povidone-iodine and place a sterile drape over the neck.Prepare the anterior neck with a skin cleansing agent such as chlorhexidine or povidone-iodine and place a sterile drape over the neck.

• Inject a local anesthetic along the anticipated skin insertion site if the patient is capable of feeling pain.

• Stabilize the larynx with your non-dominant hand by grasping the sides of the thyroid cartilage with your thumb and middle finger. Maintain stabilization until the airway catheter is in place.

• Insert the needle with the fluid-containing syringe attached, through the cricothyroid membrane, aiming caudally at an angle of about 45 degrees. Keep back-pressure on the syringe plunger as you advance.

• Confirm needle placement in the airway by feeling a pop as the needle enters the trachea and by seeing air entering the syringe, visible as air bubbles in the saline. Stop advancing the needle as soon as air is returned.

• Continue advancing the catheter into the trachea while simultaneously withdrawing the needle and syringe together.

• Attach the adapter from a 7.0 endotracheal tube to the plunger end of the 3-mL syringe.

• Reattach the 3-mL syringe to the angiocatheter which was placed into the trachea.

• Attach the bag-valve-mask device to the adapter of the endotracheal tube.

• Resume ventilation using the newly established airway.

• Secure the device in place using tape to secure the angiocatheter to the neck.

• When the airway is secure, confirm proper airway placement using auscultation and end-tidal carbon dioxide detection.

• Needle cricothyrotomy is a temporary airway and conversion to a more definitive airway such as a surgical tracheostomy should be performed as soon as possible.

1. 1. Berger-Estilita J, Wenzel V, Luedi MM, Riva T. A Primer for Pediatric Emergency Front-of-the-Neck Access. A A Pract. 2021;15(4):e01444. doi:10.1213/XAA.0000000000001444