• Patients who cannot be adequately oxygenated or ventilated using bag-mask ventilation.
• Patients in whom it is impossible to establish an airway via oral or nasal endotracheal intubation due to any of the following:
• Bleeding from upper airway structures.
• Massive emesis.
• Masseter spasm.
• Spasm of the larynx or pharynx.
• Laryngeal stenosis.
• Structural deformities of the upper airway.
• To avoid delay in airway control in patients with upper airway obstruction, thus preventing or shortening periods of anoxia.
• Patients with maxillofacial trauma, laryngeal trauma (except for tracheal transection), and unstable cervical spine fractures to minimize movement of the neck.
• An elective situation when a patient is undergoing surgery of the head, face, or neck.
• Cricothyrotomy should not be performed in any patient who can quickly and easily be intubated using nonsurgical means.
• Patients with a fractured or significantly damaged larynx.
• Patients with tracheal transection.
• The cervical fascia may be tenuously holding the airway together.
• The incision required to perform a cricothyrotomy may transect the fascia causing the distal airway to retract into the mediastinum.
• In such cases, tracheostomy is the preferred method for controlling the airway.
• Coagulopathy.
• Preexisting infection.
• Significant neck distortion.
• Massive neck edema.
• In children younger than 5 years, needle cricothyrotomy with transtracheal jet ventilation is recommended due to the difficulty of performing a surgical cricothyrotomy. (Some clinicians recommend transtracheal jet ventilation for children younger than 12 years.)
• Establishing an airway should supersede any relative contraindication in a patient in extremis.
• Scalpel.
• Tracheal dilator (Trousseau dilator) or spreader or hemostat.
• Appropriate size tracheostomy or endotracheal tube.
• 25-gauge needle and syringe with 1% lidocaine (for local anesthesia).
• Preparation solution (either 2% chlorhexidine-based preparation in patients older than 2 months of age or 10% povidone-iodine).
• Sterile gauze pads.
• Ties for tracheostomy tube.
• Oxygen source and suction.
• Bag-valve device.
• 12- or 14-gauge needle or over-the-needle catheter.
• 5- or 10-mL syringe.
• High-pressure tubing.
• Stopcock.
• High-pressure oxygen source at 50 psi.
• If a high-pressure oxygen source is not available, use a bag-valve device with the proximal connector of an 8.0 endotracheal tube and 3-mL syringe or the proximal connector of a 3.0 endotracheal tube.
• Remember, the thyroid gland lies inferior to the larynx. Therefore, if the thyroid gland is visualized, the incision should be extended cranially, toward the larynx.
• After making an incision through the cricoid membrane, it may be necessary to lift and hold the larynx anteriorly with a tracheal hook in order to avoid posterior displacement of the larynx.
• If needle cricothyrotomy is performed and there is no pressurized oxygen source available, the patient can be ventilated using a bag-valve apparatus connected to the catheter (Figure 5–1).
• Attach a 3-mL syringe to the needle/catheter and then the proximal end of an 8.0 endotracheal tube connector into the back of the 3-mL syringe.
• Alternatively, attach the proximal end of a 3.0 endotracheal tube connector to the needle/catheter, and then, connect a bag-valve apparatus to the distal side of the endotracheal tube connector.
• Time permitting, sterilize the patient’s neck with either 2% chlorhexidine-based preparation in patients older than 2 months or 10% povidone-iodine. Then, administer local anesthesia using a 25-gauge needle and syringe with 1% lidocaine.
• Sedation can be used sparingly in patients whose agitation may hinder the procedure; however, sedation may cause respiratory depression in patients with an already compromised airway.
• In emergent situations, there may not be time to administer local anesthesia or sedation.
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