Preparing for a cricothyrotomy procedure

Siamak Moayedi, MD
19th Nov 2020

Anatomy of the throat

First, you need to find the cricothyroid membrane (i.e., cricoid ring), which is the hardest part of this procedure. The cricoid ring is the cartilage immediately below the thyroid cartilage (i.e., Adam’s apple). This membrane will need to be cut so that the endotracheal tube (ETT) can be placed through it. At the level of the cricothyroid membrane, the ETT will need to be inserted below the vocal cords.

It’s easy to find these structures in thin people. But, it is very challenging when your patient is dying, sweat-covered, and morbidly obese!

Front and side view of throat cartilage with labels for the thyroid cartilage, cricothyroid membrane, cricoid cartilage, and vocal cords. Illustration. 

Figure 1. Anatomy of the throat. 

You’ll have to do your best to feel for the structures. If all else fails, just pick the middle of the neck and make your initial vertical incision. Then, feel for the structures once you’ve cut past the fat. It’s okay to extend the incision if it’s too high or too low. 

Keep in mind, a cricothyrotomy is one of the bloodiest procedures you’ll ever do. Wear a face shield and be prepared to get blood on your face!

Because of the bleeding, you won’t be able to see anything. This is a tactile procedure, you will only be able to figure out where the structures are by feeling with your fingers.

 

 

Identifying the tools for a cricothyrotomy procedure

Instead of using a manufacturer’s kit for cricothyrotomy, it is recommended to keep it simple and use the tools listed below. The cricothyrotomy kits are dangerous, because by the time you find the kit at the bottom of a drawer and open the package, your patient may already be brain dead from hypoxia! 

  • Disposable #10 surgical blade 
  • 6.0 ETT tube with an attached 5 cc syringe
  • Bougie  

The reason why we suggest the 6.0 ETT is because it has a diameter of 1 cm, which is the size of an average adult’s cricothyroid space. 

Multi-component image of a blade, endotracheal tube with attached syringe, and bougie. Cartoon.

Figure 2. Tools for a cricothyrotomy procedure include a #10 scalpel, 6.0 ETT with 5 cc syringe, and a bougie. 

 

Preparing for a cricothyrotomy procedure

If you have the luxury of time to prepare for this procedure (which you usually never do), it’s good to have sterilizing solution and a face mask with a shield. Take a deep breath. This is a stressful procedure! 

The next step is to prepare the 6.0 ETT: 

  1. Cut the tube in half right above the balloon tubing. 
  2. Take the ventilator attachment (white plastic connector) and attach it back to the cut tube. 
  3. Load the shortened 6.0 ETT onto the bougie. 

Multi-component image of a 6.0 ETT cut in half with ventilator attachment and loaded onto a bougie. Cartoon.

Figure 3. Preparing the 6.0 ETT. 1) Cut the tube in half above the balloon tubing. 2) Attach the ventilator attachment back to the cut tube. 3) Load the ETT onto the bougie. 

So that's it! You’ve learned how to prepare for a cricothyrotomy procedure.

 

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Recommended reading

  • Hill, C, Reardon, R, Joing, S, et al. 2010. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med17: 666–669. PMID: 20491685
  • MacIntyre, A, Markarian, MK, Carrison, D, et al. 2007. Three-step emergency cricothyroidotomy. Mil Med172: 1228–1230. PMID: 18274018
  • Quick, JA, MacIntyre, AD, and Barnes, SL. 2014. Emergent surgical airway: comparison of the three-step method and conventional cricothyroidotomy utilizing high-fidelity simulation. J Emerg Med46: 304–307. PMID: 24188608