Emergency Tracheostomy in Young Children

Aka: Emergency Tracheostomy in Young Children, Slash Tracheostomy

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II. Indications

  1. "Can't Intubate, Can't Oxygenate" (CICO) scenario in children under age 8 years
    1. Although variable, Cricothyrotomy is difficult in age <8 years due to Neck Anatomy
    2. Cricothyroid membrane is typically not palpable in age <8 years (and up to <12 years)
    3. Slash Tracheostomy is a critical intervention in age <8 years, when other Advanced Airway is impossible
    4. Once identifying CICO, move quickly and decisively to Tracheostomy without delay
  2. In age >8-12 years, Cricothyrotomy is a life-saving definitive tool in "Can't Intubate, Can't Oxygenate" scenarios
    1. Indicated as a critical rescue technique when other Advanced Airways have been attempted without success
    2. Cricothyrotomy may be performed in age 8-12 years IF the cricothyroid membrane may be palpated
  3. Needle Cricothyrotomy has historically been recommended as an alternative to Cricothyrotomy in age <8 years
    1. However, efficacy is poor, and offers only a brief temporizing effect for Apneic Oxygenation

III. Preparation: Equipment

  1. Scalpel (#10 Blade)
  2. Kelly Clamp
  3. Endotracheal Tube
  4. Suction
  5. Adequate lighting (headlight)
  6. Capnography

IV. Technique

  1. Prepare the neck if time (e.g. double set-up with another provider attempting Endotracheal Intubation)
    1. Splash with Topical Antiseptic
    2. Local Anesthetic
  2. Extend the neck
    1. Place a Shoulder roll
    2. Position the neck in extension to expose the anterior neck structures
  3. Using the non-dominant hand, grasp the trachea between the thumb and middle fingers
    1. Palpate the midline trachea with the index finger
    2. Palpate the cartilaginous rings (unique to the trachea)
    3. Continue to maintain firm tracheal grasp throughout the procedure
  4. VERTICAL skin incision
    1. Make this long enough for clear visualization of several catilaginous rings
    2. Vertical skin incision avoids the Jugular Veins, carotid arteries, and recurrent laryngeal nerves
    3. Anticipate significant bleeding from soft tissue including Thyroid Gland
      1. Assistant should suction during procedure
  5. VERTICAL tracheal incision
    1. Incise vertically through the midline, anterior trachea, through 2-3 tracheal rings
    2. Anticipate blood within trachea (suction)
    3. Unlike Cricothyrotomy, do NOT make a horizontal incision through the trachea
      1. High risk for complete tracheal transection of the pediatric airway
  6. Endotracheal Tube insertion
    1. Use the same tube size as calculated for Endotracheal Intubation (age/4+4)
    2. Insert the Endotracheal Tube directly (or over a bougie)
    3. Inflate cuff and confirm Capnography
    4. Suction Endotracheal Tube

V. References

  1. Claudius and Rosenblatt (2025) Pediatric Pearls: Slash Tracheostomy, EM:Rap, 7/7/2025

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