Surgical airway, or Cricothyrotomy is a definitive rescue technique for the failed airway in order to preserve oxygenation.
Open cricothyroid technique in adults has been shown to have a higher success rate in novice operators compared to 'over the wire' techniques. In addition, vertical incision of front of neck is advocated in patients with anatomy that is difficult to palpate.
- Cant Intubate, Cant Oxygenate (CICO) situation with decreasing SpO2
- Primary airway attempt if ETT, supraglottic airway or BVM is not feasible (e.g. massive facial trauma or burns)
- Children < 6 years of age
- Open tracheal injury
- This is a tactile procedure. Surgical field may become obscured due to haemorrhage following incision
- Incorrect pre-tracheal insertion of ETT (surgical emphysema developing in neck on ventilation of patient)
- Placement of ETT into right main bronchus (asymmetrical chest wall movement)
- Verbalise to your team that you are going to undertake a surgical airway
- Apply required Infection Prevention & Control measures as per policy
- Maintain oxygenation and ventilation with BVM or supraglottic device as best as possible
- Prepare the following equipment:
- Bougie
- Size 6 ETT
- 10mL syringe
- Alcohol/betadine swab
- BVM
- Cobbs connector
- Disposable scalpel
- Artery forceps
- Oxygen
- Suction
- Tape
- End Tidal CO2 monitoring
- Prepare the neck with antiseptic solution
- Right handed individuals – stand on right side of patient; left-handed individuals stand on left side of patient
- With non-dominant (ND) hand, identify and stabilise the laryngeal cage with thumb and middle finger and, with the index finger, identify the landmarks of front of neck if possible (thyroid cartilage, cricoid cartilage and cricothyroid membrane) as per figure 1.
- If laryngeal landmarks are not identifiable, make a longitudinal incision at least 3-4cm in length through the skin and subcutaneous tissue. Stabilise your dominant hand on the sternum of the patient when making the incision.
- Separate soft tissue with either your fingers or artery forceps to identify underlying anatomical landmarks; specifically the cricothyroid membrane
- Lift the ND index finger and using the scalpel, make a horizontal incision using the SERT technique
- Stab – with the blade facing you, insert it horizontally until resistance of back wall is felt
- Extend – continue the incision as far as possible until resistance of side wall of cartilaginous cage felt
- Reverse – turn the blade 180o and extend incision to opposite wall of cartilaginous cage
- Twist – rotate the blade vertically to create a triangular hole beside scalpel’s blade
- Remove scalpel and dispose of safely.
- Insert pinkie finger of ND hand into the incision and ensure you can feel the tracheal walls
- Insert the bougie perpendicular to the alignment of the neck, along the pad of your pinkie finger, then rotate 90° to feed down the trachea to a depth of no more than 15cm (insertion further will eventually result in hold up in the small airways)
- Railroad a lubricated size 6.0 ETT over the bougie until the balloon is in the airway and is no longer visible (rotation of ETT may be required to pass through skin into airway to mitigate hold-up)
- Ensure ETT is held secure whilst balloon inflated and bougie removed
- Attach to ETCO2 and BVM
- Confirm placement with appropriate continuous ETCO2 tracing, auscultation and bilateral rise and fall of the chest.
- Secure ETT with tape
- Assess the wound for haemorrhage and manage accordingly.
- Appropriate continuous EtCO2 tracing
- Improvement in oxygenation
- Bilateral equal chest wall movement
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Chrimes N. 2016. The Vortex: a universal ‘high-acuity implementation tool’ for emergency airway management. British Journal of Anaesthesia. 117 (S1): i20–i27.
Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark identification for cannula cricothyroidotomy. Anaesthesia. 2010 Sep;65(9):889-94.
Hessert MJ, Bennett BL. Optimizing emergent surgical cricothyrotomy for use in austere environments. Wilderness Environ Med. 2013 Mar;24(1):53-66
Heymans F, Fiegl G, Graber S, Courvoisier DS, Weber K et al. 2016. Emergency Cricothyrotomy Performed by Surgical Airway–naive Medical Personnel: A Randomized Crossover Study in Cadavers Comparing Three Commonly Used Techniques. Anaesthesiology.
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