II. Indications
- Failed airway where standard, open Cricothyrotomy is not possible (infants and small children)
- Provides only brief, bridging stabilization for definitive surgical airway management (e.g. 25 minutes)
III. Protocol: Preparation
- Adapter off the top of a 3-0 uncuffed ET Tube (some recommend top of a 7-0 ETT)
- Meconium aspirator tube may also work
- Obtain two 3 cc syringes (one attached to angiocatheter)
- 12 to 14 gauge angiocatheter attached to a 3 cc syringe (plunger still in)
- Attach second 3 cc syringe (with plunger out) to adapter acquired as above
- Ambu-bag or other bag-valve mask ventilation system attached to oxygen supply
IV. Protocol: Technique
- Sterile technique as possible (prepare with Betadine or Hibiclens)
- Angiocatheter inserted at cricothyroid membrane
- Apply back pressure to plunger while inserting needle
- Insert at 90 degrees, perpendicular to cricothyroid membrane (or very minimally angled toward torso)
- Remove needle and attached syringe (leaving angiocatheter in place)
- Adapter attached to 3 cc syringe to angiocatheter
- Ambu-bag attached to adapter, and initiate bag masking
- Secure angiocatheter (as much as possible without compressing tube)
V. Precautions
- Consider this technique only for failed airway where Cricothyrotomy is not possible (infants and small children)
- Clinicians who have performed this technique report significant difficulty in adequate ventilation through a 14 gauge angiocatheter
- Some case reports of 25 minutes of use to transition to Tracheostomy
- Jet Ventilator use has poor outcomes
- High risk if needle perforates posterior trachea
- Insufflation with a single breath into paratracheal space results in massive Pneumomediastinum and death
- Jet Vent use resulted in only a 25% survival
- Albeit a last ditch effort to temporize in CICO when other measures has failed
- High risk if needle perforates posterior trachea
VI. References
- Levitan (2013) Practical Airway Management Course, Baltimore
- Warrington (2016) Crit Dec Emerg Med 30(8): 14-15