Needle Cricothyroidotomy

Needle Cricothyroidotomy

David Ray Velez, MD

Table of Contents

General Considerations
Equipment
Technique
Management

General Considerations

Definition: An Emergent Airway Using a Needle or Angiocatheter Inserted Through the Cricothyroid Membrane

Also Known as a “Catheter Cricothyroidotomy” or “Percutaneous Transtracheal Ventilation” (PTV)

Use

  • Percutaneous Cricothyroidotomy is the Preferred Emergent Airway When Unable to Achieve Endotracheal Intubation in Young Pediatrics (Age < 10-12 Years Old)
    • The Cricothyroid Membrane is Too Delicate for Surgical Cricothyroidotomy
    • Formal Tracheostomy is Too Slow in the Emergent Setting
  • Used as a Temporary Measure to Oxygenate Until a Formal Airway Can Be Obtained
  • Insufficient to Adequately Ventilate for More than 20-45 Minutes Due to Small Needle Diameter
  • Following Stabilization, Endotracheal Intubation or Formal Tracheostomy are Necessary

Indications

  • Primarily Used in Young Pediatrics (Age < 10-12 Years Old)
  • Percutaneous Cricothyroidotomy is Indicated Emergently if Unable to Intubate or Ventilate
  • Many Follow a “Three-Strikes” Rule: If Unable to Secure Endotracheal Intubation After Three Attempts by the Most-Competent Provider, Oxygenate Through a Percutaneous Cricothyroidotomy
  • Common Causes:
    • Maxillofacial Trauma
    • Neck Trauma
    • Severe Inhalational Injury with Airway Edema
    • Anaphylaxis
    • Facial/Oropharyngeal Swelling/Edema
    • Airway Obstruction by Foreign Body (Food/Teeth)
    • Congenital Deformity

Contraindications

  • Able to Secure the Airway Through a Less Invasive Means (Endotracheal Intubation)
  • Relative Contraindications:
    • Unable to Identify Landmarks
    • Tracheal Transection
    • Severe Bleeding Disorder

Complications

  • Hypercarbia – Insufficient to Adequately Ventilate for More than 20-45 Minutes Due to Small Needle Diameter
  • Failure to Achieve Access
  • Death
  • Bleeding
  • Infection
  • Pneumothorax
  • Subcutaneous Emphysema
  • Laryngeal/Vocal Cord Injury
  • Esophageal Injury and Tracheoesophageal Fistula
  • Tracheal Stenosis

Laryngeal Anatomy and Target Site for Percutaneous Cricothyroidotomy (Red Circle)

Equipment

16-18 Gauge Angiocatheter

  • 12-16 Gauge in Adults

Syringe with Saline

Bag Valve Mask (BVM) Ventilation

  • Appropriately Sized Bag Valve Mask (BVM)
  • 3-0 Endotracheal Tube Adaptor (ETTA) – Attached Directly to the Angiocatheter
  • Alternatives:
    • 3 mL Syringe Attached to a 7-0 Endotracheal Tube
    • 10 mL Syringe Attached to a 7-0 Endotracheal Tube – ETT Inserted into the Syringe and Cuff Inflated to Seal

Jet Ventilation

  • Oxygen Tubing
  • Connection:
    • Y-Connector – One Side Attached to Oxygen Supply and One Side Open to Air
    • 3-Way Stopcock – One Side Attached to Oxygen Supply and One Side Open to Air
    • Direct Attachment – Oxygen Supply Attached Directly the Angiocatheter with a Hole Cut into the Tubing to Allow Ventilation

*There are Commercially Available Kits That Include the Needed Supplies

*Sterile Supplies (Prep, Drapes, Gown, and Gloves) are Preferred if Able

16 Guage Angiocatheter

Endotracheal Tube Adaptor (ETTA): 3-0 Endotracheal Tube (A), ETTA Disconnected (B), ETTA Attached to Catheter (C)

Connection Using a 3 mL Syringe and 7-0 ETT

Connection Using a 10 mL Syringe and 7-0 ETT – Cuff Inflated

Technique

Prep and Drape (Sterile Preparation May Not Be Possible in a True Emergency)

Palpate and Identify Anatomical Landmarks

  • Thyroid Cartilage
  • Cricoid Cartilage
  • Cricothyroid Membrane

Angiocatheter (16-18 Gauge)

  • Attach a Syringe Half-Filled with Saline to the Angiocatheter
  • Puncture Through the Skin and Cricothyroid Membrane into the Trachea at a 30-45º Angle Inferiorly
  • Applying Negative Pressure to the Syringe While Placing, Bubbles Indicate Tracheal Access
  • Advance Angiocatheter Over the Needle and Hub at the Skin
  • Remove the Needle, Leaving the Angiocatheter

Connection

  • Attach Either a Bag Valve Mask (BVM) or Jet Ventilation Connection
    • BVM: Attach the 3-0 ETTA Directly to the Angiocatheter
    • Jet Ventilation: Directly Connect the Oxygen Tubing to the Angiocatheter or Use a Y-Connector or 3-Way Stopcock
  • Secure the System
  • Begin to Ventilate

Management

Attach Either a BVM or Jet Ventilation Setup

Bag Valve Mask (BVM)

  • Attach the BVM Directly to the Endotracheal Tube Adaptor (ETTA)
  • Ventilate at a Rate of 20-30 Breaths per Minute (Once Every 2-3 Seconds)

Jet Ventilation

  • Connection Options:
    • Direct Attachment – Oxygen Supply Attached Directly the Angiocatheter with a Hole Cut into the Tubing to Allow Ventilation
    • Y-Connector – One Side Attached to Oxygen Supply and One Side Open to Air
    • 3-Way Stopcock – One Side Attached to Oxygen Supply and One Side Open to Air
  • Mechanism:
    • Occlusion: Oxygenation Occurs
    • Open: Flow Escapes Allowing Some Ventilation
  • I:E Ratio of 1:3 or 1:4
    • Occlude/Oxygenate for 1 Second
    • Release/Ventilate for 3-4 Seconds

Obtain a Definitive Airway Once Stabilized

  • Endotracheal Intubation or Formal Tracheostomy
  • Should Be Done within 20-45 Minutes

Jet Ventilation by Direct Attachment: Release/Ventilation (C), Occlude/Oxygenation (D)

Jet Ventilation with a 3-Way Stopcock: Occlude/Oxygenation (B), Release/Ventilation (C)