8-6
povidone-iodine prep, gauze, (sterile) gloves, blanket, silk free ties (for bleeders; size 3-0), 3-0 silk suture
material on a cutting needle, and tape.
What To Do: Needle and Surgical Cricothyroidotomy
- Preparation.
a. Place the casualty in the supine position.
b. Place a blanket or poncho rolled up under the casualty’s neck or between the shoulder blades to
hyperextend the casualty’s neck and straighten the airway. WARNING: Do not hyperextend the
casualty’s neck if a cervical injury is suspected.
c. Assemble needle/syringe set if not already done. - Locate and prep the cricothyroid membrane.
a. Place a finger of the nondominant hand on the thyroid cartilage (Adam’s apple) and slide the finger
down to find the cricoid cartilage.
b. Palpate for the “V” notch of the thyroid cartilage.
c. Slide the index finger down into the depression between the thyroid and cricoid cartilage, the
cricothyroid membrane.
d. Prep the skin over the membrane with povidone-iodine. - Put on gloves (sterile if available) after assembling equipment and supplies.
- Needle Cricothyroidotomy
a. Make a small nick in the skin with a #11 blade to open a hole for the IV catheter to slide through
the skin
b. Using the needle/catheter/syringe, penetrate the skin and fascia over the cricothyroid membrane at a
90° angle to the trachea while applying suction on the syringe. Advance the catheter through the
cricothyroid membrane.
c. Once air freely returns into the syringe, STOP advancement, and direct the needle toward the feet at
a 45° angle.
d. Hold the syringe in one hand, and use the other hand to advance the catheter off the needle towards
the lower trachea.
e. Slide the catheter in up to the hub—CAUTION: Do not release the catheter until it is adequately
secured into place.
f. Check for air movement through the catheter by using the syringe to inject air through it and confirm
free airflow. If air does not flow freely, straighten the tube and try again or withdraw the catheter and
begin again at step 4b above.
g. If air flows freely and the patient is breathing on his own, use the 3-0 suture to make a stitch through the
skin beside the catheter. Secure the catheter to the stitch with several knots. Connect catheter to an
oxygen source at a flow rate of 50 psi or 15 L/min. See Step 6 and 7 below for wound care and
on-going management.
h. If the patient is NOT breathing on his own, attach the syringe to the catheter, remove the plunger and
deliver artificial respirations through the syringe and catheter. If the patient does not recover
spontaneous respirations after several minutes, or if oxygen source is not available, proceed to Surgical
Cricothyroidotomy below. - Surgical Cricothyroidotomy (If Needle cricothyroidotomy is not possible or is insufficient)
a. Proceed through steps 1-3 if not already done. Test ET cuff to ensure it holds air.
b. Raise the skin to form a tent-like appearance over the cricothyroid space, using the index finger and
thumb.
c. With a cutting instrument in the dominant hand, make a 1 inch horizontal incision through the raised
skin to the cricothyroid space.
CAUTION: Do not cut the cricothyroid membrane with this incision.
d. Relocate the cricothyroid space by touch and sight.
e. Stabilize the larynx with one hand and cut or poke a 1 inch incision through the cricothyroid membrane
with the scalpel blade. NOTE: A rush of air may be felt through the opening. Look for bilateral rise
and fall of the chest.
f. Insert the ET tube or other airway tube through the opening into the trachea at a 90° angle to the
trachea. Once in the trachea, direct the tube toward the feet at a 45° angle. Do NOT