How to perform a cricothyrotomy procedure

Hear from our in-house expert on how to perform a life-saving emergency room technique, the cricothyrotomy procedure.
Last update2nd Aug 2022

Let’s look at how to grasp the cricothyroid complex with the laryngeal handshake and the steps of the cricothyrotomy procedure.

To begin, it’s important to understand the circumstances that led you to the brink of cutting your patient’s neck:

  1. You’ve sedated and paralyzed your patient.
  2. Your intubation attempt was not successful.
  3. You were unable to oxygenate your patient with a bag-valve-mask and rescue equipment (e.g., laryngeal mask airway).
  4. Your patient is cyanotic and paralyzed.
  5. You've asked for a #10 scalpel, bougie, and 6.0 endotracheal tube (ETT).

If you used succinylcholine for paralysis, your patient is about to start moving and doing a cricothyrotomy will be very challenging, so be prepared to give it again if necessary. If you used rocuronium, your patient will remain paralyzed, making this procedure easier.

How to perform a cricothyrotomy

The laryngeal handshake

The first—and very important—step is to grasp the entire cricothyroid complex in a laryngeal handshake:

  1. Stand on the side of the patient where your dominant hand will be closest to the patient’s neck.
  2. Use your non-dominant hand to grasp the lower part of the thyroid cartilage firmly between your thumb and middle fingers.
  3. At the same time, push the skin between your fingers down so the neck skin is taut and easier to cut.
  4. Your non-dominant index finger can now feel the landmarks and find the area where you’ll make the first incision with your dominant hand.
Figure 1. The laryngeal handshake procedure. 1) Stand on your dominant side of the patient. 2) Use your non-dominant hand to grasp the lower part of the thyroid cartilage. 3) Push the skin of the neck taut. 4) Use your non-dominant hand to feel for landmarks.

The first incision

Once the cricothyroid complex is firmly grasped with the laryngeal handshake, it’s time to perform the first incision:

  1. With the #10 scalpel in your dominant hand, make a vertical mid-line incision that cuts deep past the fat, running from the middle of the thyroid cartilage to the top of the cricoid cartilage.
  2. Hold the laryngeal handshake firmly during the ensuing spray of arterial blood.
  3. With your non-dominant index finger, feel past the fat and see if your landmarks are correct. You should be able to feel the cricothyroid membrane between the thyroid cartilage and the cricoid cartilage.
  4. Extend your incision up or down depending on the landmarks you feel (only an issue in obese patients).
Figure 2. The cricothyrotomy procedure—the first incision. 1) Make a vertical mid-line incision from the middle of the thyroid cartilage to the top of the cricoid cartilage. 2) Hold the laryngeal handshake firmly through the expected spurting blood. 3) Feel the landmarks with your non-dominant hand. 4) Extend your incision if you missed the landmarks.

The second incision

After the first incision is made to expose the cricothyroid membrane, it’s time to perform the second incision:

  1. Carefully stab the #10 blade past the cricothyroid membrane. Beware, if you push your scalpel too far, you’ll be cutting the back of the trachea. If your patient is not paralyzed in this step, the blood dripping into the airway will make them cough, and there will be a spray of blood.
  2. Let go of the laryngeal handshake and switch hands to hold the scalpel with your non-dominant hand.
  3. Using the scalpel like a shoehorn, pull the skin and fat of the incision towards the head to make room for the bougie (pre-loaded with a pre-cut 6.0 ETT).
  4. Insert the pre-loaded bougie through the incision and down into the trachea towards the lungs.
  5. Feed the ETT over the bougie into the airway. Depending on the size of the cricothyroid space, you may need to push hard to make room for the tube.
  6. As soon as the balloon of the tube is in the trachea, inflate the cuff.
Figure 3. The cricothyrotomy procedure—the second incision. 1) Carefully stab the blade into the cricothyroid membrane. 2) Release the laryngeal handshake and switch the scalpel to your non-dominant hand. 3) Pull the skin and fat away from the incision with the scalpel. 4) Insert the pre-loaded bougie down the trachea. 5) Feed the endotracheal tube (ETT) over the bougie into the airway. 6) When the balloon of the ETT is in the trachea, inflate the cuff.

Since you’re below the vocal cords, you have direct access to the patient’s airway and can bag your patient. Hold onto the tube until the bag is secured. You can do this the same way you secure an endotracheal tube.

You will also need to hold some pressure on any bleeding vessels that are still pumping.

Confirm the tube placement

Confirm proper ETT placement the same way as you would with regular endotracheal intubation:

  1. Listen for breath sounds at the bilateral axilla
  2. Use the end tidal CO2 detector
  3. X-ray the chest
Figure 4. Confirm the proper tube placement by listening for breath sounds at the bilateral axilla, using the end tidal CO2 detector, and taking a chest x-ray.

Great job! You’re well on your way to perfecting a cricothyrotomy procedure and saving a patient's life.

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

About the author

Siamak Moayedi, MD
Associate Professor and Director of Medical Student Education, University of Maryland and Course Director, Essential and Critical Procedures, Emergency Medicine.
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