critical care medicine
How To Do a Percutaneous Cricothyrotomy
Step by Step Description of Percutaneous Cricothyrotomy
To the extent possible, ensure adequate oxygenation and ventilation throughout this procedure, using a Bag-Valve-Mask Devices or Test the cuff of the tracheal tube balloon for leaks by using a syringe to inflate it with air. Then deflate the balloon. Apply a small amount of water-soluble lubricant to the dilator/airway assembly, including the balloon cuff, using a gloved finger. Attach a syringe, half-filled with saline, to the insertion needle. Identify the cricothyroid membrane. Move your finger caudally from the laryngeal prominence (the most prominent part of the anterior thyroid cartilage) until you feel the cricothyroid membrane, palpable as a step-off between the caudal end of the thyroid cartilage and the cricoid cartilage. Prepare the anterior neck with a skin cleansing agent such aschlorhexidineorpovidone-iodineand place a sterile drape over the neck. Inject a local anesthetic along the anticipated skin incision site (see next bullet) if the patient is capable of feeling pain. Stabilize the larynx with your non-dominant hand by grasping the sides of the thyroid cartilage with your thumb and middle finger. Maintain stabilization until the airway catheter is in place. Some operators make a 2- to 3-cm midline longitudinal incision using a scalpel over the skin and subcutaneous tissues over the cricothyroid membrane. Insert the needle (typically within a catheter), with the fluid-containing syringe attached, through the cricothyroid membrane, aiming caudally at an angle of about 45 degrees. Keep back-pressure on the syringe plunger as you advance. Confirm needle placement in the airway by feeling a pop as the needle enters the trachea and by seeing air entering the syringe, visible as air bubbles in the saline. Stop advancing the needle as soon as air is returned. Remove the syringe from the needle. If a catheter lies over the needle, advance the catheter and withdraw the needle. Thread the flexible tip of the guidewire through the needle or catheter and into the trachea. While maintaining firm control of the guidewire, gently remove the needle or catheter, leaving the guidewire in place. Make a skin incision directly below the guidewire insertion site (if not previously made) to facilitate passage of the blunt dilator and airway, which are advanced as a unit into the trachea. Carefully guide the dilator over the guidewire. Be sure the guidewire passes through the dilator and that you control the proximal end of the wire before proceeding (so the guidewire is not lost within the airway). Dissect the site further as needed to facilitate passage of the device through the tissues and into the trachea. If resistance to passage is significant, try using gentle but steady force, rotating the unit as it advances, and using further dissection if needed. Fully inserted, the hub and flange of the airway catheter should be flush against the skin. Withdraw the guidewire and the dilator. Inflate the balloon cuff to the minimum volume needed for effective ventilation. Resume ventilation using the newly established airway. Secure the device in place using cloth or tape threaded through the catheter flanges. When the airway is secure, confirm proper airway placement using auscultation and end-tidal carbon dioxide detection. 