Procedure

Needle Cricothyrotomy

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Needle Cricothyrotomy, Percutaneous cricothyroidotomy, Percutaneous Translaryngeal Ventilation, Transtracheal Jet Ventilation

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