CricothyrotomyMANAGEMENT

RESPIRATORY PRESENTATIONS · 12 SECTIONS

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453 items

☷ Legend

01Approach to the Critical Patient/attcp48

Declaration of cannot intubate cannot oxygenate

›CICO recognition and declaration

›Declaration criteria

›Failed intubation on best attempt by most experienced operator

›Failed rescue oxygenation with bag mask ventilation

›Failed rescue oxygenation with supraglottic airway

›Falling or unmeasurable SpO2 despite maximal noninvasive attempts

›The declaration must be verbalized out loud

›Say the words cannot intubate cannot oxygenate to the team

›Verbalization converts an ambiguous stall into a shared team decision

›Time to decision is the dominant determinant of outcome

›Hypoxic brain injury and cardiac arrest occur from delay, not from the incision itself

›The commonest cause of a bad outcome is hesitation, not technical failure of the procedure

›Repeated laryngoscopy attempts after CICO criteria are met is a failure mode, not a rescue

Immediate priorities once CICO is declared

›Stop and switch

›Stop further intubation attempts immediately

›No further laryngoscopy once CICO criteria are met

›No further supraglottic device attempts once CICO criteria are met

›Move to front of neck access without delay

›Assign the procedure to the most experienced operator present

›Assign a second person to continue calling for help and pulling equipment

›Team role assignment before the first incision

›One operator performs the procedure

›One assistant stabilizes the larynx and hands equipment

›One person announces elapsed time at intervals

›Positioning and access

›Neck extension if no cervical spine concern

02History/hx35

Circumstances leading to the airway emergency

›Precipitating scenario

›Failed elective or emergent intubation attempts

›Number of attempts and devices used

›Grade of laryngoscopic view obtained

›Trauma mechanism

›Direct anterior neck trauma

›Penetrating neck injury

›Airway obstruction presentation

›Angioedema or anaphylaxis

›Upper airway infection with rapid progression

›Foreign body or caustic injury

›Time course

›Rapid deterioration over minutes

›Progressive desaturation despite bag mask ventilation

›Known difficult airway history

›Prior difficult intubation documented

›Prior head and neck surgery or radiation

Risk factors for a difficult surgical airway

›Anatomic risk factors

›Obesity with reduced neck mobility and increased soft tissue depth

›Short or thick neck

›Prior neck surgery, radiation, or tracheostomy scar

›Neck mass or hematoma distorting landmarks

›Cervical spine immobilization limiting extension

›Bleeding risk factors

›Anticoagulant or antiplatelet medication use

›Warfarin, direct oral anticoagulant, or heparin infusion

03Physical Exam/exam44

Airway and neck landmark assessment

›Laryngeal handshake technique

›Palpate hyoid bone

›Most superior firm structure in the midline neck

›Palpate thyroid notch and thyroid cartilage

›Prominent midline landmark, more prominent in males

›Palpate cricothyroid membrane

›Soft depression immediately inferior to the thyroid cartilage

›Superior to the firm cricoid cartilage ring

›Palpate cricoid cartilage

›First complete tracheal ring, firm circumferential structure

›Palpate trachea below cricoid

›Confirms midline orientation for the incision

›Bimanual technique

›Non-dominant hand fixes and stretches the larynx

›Dominant hand walks fingers from hyoid to sternal notch to relocate the membrane

›Confirming physiologic severity

›Ongoing desaturation trend

›SpO2 trajectory since last measured

›Chest rise assessment

›Absent chest rise with bag mask ventilation attempts

›Skin and mucosal color

›Cyanosis as a late and unreliable early marker

Impalpable landmarks

›Obese or distorted neck approach

›Ultrasound assisted identification

›Linear probe transverse then longitudinal over anticipated membrane location

›Identify cricothyroid membrane as a hyperechoic line between thyroid and cricoid cartilage shadows

04Differential Diagnosis/ddx34

Indications prompting front of neck access

›Primary indication

›Cannot intubate cannot oxygenate scenario in the emergency department

›Failed intubation and failed rescue oxygenation

›Massive airway hemorrhage precluding visualization

›Blood obscuring the airway despite suction

›Severe maxillofacial trauma precluding oral or nasal access

›Panfacial fracture with airway compromise

›Upper airway obstruction unresponsive to medical therapy

›Angioedema, anaphylaxis, or infection with impending total obstruction

Contraindications and situations requiring tracheostomy instead

›Absolute contraindications to cricothyrotomy

›Laryngeal fracture or laryngotracheal separation

›Cricothyrotomy risks completing the transection or creating a false passage below an already disrupted airway

›Tracheostomy performed lower in the neck by a surgeon is required

›Tracheal transection

›Distal airway may retract into the mediastinum

›Surgical exploration and tracheostomy or direct cannulation of the distal segment required

›Pre-existing subglottic or tracheal stenosis at the level of the membrane

›Known tracheal pathology below the cords

›Relative contraindications

›Known laryngeal or thyroid malignancy distorting anatomy

›Bleeding diathesis not correctable in the time available

›Does not defer the procedure in a CICO emergency but should prompt earlier surgical or ENT involvement when time allows

›Clinical decision principle

›In a true CICO emergency, a relative contraindication does not delay the procedure

›An absolute contraindication changes the target procedure to tracheostomy, not the decision to secure the airway

05Laboratory Tests/lt20

Peri-procedural physiology and coagulation labs

›Gas exchange and perfusion

›Arterial or venous blood gas after airway secured

›Confirms adequacy of oxygenation and ventilation once the tube is placed

›Should not be obtained before the procedure at the expense of time to incision

›Serum lactate

›Marker of hypoxic time and shock burden

›Trend after airway secured to assess resuscitation response

›Bleeding risk labs when time allows

›International normalized ratio for known or suspected warfarin use

›Does not delay the procedure in a true CICO emergency

›Platelet count in known thrombocytopenia or marrow suppression

›Informs post-procedure hemostasis expectations

Point of care testing

›Bedside tests

›Point of care glucose in altered mental status

›Hypoglycemia exclusion as a contributor to the presenting emergency

›Point of care hemoglobin if significant airway or neck bleeding

›Baseline for transfusion decision making

PITFALLS

›Lab limitations

›Waiting for any laboratory result before proceeding to front of neck access

›No laboratory value changes the decision to secure a CICO airway

06Diagnostic Tests/dt30

Scoring Systems

›Difficult airway prediction tools

›LEMON assessment

›Look externally, evaluate 3-3-2, Mallampati, obstruction, neck mobility

›Predicts difficult laryngoscopy, prompting earlier front of neck access planning

›Difficult surgical airway predictors

›Obesity, short neck, prior neck surgery or radiation, mass or hematoma

›A patient flagged as a difficult surgical airway warrants earlier equipment preparation and senior notification

›Clinical decision principle

›Scoring tools inform preparation before the emergency, not the decision to act once CICO criteria are met

MRI

›MRI role

›No role in the acute CICO emergency

›Time and monitoring requirements are incompatible with an unsecured airway

›Selected delayed use

›Post-procedure evaluation of suspected tracheal or laryngeal injury when stable

›CT neck role

›No role in the acute CICO emergency

›Imaging must never delay front of neck access once criteria are met

›Post-procedure or pre-procedure stable-patient use

›Suspected laryngeal fracture or tracheal injury in a patient with a secured airway

›Confirms tube position relative to the injury before planned tracheostomy

Ultrasound

›Pre-procedure and procedural ultrasound

›Cricothyroid membrane localization

›Linear high frequency probe, transverse then longitudinal views

›Used preemptively in a predicted difficult airway when time allows, and intraprocedurally in an obese or distorted neck

07Disposition/dispo25

Immediate post-procedure destination

›Level of care

›Intensive care unit admission for all patients after emergency front of neck access

›Ventilator management

›Sedation and analgesia titration

›Operating room transfer when feasible

›Formal surgical airway revision or conversion to tracheostomy

›Definitive hemostasis under controlled conditions

Specialist involvement

›Consultation

›Otolaryngology or trauma surgery notified immediately after the airway is secured

›Planning for conversion to formal tracheostomy

›Assessment for laryngeal or tracheal injury from the emergency procedure itself

›Anesthesia involvement for ongoing airway and sedation management

Transfer criteria

›Higher level of care transfer

›No otolaryngology or surgical capability onsite for conversion or revision

›Stabilize the airway and ventilation before transfer

›Critical care transport with airway management capability

›Pediatric center transfer

›Needle cricothyrotomy performed as a bridge in a child under the surgical age threshold

›Pediatric anesthesia, ENT, and ICU availability required at receiving center

Conversion to formal tracheostomy timing

›Timing principle

›Conversion planned within 24 to 72 hours of the emergency procedure when the patient remains intubated

›Reduces the duration of cricothyroid membrane and cricoid cartilage instrumentation

›Cricoid cartilage injury from prolonged tube dwell time is the principal driver of later subglottic stenosis

›Earlier conversion if ongoing bleeding, tube malposition, or subcutaneous emphysema at the emergency site

08Treatment/t133

Preparation and equipment

›Standard surgical cricothyrotomy kit contents

›Scalpel

›Number 10 blade preferred, number 20 blade acceptable if available

›Bougie

›Standard adult gum elastic bougie with a coude tip

›Endotracheal tube

›Cuffed tube internal diameter 6.0 mm for a standard adult

›Range 6.0 to 7.0 mm depending on patient size, sized smaller than a routine oral intubation

›Adjuncts

›Tracheal hook to stabilize the larynx if a two-person technique is used

›10 mL syringe for cuff inflation

›Suction immediately available

Scalpel bougie tube technique step by step

›Sequential technique

›Step one, stabilize and identify

›Non-dominant hand performs the laryngeal handshake and holds the larynx fixed throughout

›Thumb and middle finger stabilize the thyroid cartilage laterally, index finger confirms the cricothyroid membrane

›Step two, incision

›Vertical midline skin incision approximately 3 to 4 cm if landmarks are uncertain, shorter transverse incision acceptable if landmarks are confidently palpated

›Vertical orientation preferred when landmarks are difficult because it can be extended without crossing new tissue planes

›Incise through skin and subcutaneous tissue down to the laryngeal framework in one firm motion

›Step three, membrane puncture

›Palpate the cricothyroid membrane again with a finger before the second cut

›Horizontal stab incision through the cricothyroid membrane, blade angled slightly caudad to avoid the vocal cords superiorly

›Blade turned 90 degrees and the flat rotated to open the space, or a finger inserted to maintain the tract

›Step four, bougie placement

›Bougie inserted through the membrane incision with the coude tip directed caudad toward the carina

›Gentle advancement, tracheal rings should be felt as a washboard sensation confirming intraluminal position

›Resistance at approximately 30 to 40 cm suggests bronchial placement and the bougie should be withdrawn slightly

›Step five, tube railroading

›Cuffed endotracheal tube advanced over the bougie into the trachea

›Gentle twisting motion if resistance is felt at the skin incision

›Bougie withdrawn once the tube is seated, cuff inflated immediately

›Step six, securing and confirming

›Tube secured with a tie or commercial holder before releasing manual stabilization

›Ventilation initiated immediately after cuff inflation

Confirmation of placement and troubleshooting

›Confirmation sequence

›End tidal carbon dioxide waveform

›Sustained waveform is the primary confirmation method

›Absent waveform prompts immediate reassessment of tube position

›Bilateral chest rise and bilateral breath sounds

›Absence of breath sounds on one side raises concern for endobronchial placement or pneumothorax

›Improving oxygen saturation

›Expected trend once ventilation is effective

›Point of care ultrasound lung sliding

›Adjunct confirmation, particularly if capnography is equivocal

›If unable to ventilate after tube placement

›Reassess for false passage

›Tube tracking in the pretracheal soft tissue rather than the airway lumen

›Subcutaneous emphysema on the neck as a sign of extraluminal placement

›Reassess for tube obstruction

›Blood or secretions occluding the lumen, suction and consider tube exchange over the bougie

›Reassess for tension physiology

›New hypotension and tracheal deviation after positive pressure ventilation begins

›Needle decompression if tension pneumothorax is suspected

›If all troubleshooting fails, repeat the procedure one level lower or convert to an open surgical approach with direct visualization

Needle cricothyrotomy

›Technique

›Large bore over the needle catheter, 12 to 14 gauge, inserted through the cricothyroid membrane directed caudad at approximately 45 degrees

›Aspirate air to confirm intratracheal position before advancing the catheter

›Jet ventilation

›High pressure oxygen source at 30 to 50 psi delivered through the catheter with a dedicated jet ventilator device

›Intermittent delivery, approximately 1 second on and 4 seconds off, to allow passive exhalation

›Low flow oxygenation alternative

›Standard wall oxygen at 15 L/min connected via tubing with a side hole or three way stopcock if a jet ventilator is unavailable

›Provides oxygenation only, does not provide effective ventilation

›Serious limitations

›Cannot achieve adequate ventilation

›Carbon dioxide accumulates over time even when oxygenation is initially maintained

›Buys minutes only, is not a definitive airway

›Barotrauma risk

›Pneumothorax from jet ventilation, particularly if exhalation is obstructed

›Subcutaneous and mediastinal emphysema from catheter misplacement or upper airway obstruction preventing passive exhalation

›Tension physiology can develop rapidly if the upper airway is completely obstructed and gas cannot escape

›Catheter kinking or dislodgement

›Small caliber catheter prone to kinking with neck movement

›Requires continuous manual stabilization

›Why surgical technique is preferred in adults

›Surgical cricothyrotomy provides a cuffed definitive airway capable of full ventilation

›Needle technique is a temporizing bridge only, used when surgical expertise or equipment is not immediately available or while surgical equipment is being gathered

›Adult cricothyroid membrane is large enough to reliably accept a scalpel and tube

›This anatomic margin is the basis for preferring the surgical route over needle technique once equipment is available

Pediatric alternative below the surgical age threshold

›Needle technique as the primary approach under approximately 8 years

›Needle cricothyrotomy with jet or low flow oxygenation as above, scaled to a smaller catheter size

›Verify against current pediatric guideline before use

›Surgical cricothyrotomy avoided in this age group

›Small conical cricoid ring at high risk of long term subglottic stenosis if incised

›Alternative approach in this age group if needle technique fails

›Continued bag mask ventilation with an oral or nasal airway adjunct while calling for the most experienced available airway operator

›Emergent otolaryngology or pediatric surgery bedside tracheostomy if needle technique fails and ventilation cannot be achieved

›Verify against current pediatric guideline before use

Anticoagulation and anatomic considerations

›Anticoagulated patients

›Anticoagulation does not delay the procedure in a true CICO emergency

›Airway death occurs in minutes, bleeding complications are managed after the airway is secured

›Anticipate increased bleeding at the incision site

›Direct pressure and packing around the tube after placement

›Reversal agents initiated once the airway is secured

›Anatomic considerations

›Obese or distorted neck as above under impalpable landmarks

›Prior tracheostomy or neck surgery scar

›Scar tissue may obscure normal tissue planes, blunt finger dissection preferred over blind instrumentation

Sedation and analgesia after the airway is secured

›Post-procedure sedation

›Fentanyl IV 1 mcg/kg bolus then infusion 0.5 to 2 mcg/kg/hour

›Titrate every 15 minutes to comfort and ventilator synchrony

›Maximum infusion 5 mcg/kg/hour before adding a second agent

›Propofol IV infusion 5 to 50 mcg/kg/minute

›Titrate every 5 to 10 minutes by 5 mcg/kg/minute increments to sedation target

›Decelerate in smaller 5 mcg/kg/minute steps once near target rather than large jumps, to avoid overshoot hypotension

›Maximum 50 mcg/kg/minute, reassess hemodynamics before exceeding 30 mcg/kg/minute

›Monitoring cadence

›Continuous pulse oximetry and capnography for the duration of the infusion

›Blood pressure every 5 minutes during titration, then every 15 minutes once stable

›Sedation scale reassessment with every rate change

›Bolus omission caveat

›If hypotension or marginal perfusion, omit the propofol bolus and start the infusion at the low end of the range

Iatrogenic harms from routine emergency department interventions in this patient

›Intervention by intervention review

›Intubation attempts

›Repeated laryngoscopy after CICO criteria are met worsens bleeding and edema and is the single most correctable harm in this topic

›Sedation and paralysis

›Paralytic administration without a confirmed rescue pathway can convert a difficult airway into a CICO emergency, front of neck access equipment must be open and ready before paralysis in any predicted difficult airway

›Fluid loading

›Large volume resuscitation is not contraindicated but positioning for fluid access should not delay airway positioning

›Oxygen delivery

›Apneic oxygenation via nasal cannula during the procedure extends safe apnea time and should not be omitted

›Jet ventilation without a patent exhalation path causes barotrauma as detailed above

›Vasopressors

›Hypoxia and vagal stimulation during airway manipulation can cause bradycardia and hypotension, vasopressor and atropine availability at the bedside is appropriate

›Mechanical circulatory support including intra-aortic balloon pump

›Not indicated for airway obstruction physiology, relevant only if concurrent cardiogenic shock is present from a separate cause

›Anticoagulation

›Ongoing therapeutic anticoagulation increases incision site bleeding but does not change the decision to proceed in a CICO emergency

›Fibrinolysis

›Recent thrombolytic administration for stroke or myocardial infarction is a relative contraindication to elective surgical procedures but does not delay emergency front of neck access, expect increased bleeding and plan for direct pressure and surgical hemostasis after the airway is secured

›Analgesia

›Opioid administration for a painful condition can suppress respiratory drive and precipitate the deterioration that leads to a CICO scenario, especially with concurrent sedatives

09Special Populations/sp26

Pregnancy

›Pregnancy considerations

›Airway edema and reduced functional residual capacity increase both the likelihood of a difficult airway and the speed of desaturation

›Lower threshold to declare CICO early rather than persisting with repeated attempts

›Positioning

›Left lateral tilt or manual uterine displacement during the procedure if uterus is palpable above the umbilicus

›Anatomy is otherwise unchanged

›Same landmark technique and equipment sizing as the nonpregnant adult

Geriatric

›Older adult considerations

›Anatomic changes

›Laryngeal calcification can make palpation firmer but membrane identification is usually still reliable

›Reduced neck extension from cervical spondylosis

›Comorbidity burden

›Anticoagulant use more prevalent, anticipate bleeding as above

›Reduced physiologic reserve for hypoxia, declare CICO earlier

›Post-procedure care

›Lower threshold for early otolaryngology involvement given higher complication risk with age and comorbidity

Pediatrics

›Pediatric specific approach

›Surgical cricothyrotomy relatively contraindicated under approximately 8 years

›Needle technique with jet or low flow oxygenation preferred as above

›Verify against current pediatric guideline before use

›Between the surgical age threshold and adult size

›Surgical technique may be used with smaller tube sizing based on age and size

›Verify against current pediatric guideline before use

›Equipment sizing

›Smaller catheter gauge for needle technique in infants and young children

10Background/b27

Epidemiology

›Frequency and context

›Rare procedure overall

›Performed in well under 1% of emergency department intubations in most reported airway registries

›Higher frequency in trauma airway registries

›Reported in roughly 1 to 2% of emergency trauma airway attempts in some series

›Success rates

›Reported first pass success for the scalpel bougie technique above 90% in simulation and case series when performed by trained operators

›Complication rates

›Reported complication rates vary widely across series, commonly cited in a range of roughly 10 to 40% including minor bleeding

Pathophysiology

›Mechanism and anatomy

›Cricothyroid membrane anatomy

›Avascular midline structure between the thyroid and cricoid cartilages

›Relatively superficial and free of major vessels compared to lower tracheal levels

›Physiology of the CICO state

›Combined failure of upper airway patency and rescue oxygenation leads to progressive hypoxemia and hypercarbia

›Hypoxic cardiac arrest is the terminal event if the airway is not secured

›Why the cricothyroid route is favored over tracheal puncture

›Superficial location shortens the distance from skin to airway lumen compared to a lower tracheal approach

›Fixed cartilaginous landmarks make the membrane identifiable even when other neck anatomy is distorted

Therapeutic Considerations

›Why the technique works

›Scalpel bougie tube sequence rationale

›The scalpel creates a controlled tract through tissue that a needle cannot reliably traverse

›The bougie confirms intraluminal tracheal position by tactile feedback before the tube is committed

›Railroading the tube over a confirmed bougie reduces the chance of a false passage compared to blind tube insertion

›Why needle technique is a bridge, not a destination

11Patient Discharge Instructions/pdi18

copy discharge instructions

›Discharge instructions

›This procedure is not a discharge-from-ED pathway

›Every patient who undergoes emergency cricothyrotomy or needle cricothyrotomy is admitted to an intensive care unit

›These instructions apply after eventual hospital discharge following definitive airway management and any conversion to tracheostomy

›Wound and stoma care after discharge

›Keep the tracheostomy or healed incision site clean and dry

›Report increasing redness, swelling, or drainage at the site

›Voice and breathing changes

›Report new or worsening hoarseness beyond several weeks

›Report noisy breathing, stridor, or increasing shortness of breath, which can signal subglottic stenosis developing over weeks to months

›Return to ED now for red flags

›Any difficulty breathing

›Bleeding from the neck incision or stoma site

›Fever above 38.3 degrees Celsius with neck redness or swelling

›Tube or stoma dislodgement if a tracheostomy tube remains in place

›Follow up

›Otolaryngology follow up within 1 to 2 weeks for wound check and airway assessment

›Scheduled endoscopic airway evaluation if subglottic stenosis risk was flagged at discharge

12References/r13

Guidelines and evidence

›Reference set

›Difficult Airway Society guidelines on management of unanticipated difficult intubation and the cannot intubate cannot oxygenate algorithm

›Scalpel bougie tube technique as the recommended surgical approach in adults

›Emphasis on early declaration and stopping repeated laryngoscopy attempts

›American Society of Anesthesiologists difficult airway management practice guidelines

›Front of neck access as the final step of the difficult airway algorithm

›Advanced Trauma Life Support course materials on surgical airway management

›Contraindications in laryngeal trauma and the role of tracheostomy

›Pediatric advanced life support and pediatric airway consensus materials

›Age based preference for needle over surgical technique in young children

Internal specification source

›Source file citations

›Clinical management system generator specification

›Checkbox nesting and subsection container requirements applied

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed September 13, 2026

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