Chapter 10: Other Critical Care Procedures

NEEDLE CRICOTHYROTOMY

This procedure involves the creation of a communication between airway and skin via the cricothyroid membrane. An over-the-needle catheter is then passed through the membrane. This procedure provides a temporary secure airway to oxygenate and ventilate a patient in severe respiratory distress when less invasive measures have failed or are unlikely to be successful.

A high pressure gas source such as Jet Ventilation or percutaneous transtracheal ventilation (PTV) is then used to deliver oxygen to the lungs through the catheter. The gas source attaches to the inserted catheter through an improvised device. One can attach the catheter to a 3-mL syringe with the plunger removed and then attach the syringe to the proximal connection piece of a 7.5-mm internal diameter endotracheal tube (Figure 10-1). Alternatively, one can insert an endotracheal tube into the barrel of the 3-mL syringe and inflate the cuff.

Needle cricothyrotomy is considered preferable in children less than 12 years of age because of the membrane's small size and close proximity of vascular structures

Advantages over tracheostomy:

• Simplicity

• Speed

• Bloodless field

• Minimal training required

• Avoidance of hyperextension of neck

Indications:

• Inability to intubate

• Inability to ventilate

• Rescue laryngeal mask airway cannot be inserted/passed

Contraindications:

• Injury to larynx with damage to cricoid cartilage

• Laryngeal fracture

• Tracheal rupture

• Relative contraindications include anterior neck swelling that distorts anatomic landmarks, anatomic anomalies that distort the larynx or trachea, and bleeding disorders.

• In most cases, the need for securing an airway will outweigh the risks involved in this procedure.

TECHNIQUE

1. Position patient supine with neck extended, if possible

2. Identify surface landmarks: thyroid cartilage, cricoid cartilage, and cricothyroid membrane (Figure 10-2)

3. Clean and sterile drape (universal precautions)

4. If time, inject 1% lidocaine into the skin, through the cricothyroid membrane and into airway, to anesthetize the airway and suppress the cough reflex

5. Palpate landmarks; fix thyroid cartilage with the first and third fingers of the nondominant hand, leaving the second finger to locate/palpate the cricothyroid membrane

6. With the dominant hand, pass a 12- or 14-gauge intravenous cannula attached to a syringe filled with sterile saline through the membrane, angling the needle caudally or inferiorly at 45-degree angle (Figure 10-3)

7. Apply negative pressure to the syringe; if in the trachea, escaping air should create air bubbles in the syringe

8. Advance the cannula and remove the needle

9. Secure catheter

10. Attach Jet ventilator and ventilate at 15 L/min

11. Monitor adequacy of ventilation by chest wall movement and breath sound auscultation. Can also interpose ETCO₂ in the circuit to monitor exhalation

• Complications:...