Bougie-Assisted Cricothyrotomy

Background: Cricothyrotomy is a high acuity low occurrence (HALO) procedure that is time critical.  It is the common final step in the cannot intubate cannot oxygenate (CICO) and/or cannot intubate cannot ventilate (CICV) situation. Due to the time critical nature of the procedure, any approach must include three facets:

1. Be as simple and rapid as possible
2. No special equipment required
3. High success and low complication rate

[embedyt] https://www.youtube.com/watch?v=isP9nH3Nitk[/embedyt]

14 minute video on anatomy and procedure of bougie-assisted cricothyrotomy

Hardest Part of the Procedure:

• Making the decision to cut
• Cricothyrotomy typically performed too late to prevent poor outcome
  • The time taken to act
  • The time taken to prepare
• Important to remember there is no absolute contraindications to this procedure

Equipment Needed:

• 10 or 11 blade scalpel
• Bougie
• 6.0 – 6.5 endotracheal tube

Anatomy You Need to Know:

• Thyroid Cartilage
• Cricothyroid Membrane/Ligament
  • In adults this is 9 to 19mm horizontally & 9 to 20mm vertically)
• Cricoid Cartilage
• Trachea

Laryngeal Handshake:

• Palpate thyroid cartilage
• Palpate cricoid cartilage
• Cricothyroid membrane/ligament will be a slight depression between the two

The Procedure:

• Vertical incision
• Place finger into incision and palpate ligament prior to stab incision
• Horizontal incision (stab blade into membrane then drag, flip, drag without removing scalpel)
  • Want to make horizontal incision in lower half of the cricothyroid membrane
  • Potentially avoids cricothyroid arteries and vocal cords
• Remove the scalpel and insert the tip of the finger into the incision
  • Confirms that the incision has penetrated into the laryngeal lumen
  • Confirms the incision is large enough to accommodate an endotracheal tube
• Bougie slides in right behind finger
• Endotracheal tube slide over bougie
  • Cricothyroid membrane is located below vocal cords therefore avoid feeding endotracheal tube too far in (Feed until cuff disappears into tracheal lumen)

Practice Practice Practice:

• Training should be repeated at least once a month to maintain fidelity with the procedure
  • Can use 3D printed models
  • Electrical Tape = Membrane
  • Foam Tape = Skin

References:

1. Sorbello M et al. Front-of-Neck Access and Bougie Trapping. Anaesthesia 2018. PMID: 30132808
2. Paix BR et al. Emergency Surgical Cricothyroidotomy: 24 Successful Cases Leading to a Simple ‘Scalpel-Finger-Tube’ Method. Emerg Med Australas 2012. PMID: 22313556
3. Langvad S et al. Emergency Cricothyrotomy – A Systematic Review. Scand J Trauma Resusc Emerg Med 2013. PMID: 23725520

For More Thoughts on This Topic:

• EMCrit: Podcast 131 – Cricothyrotomy – Cut to Air – Emergency Surgical Airway
• EMCrit: Mind Blowing Cricothyrotomy Video
• LITFL: Surgical Cricothyroidotomy
• EMCrit: Wanted Dead or Alive, Your FONA Experiences

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)