8-5
- Hyperventilate with 100% O 2 for several minutes using BVM.
- Have assistant hold cricoid pressure if aspiration is a risk.
- If orotracheal intubation is planned, hold the laryngoscope in left hand and insert the blade on right side
of mouth pushing the tongue to the left and avoiding the lips, teeth and tongue. Holding the left wrist rigid
(to avoid using the scope as a fulcrum and damaging the teeth), visualize the epiglottis. - If a straight (Miller) blade is used, pass the blade tip beneath the laryngeal surface of the epiglottis and
lift forward and upward to expose the glottic opening. If a curved (Macintosh) blade is used, advance the
tip of the blade into the space between the base of the tongue and the pharyngeal surface of the epiglottis
(the vallecula) to expose the glottic opening. - Insert the ET with the right hand through the vocal cords until the cuff disappears. Remove the stylet and
advance the tube slightly further. Inflate the cuff with air until no leak is heard when ventilated with bag.
Adult women use a 7.0mm; men use an 8.0mm ET. - Verify correct placement by listening over both lungs for bilateral, equal breath sounds and observe
the chest for symmetric, bilateral movements. Listen over the stomach, where you should not hear breath
sounds. Note depth of insertion by centimeter markings on the tube at the lips, and tape the tube in place. - For nasotracheal intubation when the mouth cannot be opened or the patient cannot be ventilated by
another means, or if the patient is conscious and requiring intubation, follow steps 1-3 using a lubricated
(water-soluble), size 7-7.5 ET without the stylet. Insert the ET tube straight down into the larger nares
until it reaches the posterior pharyngeal wall. If doing a blind nasal intubation, listen for the patient to
inhale and insert the ET quickly into the trachea with a single smooth motion. If intubating under direct
visualization, now insert the blade as previously described and pass the ET through the cords. Inflate the
cuff and verify placement as above.
What Not To Do:
- Do not mishandle laryngoscope blade and handle. Teeth can be broken and aspirated, or lips or gums
lacerated with resultant bleeding. In addition, cardiac arrhythmias can occur with manipulation of the
trachea and esophagus. - Do not allow the ET tube to be moved or removed accidentally. It must be adequately secured after
successful placement to avoid compromising respiratory status in order to replace it. - Never perform a nasal intubation in a patient with a known or suspected basilar skull fracture or cribriform
plate fracture. The ET can end up in the brain! Never force the ET against tissue resistance. Bleeding and
inflammation can result, making future attempts at intubating difficult or impossible.
Procedure: Cricothyroidotomy, Needle and Surgical
18D Skills and Training Manual, Adapted by COL Warren Whitlock, MC, USAWhat: Methods to establish a temporary emergency airway through the neck.
When: Consider cricothyroidotomy to establish an airway in casualties having a total upper airway obstruc-
tion or inhalation burns preventing intubation. Two methods are available:
- Needle penetration of the cricothyroid membrane
- Surgical placement of an airway tube through the cricothyroid membrane - when a cricothyroidotomy
needle is unavailable or performing a needle cricothyroidotomy is not effective.
What You Need: Gather pre-assembled cricothyroidotomy kit (every medic should have an easily acces-
sible ‘Cric Kit’ that contains all required items) or minimum essential equipment as below:
Cutting instrument: #10 or 11 scalpel, knife blade, 12-14 Gauge catheter-over-needle (e.g., Angiocath) with
10cc syringe attached for needle cricothyroidotomy (below). Syringe can also be used to inflate cuff on ET
tube. Airway tube: IV catheter 12-14 gauge (from above), ET tube, cannula, or any noncollapsible tube that
will allow sufficient airflow to maintain O 2 saturation. In a field setting, an ET tube is preferred because it is
easy to secure. Use a size 6 -7 and insure that the cuff will hold air. Other instruments: 2 Hemostats, needle
holder, tissue forceps, scissors. Other supplies: Oxygen source and tubing, Ambu bag, suctioning apparatus,