Note that this technique is preferred as it requires no specialized equipment and can be performed quickly relative to other techniques
Identify landmarks as in other techniques
Prep the neck as in other techniques
Stabilize larynx with left hand
Make a 4 cm vertical incision at neck midline over cricothyroid membrane
Palpate cricothyroid membrane with left index finger
Make a horizontal incision into the cricothyroid membrane and dilate using finger or scalpel
Insert left index finger into trachea
Pass bougie over left index finger into trachea
Pass endotracheal tube over bougie just until balloon is no longer visible
Inflate balloon
Secure tube and confirm placement as with other techniques
Identify the Landmarks
Starting at the Sternal Notch, palpate superiorly until the Laryngeal Prominence is felt. The Cricothyroid Membrane will be approximately one fingerbreadth below this.
If not palpable with the prior method, place four fingers longitudinally across the neck with the 5th finger on the Sternal Notch. The Cricothyroid Membrane will be below your Index finger.
Prepare the Neck
Clean the neck with antiseptic. If time allows, infiltrate the skin and soft tissue with Lidocaine.
Stabilize the Larynx
Note: This is ESSENTIAL to success.
With the thumb and middle finger of the non-dominant hand, grip the posterolateral aspects of the Larynx, while leaving your index finger free to re-palpate the Cricothyroid membrane at any time.
Incise the Skin
With your dominant hand, make a 3.5 cm midline VERTICAL incision over the membrane.
Re-identify the Membrane
Use the non-dominant index finger to again relocate the membrane.
Incise the Membrane
Make a 1 cm HORIZONTAL incision on the lower edge of the membrane.
Note: The Cricothyroid vessels lie on the superior edge of the membrane. Making a lower incision helps avoid these vessels.
Aim the scalpel caudally to avoid injuring the vocal cords.
Once you have made the incision, slide the index finger of your non-dominant hand into the incision so as to not lose the opening.
Insert the Tracheal Hook
With your dominant hand, insert the hook TRANSVERSLY. Then, rotate it 90 degrees, so that the hook is oriented cephalad and lift the Larynx upward and cephalad. The hook may now be switched to your non-dominant hand or held by an assistant (preferable).
Insert the Trousseau Dilator
With your dominant hand, insert the dilator into the incision and GENTLY enlarge the incision in a vertical direction.
Remove the dilator place the tracheostomy (or endotracheal) tube over your finger and into the opening.
Note: A gum elastic bougie may be used in place of the above tubes.
Inflate the cuff and confirm placement.
Starting at the Sternal Notch, palpate superiorly until the Laryngeal Prominence is felt. The Cricothyroid Membrane will be approximately one fingerbreadth below this.
If not palpable with the prior method, place four fingers longitudinally across the neck with the 5th finger on the Sternal Notch. The Cricothyroid Membrane will be below your Index finger.
Clean the neck with antiseptic. If time allows, infiltrate the skin and soft tissue with Lidocaine.
Note: This is ESSENTIAL to success.
With the thumb and middle finger of the non-dominant hand, grip the posterolateral aspects of the Larynx, while leaving your index finger free to re-palpate the Cricothyroid membrane at any time.
With your dominant hand, make a 3.5 cm midline VERTICAL incision over the membrane.
Use the non-dominant index finger to again relocate the membrane.
Make a 1 cm HORIZONTAL incision on the lower edge of the membrane.
Note: The Cricothyroid vessels lie on the superior edge of the membrane. Making a lower incision helps avoid these vessels.
Aim the scalpel caudally to avoid injuring the vocal cords.
With your dominant hand, insert the hook TRANSVERSLY. Then, rotate it 90 degrees, so that the hook is oriented cephalad and lift the Larynx upward and cephalad. The hook may now be switched to your non-dominant hand or held by an assistant (preferable).
With your dominant hand, insert the dilator into the incision and GENTLY enlarge the incision in a vertical direction.
Note: A gum elastic bougie may be used in place of the above tubes.
Surgical cricothyrotomy
Needle cricothyrotomy
Pulmonary antibiotics
Surgical airways
Advanced airway adjuncts
Nasal intubation
Bag valve mask ventilation
Airway pressure release ventilation