To provide emergent airway access only when a safer, less invasive airway cannot be established or is contraindicated

 For children younger than 12 years, needle cricothyroidotomy is the surgical airway of choice

CONTRAINDICATIONS

 Absolute

    An oral or nasal airway can be established

    Significant injury or fracture of the cricoid cartilage or larynx (tracheostomy is the procedure of choice)

    Tracheal fracture or transection

    Obstruction below the cricothyroid membrane

    Patients younger than 12 years (needle cricothyroidotomy is the procedure of choice for this age-group)

 Relative

    Neck mass, swelling, or cellulitis

    Neck hematoma

    Coagulopathy

LANDMARKS

 The cricothyroid membrane—an elastic membrane located anteriorly and midline in the neck, measuring 9 mm longitudinally and 30 mm transversely. Bordered superiorly by the thyroid cartilage (“Adam’s apple”) and inferiorly by the cricoid cartilage.

 In children, the larynx is positioned more superiorly than in adults and is relatively smaller in size (FIGURES 6.1 and 6.2)

STANDARD CRICOTHYROIDOTOMY

 Supplies

    Antiseptic solution, drapes, towel clips

    Lidocaine with epinephrine

    No. 11 blade scalpel with handle

    Tracheal hook

    Trousseau dilator

    Tracheostomy tube

    Neck tie or sutures

 Technique

    Preparation

       Hyperextend the neck to more readily identify landmarks, unless the patient has a known or suspected cervical spine injury

       Preoxygenate the patient by bag-mask ventilation

       Test the integrity of the balloon on the tracheostomy tube by injecting with 10 mL of air

       If time permits, apply appropriate antiseptic solution and drape the area with sterile towels

       If time permits and patient is conscious or responding to pain, infiltrate the skin of anterior neck with 1% lidocaine solution with epinephrine

 Identify the Landmarks (See Earlier “Landmarks” Section)

 Stabilize the Larynx

    Grasp both sides of the thyroid cartilage with the thumb and middle finger using the nondominant hand

    Palpate the depression over the cricothyroid membrane with the index finger

    Control the larynx throughout the procedure by stabilizing it in this manner and reidentify the cricothyroid membrane at any time during the procedure

 Incise the Skin

    Using a no. 11 scalpel blade in the dominant hand, make a vertical midline incision through the skin and subcutaneous tissue approximately 2 to 3 cm in length

    Care should be taken to extend the incision down to but not through any of the deep structures of the neck

 Reidentify the Cricothyroid Membrane

    Using the index finger of the nondominant hand, reidentify the cricothyroid membrane while maintaining immobilization of the larynx with the thumb and middle finger

    If the cricothyroid membrane cannot be palpated, extend the initial incision superiorly and inferiorly and try to palpate again

 Incise the Cricothyroid Membrane

    Using the stabilizing index finger as a guide, incise the cricothyroid membrane at least 1 cm in length in the horizontal direction

    Note that the skin incision is vertical and the incision through the membrane is horizontal

    Place the index finger into the stoma temporarily while exchanging the scalpel for the tracheal hook

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