Experience Summary

Failed intubation and management of the difficult airway is a life threatening emergency. In this video, watch the anaesthetic team perform an emergency cricothyroidotomy on a patient where the cricothyroid membrane is impalpable.

Clinical Context

An emergency cricothyroidotomy or ‘emergency front of neck access’ is indicated when other intubation modalities (including a supraglottic airway device and final attempts at face mask ventilation) have been unsuccessfully attempted, and the patient cannot be adequately oxygenated. This situation may occur in the operating theatre, in the Emergency Department, or during other airways emergencies (e.g. during anaphylaxis).

The difficult airway society have released guidance the management of this situation and what is required should a ‘can't intubate, can't ventilate’ situation arise.

Before performing this procedure, the following steps should be taken:

• 100% oxygen should be applied to the upper airway.
• Neuromuscular blockade should be ensured throughout the procedure.
• The patient should be positioned to extend their neck and allow adequate access to the larynx and cricothyroid membrane.

The following equipment should be assembled prior to starting the procedure:

• Scalpel (number 10 blade)
• Bougie
• Endotracheal tube (cuffed 6.0mm, checked for leaks, fully deflated and lubricated)

A laryngeal handshake should then be performed to identify the hyoid bone and stabilise the larynx. The cricothyroid membrane may then be located by palpating inferiorly down the neck. Watch our associated video to view the procedure for an emergency cricothyroidotomy in a patient with a palpable cricothyroid membrane. If the membrane cannot be identified, the steps in this video should be followed to place an endotracheal tube and successfully oxygenate the patient.

When the cricothyroid membrane is palpable, the initial skin incision is a transverse stab across the cricothyroid membrane. This differs from the procedure when the cricothyroid membrane is impalpable, as the initial skin incision is instead ~8-10cm and made caudally to cranially. This incision is then blunt dissected using fingers, so the clinician can identify the larynx and stabilise it. The cricothyroid membrane can then be identified and the subsequent procedure followed as for a patient with a palpable cricothyroid membrane i.e. a transverse stab across the cricothyroid membrane.

Learning Outcomes

1. Understand the indications for performing an emergency cricothyroidotomy.
2. Understand the equipment required to perform an emergency cricothyroidotomy.
3. Understand the procedural steps of an emergency cricothyroidotomy in a patient with an impalpable cricothyroid membrane.
4. Understand how the procedure of an emergency cricothyroidotomy differs in those with palpable versus impalpable cricothyroid membranes.
5. Understand the checks required to ensure the endotracheal tube is correctly situated following an emergency cricothyroidotomy.

External Resources

• Difficult Airway Society Guidelines - Difficult Intubation