Airway - Cricothyroidotomy (needle)

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We outline an approach using equipment available in all emergency departments

Regular physical practice of your chosen method is recommended

Unfamiliar equipment is best avoided in an emergency

Indications

Inability to oxygenate and ventilate by other means (BVM, LMA, ETT)

and

Age under 10 years

Contraindications (absolute in bold)

Tracheal rupture or transection

Laryngeal fracture

Alternatives

Bag valve mask ventilation

Laryngeal mask airway

Intubation

Surgical cricothyroidotomy

Tracheostomy

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Coughing

Failure (incorrect position, blockage, kinking, dislodgement and surgical emphysema)

Neurovascular, oesophageal and laryngeal injury (cord, tracheal)

Bleeding (with potential aspiration)

Barotrauma (pneumothorax and acute lung injury)

Hypercapnia

Infection

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: non-sterile gloves, aprons, surgical mask and protective eyewear or face shield

Area

Resuscitation bay

Staff

Procedural clinician

At least one assistant

Equipment

5ml Luer syringe containing 2ml sterile water or saline

5ml Luer lock syringe

16-18g non-safety cannula

Oxygen tubing and supply

Tape to secure cannula

Positioning

Patient supine with neck extended and held midline by assistant

Procedural clinician lateral to patient with dominant hand towards head (patient’s left side if right-handed)

In children, the laryngeal prominence (thyroid cartilage) is not developed. Palpate the trachea above the suprasternal notch and move superiorly until the prominence of the cricoid cartilage is felt. The needle should be placed just above the cricoid cartilage in the midline. Consider marking membrane and infiltrating with lignocaine and adrenaline after induction for predicted difficult intubations.

Medication

2ml lignocaine 1% with adrenaline (1:100,000)

Sequence (needle cricothyroidotomy)

Brief team ‘I’m performing a needle cricothyroidotomy now’ and allocate roles

Identify cricothyroid membrane

Connect the 5ml syringe with 2ml water to the non-safety cannula

Stabilise larynx with thumb and middle finger of non-dominant hand ‘laryngeal handshake’

Palpate cricothyroid membrane with index finger

Insert cannula into cricothyroid membrane caudally at 30-45 degrees from skin with dominant hand

Advance cannula applying negative pressure to syringe until bubbles appear confirming intratracheal placement

Anchor the needle and advance cannula over needle into airway, until hub rests on skin surface

Remove the needle and syringe

Connect the second 5ml syringe to the cannula and aspirate tracheal air to 5ml to re-confirm position

Perform jet insufflation (below)

Allocate an assistant to hold the cannula hub at the skin until a definitive airway is placed

Secure cannula hub at skin with tape after first inflation and place NPA and OPA to aid exhalation

Sequence (jet insufflation)

Allocated assistant continues to hold cannula hub at skin

After aspiration of 5ml tracheal air with syringe, remove plunger from syringe

Turn on oxygen attached to oxygen tubing at 1l/min/year of age maximum (10l/min)

Place oxygen tubing deeply into secured syringe without plunger (syringe helps transfer pressure to cannula)

Inflate for 2-4 seconds, watch for chest rise then remove oxygen tubing from syringe

Observe for 20 seconds, noting improvement in saturations

Further inflation of two seconds when saturations fall 5% from maximum reached

Sequence (failure to aspirate air on insertion)

Repeat insertions progressing laterally and alternating side until you have five punctures

Vertical cut down through skin with finger dissection to larynx or trachea followed by repeat puncture

Post-procedure care

Urgent anaesthetic and ENT assessment for definitive airway

Dedicated team member continues to hold cannula at hub until definitive airway placed

Provide ongoing sedation and paralysis

Monitor for barotrauma (pneumothorax) and failure (blocking, kinking, dislodgement)

Document after definitive airway placed (completion, complications)

Tips

Avoid safety cannulas that cannot be connected to a syringe

If cricothyroid anatomy uncertain or injured aim for palpable tracheal rings with identical technique

Wall oxygen can easily cause barotrauma, avoid prolonged inflation

Jet insufflation may be possible for hours despite hypercarbia (unless total upper airway obstruction)

In complete upper airway obstruction, inspiratory to expiratory ratios greater than 1:8 are required to reduce risk of barotrauma

Ultrasound may be used in preparing to intubate a difficult airway to locate the cricothyroid membrane

Discussion

Needle cricothyroidotomy is preferable to surgical cricothyroidotomy in infants and children as the cricothyroid membrane is small and undeveloped at a younger age. This makes a needle procedure anatomically easier to perform with less potential damage to the larynx and surrounding structures.

There is no clear evidence on the age cut off for transitioning from a needle to a surgical cricothyroidotomy, expert consensus guidelines most commonly suggest age ranges from 10-12 years old. The size of the child is probably more important than the age.

The cricothyroid membrane has a mean height of 2.6mm (SD: 0.7) and width of 3mm (SD: 0.6) in neonatal cadavers (mean height of 44.9cm and a mean weight of 2kg). This suggests an 18g cannula is still appropriate in this age group.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323‐352. doi:10.1016/j.bja.2017.10.021

Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827‐848. doi:10.1093/bja/aev371

Greater Sydney Area Helicopter Emergency Medical Service. Prehospital emergency anaesthesia manual. (Ver.3.) Sydney: NSW Ambulance; 2017. Available from: https://nswhems.files.wordpress.com/2018/06/prehospital-emergency-anaesthesia-manual-3-01.pdf

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Walls RM, Murphy, MF. Manual of emergency airway management. (4th ed). Philadelphia PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.

Begley JL, Butson B, Kwa P. The emergency surgical airway. Emerg Med Australas. 2017;29(5):570‐575. doi:10.1111/1742-6723.12850

Sakles JC. Emergency cricothyrotomy (cricothyroidotomy). In: UpToDate. Waltham (MA): UpToDate. 2020 Apr 23: Retrieved May 2020. Available from: https://www.uptodate.com/contents/emergency-cricothyrotomy-cricothyroidotomy

Chrimes N. The vortex approach to the difficult airway. 2016. [Cited Feb 2017.] Available from: http://vortexapproach.org

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