Cricothyrotomy and Transtracheal Jet Ventilation 111 - Fig

C 110 II ● RESPIRATORY PROCEDURES step in any critical care algorithm. care critical any in step first the invariably is airway what the securing used, of is technique Regardless cricothyrotomy. used with sometimes interchangeably are cricothyroidotomy and laryngotomy, cricothyrostomy, as such terms Other membrane. cothyroid cri the to inferior rings tracheal the is of two airway between the gained to access that in techniques other the of both implies, name the As attached. be to apparatus ventilation a allow to membrane cricothyroid the of puncture needle percutaneous via catheter a of insertion the opening in the airway. maintain to used is tube ET modified or tube tracheostomy a anatomic the cricothyroid membrane is incised with a scalpel blade and other with those and patients restrictions. obese in impossible nearly be can and successful, always not areprocedures, easy not are airway.the to access gain to skin overlying the through puncture membrane cricothyroid entail (TTJV) ventilation jet transtracheal percutaneous and cricothyrotomy surgical emergency.airway an accompany that conditions to perform this procedure under the most stressful and chaotic when the circumstances arise, the ED clinician may be required “Adam’s apple.” The internal aspect of the anterior body of body anterior the of aspect internal the The as “Adam’sapple.” known commonly is and males is in which pronounced prominence, more laryngeal the form to midline the in angle acute an at join that laminae lateral two of consists lage carti thyroid The it. to superior cartilage thyroid prominent to location ideal airway.the access an it making subcutaneous, is portion lar triangu central the but muscles, cricothyroid the by covered The cartilage. lateral aspects of the cricothyroid cricoid membrane are partially the by inferiorly and cartilage thyroid the midline in and the neck. The membrane is bordered superiorly anteriorly by located membrane elastic an is which brane, The central structure of importance is the cricothyroid mem ANATOMY required, rarely is airway surgical the Although intubation. (ET) endotracheal traditional through controlled be cannot that patient’sairway a than clinician (ED) department gency emer the of mind the in concern more evoke situations Few Mace E. Sharon and Bose, Sudip Hebert, B. Randy Ventilation TranstrachealJet and Cricothyrotomy cricothyrotomy refers to the technique in which in technique the to refers cricothyrotomy Surgical Both resort. last of procedure a is cricothyrotomy Often, R E T P A H C Identify the cricothyroid membrane by first locating the locating first by membrane cricothyroid the Identify BACKGROUND

can

found Needle cricothyrotomy refers to the 6

E xpert 5 differs from differs tracheostomy

C onsult

These 1–4 - - - - - teeth with the mouth open, three fingers can be placed in the in placed be can fingers three open, mouth the with teeth lower and patient’s upper the between placed be can fingers to rule” three If intubation. for “3-3-2 oropharynx the of adequacy the assess the Use cricothyrotomy. surgical for tions rud h airway. the and around in hemorrhage or edema, macroglossia, neck, and face difficult. be the of obesity,deformity marked trauma, include clues Some may ventilation bag-mask-valve or intubation that clues external for look to moment a take intubation, for thataccurately factors atidentifying prepared being is patient the As intubation. difficult a predict attempts with filled cricothyrotomy.to laryngoscopy from shifted is attention which at point well-defined a with tory distress, the clinician must have a clear algorithm in mind tures are protected by the thyroid cartilage struc cord vocal the of attachments anterior The membrane. pyramidal aberrant an although lobe of the gland may extend just superior to the cricothyroid rings, tracheal third and The second the membrane. overlies often most the gland thyroid the to of isthmus inferior muscles cricothyroid the laryngeal superior the nerve runs along the lateral of aspect of the larynx and innervates branch external The membrane. tomotic arch traversing the superior aspect of the cricothyroid from the superior thyroid arteries and may form a small anas- nificant anatomic structures. The cricothyroid arteries branch thyroid membrane is relatively avascular and free of other sig hypoxia. surgical ongoing from incur will patient the risks the outweigh airway the of benefits the and futile become intubation at techniques. intubation alternative However, at some try point, it becomes clear to that further attempts or times multiple intubate to attempt to appropriate be may allow,it situation less invasive measures have failed. When the time and clinical until attempted be not should and complications significant above the sternal notch. sternal the above fingerbreadths four or prominence 3 laryngeal the to to 2 inferior about at membrane cricothyroid the the of estimate location swelling, tissue soft by obscured is depression 9 about ously mentioned structures as a shallow depression measuring cartilage. cricoid a the form to laterally tapers narrow anterior arch. The tracheal rings descend that inferiorly to segment posterior broad a of composed is It larynx. the of structure cartilaginous ential cricothyroid membrane and is the only completely circumfer foramina. laterally located its through nerve laryngeal superior the of branch internal the and vessels laryngeal superior the of passage the for allows which membrane, thyroid the is bone hyoid the to vocal it connecting and cartilage thyroid the the to Superior ligaments. for attachment the provides cartilage thyroid the with impending or ongoing hypoxia. ongoing or impending with ity to secure the airway by noninvasive techniques in a patient The chief indication for surgical cricothyrotomy is the inabil Contraindications and Indications CRICOTHYROTOMYSURGICAL h aetei ad mrec mdcn ltrtr are literature medicine emergency and anesthesia The The area overlying and immediately adjacent to the crico Surgical cricothyrotomy,Surgical has procedure, invasive any like Identify the cricothyroid membrane between the previ the between membrane cricothyroid the Identify the of border inferior the forms cartilage cricoid The

20 m longitudinally mm In summary, when approaching a patient in respira 21–24

s ls o rltv indica- relative of list a is Table 6–1 14–16 n 30 and

m transversely mm 19 17,18 (Fig. 6–1 ). I the If .

cm ------

6 ● Cricothyrotomy and transtracheal jet ventilation 111 - Fig. 6–2). Class II Class IV classes. Cricothyrotomy

Surgical

for

Modified Mallampati

Indications

concluded that the higher the score, the more Figure Figure 6–2 Class I Class III 26 Oropharyngeal Oropharyngeal edema Laryngospasm Mass polyp, effect tumor, web, (cancer, or other mass) Oropharyngeal edema Foreign body obstruction Laryngospasm Obstruction secondary to a mass effect or displacement Stenosis Massive oral, nasal, or pharyngeal hemorrhage Massive regurgitation or emesis Masseter spasm Clenched teeth Structural deformities of oropharynx (congenital or acquired) Stenosis of upper airway (pharynx or larynx) Laryngospasm Mass polyp, effect tumor, web, (cancer, or other mass) Nontraumatic Traumatic Maxillofacial injuries Cervical spine instability Laryngeal surgery Oral surgery Maxillofacial surgery Laser surgery Bronchoscopy difficult or potentially hazardous (relative) upper airway Failure Failure of oral or nasal endotracheal intubation Airway obstruction (partial or complete) injuries Traumatic making oral or nasal endotracheal intubation Need for prolonged intubation Need for definitive airway during procedures on face, neck, or TABLE 6–1 TABLE soft palate, and base of the uvula can be visualized ( Mallampati difficult ET intubation would be. Unfortunately, many condi many Unfortunately, be. would intubation ET difficult tions that prohibit ET intubation also make cricothyrotomy difficult.

- A, Skin and Ary-epigottic fold Cricothyroid membrane Tracheal rings Hyoid bone Cricothyroid membrane Tracheal rings B, Muscles and cartilages of Any distance shorter than that indi that than shorter distance Any 25 C, Normal adult larynx. Anatomy of the neck. Normal adult larynx. Anatomy of the neck.

Cricoid cartilage C B A Cricoid cartilage Vocal chords Vocal Base of tongue Vallecula Epiglottis Hyoid bone Thyoid cartilage Thyoid cartilage distance from the mentum to the hyoid bone, and two fingers two and bone, hyoid the to mentum the from distance can be placed in the space between the thyroid notch and the hyoid bone, there is sufficient spaceintubation. ET perform in the oropharynx to Figure Figure 6–1 superficial landmarks of the anterior neck. the anterior neck. cates a difficult intubation.another method to assess for a difficult Use intubation. It was ini- the Mallampati tially developed score as as a preoperative examination to assess the patient’s oropharynx prior to the operating room. Ask the patient to a sit on the edge of the controlled intubation stretcher and lean in slightly forward. Ask the patient to open his or her pillars, faucial mouth the which to degree the by score as the Determine wide as possible without vocalizing. C 112 II ● RESPIRATORY PROCEDURES or 12 years 12 or years Various 5 from defined. limit age lower well the list textbooks not and controversial is done be can dren. However, chil young the and exact infants age in at contraindicated which been cricothy- a has surgical rotomy surgical cricothyrotomy larynx, pediatric funnel compliant rostral more shaped the and membrane cricothyroid smaller the anatomic differences between children versus adults including the of Because age. is contraindication absolute only the that state authors most ventilating, or oxygenating not is patient only after other techniques have been unsuccessful and/or the to 1 year, and the child airway as age 1–8 years. 1–8 age as airway child the year,and 1 to ences. cricothyrotomy. Eighteen-gauge needles bent to 90° may be used in used be may 90° to bent needles cricothyrotomy.Eighteen-gauge place of a tracheal hook. tracheal a of place 6–3 Figure material. preparation antiseptic 4 solution, towels, or drapes local for sterile epinephrine anesthesia, with lidocaine and syringe a include may tray sterile the addition, In hooks. tracheal for substitute ( tube ET modified or a blade, 11 tube tracheostomy a No. and hook, a tracheal Trousseaua dilator, with scalpel a includes surgical cricothyrotomy traditional a perform to necessary equipment The Equipment Elsevier Inc. All rights reserved.) rights All Inc. Elsevier 2008 Copyright Module. Medicine Consult —Emergency Procedures Given that surgical cricothyrotomy is often resorted to resorted often is cricothyrotomy surgical that Given B A 30 scalpel 11-blade 18 gauge over-the- ACLS and PALS define the infant airway as age up age as airway infant the define PALS and ACLS catheter needle

and A 29 4 sterile gauze, scissors, hemostats, and suture and hemostats, scissors, gauze, sterile 4 × and only one of these textbooks cites any refer any cites textbooks these of one only and 12 mL syringe Equipment required for traditional surgical traditional for required Equipment B, scalpel 11-blade hook Tracheal

and (A ). Bent 18-gauge needles may needles 18-gauge Bent 6–3). Fig. , From Thomsen T,G Thomsen Setnik From B, dilator Trousseau Melker airwaycatheter plastic housing Guidewire in tube Tracheostomy tube endotracheal Cuffed 6.0 27 to 10 years 10 to [eds]: 28 - -

tively. of diameter inner an has tube 4 No. The EDs. most in able avail- commonly are tubes tracheostomy Shiley sizes. various in come they and recommended, are size. tubes appropriate tracheostomy the Cuffed select to order in tubes ET and tomy tracheos standard several of dimensions the with yourself ize airway catheter.airway uncuffed or cuffed a place to used is technique Seldinger the which in IN) Bloomington, Care, Critical Cook Kit, rotomy Cricothy (Melker cricothyrotomy percutaneous for Kit omy Cricothyrot- Melker the include kits available Commercially technique. the of variations some in recommended 20 is No. blade a used, commonly most is blade 11 No. a although Procedure and 8.0 6.0 of diameter inner an with tubes ET tube. tracheostomy a of place in temporarily used often are tubes ET 6–4). (Fig. insertion after removed and a solid is that obturator removable and cannula, inner removable a cannula, outer cuffed the 10.8 6.4 of diameter inner an has 5.0 9 about and inner cannula. inner and 6–4 Figure steps preparatory All gown. and goggles, mask, a wearing by 10 with it the injecting by tube ET of or tracheostomy the integrity on balloon the Test anesthetic. local a as epinephrine with lidocaine of injection transtracheal and subcutaneous a give pain, to responding or awake is patient the If towels. or drapes using field sterile a create and solution antiseptic with neck anterior the of skin the Prepare ventilation. bag-mask to important is injury,it spine suspected cervical or known a has patient the the Unless with exposed. neck position supine the use feasible, When indicated. contra otherwise not if positioning aid and cooperation may patient and drive respiratory Ketamine suppress not recline. does anesthesia cannot often patients hypoxic example, For parameters. clinical on based impossible, be may positioning however,the success; in role critical a plays Positioning a sie movement. spine cal cervi- minimal with performed successfully and safely be can cricothyrotomy Surgical landmarks. the identify readily more

cc of air. Wear sterile gloves and take standard precautions mm and an outer diameter of 9.4

Given that the average adult’s cricothyroid membrane is adult’smembrane average cricothyroid the that Given mm. Shiley tracheostomy tubes come with three parts: three with come tubes tracheostomy Shiley mm. 31

Scalpel blades are also available in different sizes, and sizes, different in available also are blades Scalpel

mm have mm longitudinally mm

Standard Shiley tracheostomy tube with removable trocar removable with tube tracheostomy Shiley Standard outer diameters of 8.2 and 10.9 32 royeae h ptet y a of way by patient the Preoxygenate and 30 and

m and mm

mm horizontally mm

mm, and hyperextend the neck the hyperextend n ue daee of diameter outer an the No. 6 tube

mm, respec , familiar , ideal to - - - - - C

6 ● Cricothyrotomy and transtracheal jet ventilation 113 Continued Inset to McGill and horizontally. 12 length. cm in

emphasized the importance B, Insert the tube through the 34 35 vertical skin incision and using a relatively midline skin incision, 3–5 described the addition of a tracheal hook for vertical 33 membrane A, Rotate the dilator 90° Cricothyroid 4 thyroidotomy thyroidotomy by Brantigan and Grow in 1976. coworkers of making an initial small (No. 4 Shiley) tracheal tube. These generally been accepted and modificationsare commonly described as have part of the traditional technique. emergency emergency cricothyrotomy in 1982. In a follow-up report in 1989, Erlandson and associates Step 1: Immobilize the larynx and palpate the cricothyroid membrane with

- vertically. Step 6: Fig. ). 6–5 This technique has horizontal, and expand the incision vertical. Step 4: Insert the tracheal hook and have an assistant provide upward traction. Step 5: Insert the (From Custalow CB: Color Atlas of Emergency Department Procedures. Philadelphia, Elsevier Saunders, 2005.)

1 C, Keep the thumb on the obturator throughout the procedure. Step 7: Remove the Step obturator. 8: Replace the inner 2 Inset to step 1: As an option to guide subsequent advance surgery, an 18-gauge needle on a syringe into the trachea, and when Step-by-step diagram of traditional surgical cricothyrotomy. 3

blades into the trachea. step 2: Palpate the cricothyroid membrane through the skin incision to confirm Step anatomy. 3: Incise the cricothyroid membrane Note that the skin incision was dilator Trousseau with the blades cannula and inflate the tube. Figure Figure 6–5 the index finger. air is aspirated, remove the syringe and leave the needle in the trachea. Step 2: Make a Traditional Technique Traditional Most EDs use a prepackaged kit, with or without a Seldinger apparatus. the However, “traditional” (open) cricothyrotomy technique is described here ( changed little since the original description of elective crico are time permitting and depend on the urgency with which the procedure is to be performed. C 114 II ● RESPIRATORY PROCEDURES 6A 6B 7 5 Figure 6–5, cont’d6–5, Figure 6C 8 C

6 ● Cricothyrotomy and transtracheal jet ventilation 115 - - - - - cm

cm in

the tip the Insert Insert the inner cm from cm

B, Replace the adapter on Fig. 6–5 step 8). Remove , bilateral chest movement, chest bilateral , 2 Fig. 6–5 step 7). Cut proximal to the inflation device developed a rapid four-step tech- 40 A, Modify the standard endotracheal tube for use in

If a tracheostomy tube is not available, or if there is Confirm properplacement in the same manner as with 38,39 B A the Trousseau dilator (see cannula and inflate the balloon (see the puncture to not careful especially being hook, tracheal the cuff. Figure Figure 6–6 incision with a No. 20 blade scalpel approximately 1.5 length through the skin, the cricothyroid subcutaneous membrane. tissue, With and the scalpel the blade as a pick guide, up trachea. the the stabilize to direction cricoid caudal the in traction provide cartilage with the tracheal hook and ventilator. Advance the ET tube only about 5 about only tube ET the Advance ventilator. to avoid main stem intubation. Keep in mind that standard ET tubes do not have centimeter markings at the distal end. Inserting the ET tube so that the distal beyond cuff is the about cricothyroid 2 membrane usually ensures placement. proper CO end-tidal placement: tube ET surgical cricothyrotomy. surgical Cut cricothyrotomy. the proximal ET tube end but be careful not to cut the balloon inflation apparatus. the cut end of the tube. difficulty placing the tracheostomy tube into the opening in the cricothyroid membrane, try using a 6-0 cuffed ET tube cut to a shorter length. The inner–to–outer tubes. ET diameter of those ratios with comparable are tubes tracheostomy of may bougie elastic gum a or stylet tube ET semirigid a of Use facilitate the placement of an ET tube through the cricothy roid membrane into the trachea. The advantage of using the bougie is that you can get immediate confirmation that the device is inside the trachea, owing to the “washboard” vibra rings. tracheal the contacts it as makes tip curved the that tion The operator can modify the ET tube by cutting the end distal and replacing the adapter to the cut end (Fig. 6–6). careful not Be to cut the balloon inflation tube. If the ET tube is shortened, it is less likely to kink once it is attached to a nique (RFST) to decrease the amount of establish an airway and time thus reduce complications of hypoxia required to (Fig. 6–7). It combines aspects of traditional cricothyroidot omy and ET intubation. If stand you at the bedside are to the left. patient’s right-hand Palpate the depres dominant, sion over the cricothyroid membrane with the nondominant the dominant hand, make a single horizontal stab hand. With and breath sounds. Secure the tracheostomy tube with a cir cumferential tie around the neck or with postprocedure portable chest x-ray. sutures. Order a Rapid Four-Step (Brofeldt) Technique Brofeldt and colleagues

. - - - - - ° 37 . so that so Fig. 6–5 Fig. 6–5 Fig. Fig. 6–5 spreading spreading Note that the that Note Fig. 6–5 step (see length through length vertical incision mm) in this direc

rotate the handle 90 handle the rotate cm in cm C). Carefully remove 30

Fig. 6–5 step 4). Use the 36 step 3). step 6–5 Fig. insert the obturator, take the tube insert it between the blades of the Fig. 6–5 step 5). It is important to Fig. 6–5 step 6 incision of less than 1.0 than less of incision B). Keep the thumb on the obturator through When air is obtained, disconnect the syringe and leave and syringe the disconnect obtained, is air When no need to dilate the incision horizontally because the At this juncture, At an this option juncture, is to enter the trachea through horizontal inset). It is important to understand that the remainder Dilate the incision vertically with the dilator. Trousseau With the dominant hand, place the tips of the Trousseau the With dominant hand, place the tips of the Trousseau Using the dominant hand, place the tracheal hook into If you are right-hand dominant, stand on the patient’s Holding the scalpel with a No. 11 blade in the dominant skin incision is vertical, but exchange to the momentarily stoma membrane the incision into finger is index the horizontal Place the scalpel for the tracheal hook. the cricothyroid membrane (see membrane cricothyroid the tion. Hold on to the handles of the and upward palm hand, nondominant Trousseau dilator the with until the handle is vertical or parallel to the step neck 6A). Perform this rotation because, if the dilator is still horizontal, the blades of the dilator prevent passage trachestomy tube into of the trachea. Prepare the tracheostomy the tube by testing the balloon, removing the inner cannula, and While inserting holding the the solid dilator white obturator. with the nondominant hand, in the dominant hand and dilator until the flanges rest against the skin of theneck (see Fig. 6–5 step 6 out the procedure (see There is cricothyroid membrane is the widest (∼ tion or provide traction yourself by passing the handle of the hook to the nondominant hand (see tracheal hook to stabilize the throughout the larynx remainder of the procedure. and keep it in place dilator into the opening in the membrane with the the opening in the cricothyroid inferior membrane border and of the grasp thyroid the cartilage with handle cephalad and ask it. an assistant to Rotate provide upward trac the plane vertical or longitudinal the in initially oriented action the handle is facing horizontally or direction perpendicularly of the neck to (see the note that this instrument works opposite to instruments, such as hemostats, so that when you squeeze the most ordinary handles, the blades open rather than close. This can be con the larynx throughout the procedure by stabilizing it in this manner. the membrane with an 18-gauge needle on a syringe (see fusing the first time you try to use the instrument; it is worth practicing before you need it in an If emergency. this instru scissors, Mayo a emergency, an in you to available not is ment a hemostat, or even the blunt end of a scalpel handle can be used to dilate the incision in the cricothyroid membrane. right side. Stabilize the larynx with the nondominant hand by hand nondominant the with larynx the Stabilize side. right grasping both sides of the lateral thyroid cartilage with thumb the and middle finger. Palpate the cricothyroid depression over the membrane with the index finger. Control inset). 1 step the needle in place as a guide to further surgical procedures hand, make an approximately through the 2- skin and subcutaneous tissues to (see 3-cm 2). With the index finger of the nondominant hand,palpate (see incision the through membrane cricothyroid the step 2 of the procedure should be performed by not visualization, because bleeding may obscure the anatomy, palpation of the field and there is no timepalpated, be cannot membrane cricothyroid the If hemostasis. to delay while trying to achieve extend the initial incision superiorly and inferiorly and try to palpate again. Using the stabilizing index fingeras a make a guide, C 116 II ● RESPIRATORY PROCEDURES advanced inside the trachea. the inside advanced is it as device the of feeling) (washboard feedback immediate the and placement of ease the previously,is noted as the bougie, using of advantage The motion. twisting a with bougie the over tube the railroad Then first. trachea the into ducer) smaller the through incision. Try tube advancing a gum elastic bougie (or similar intro tracheostomy the passing is tion tube through ET the opening. cuffed 6-0 a or tube tracheostomy cuffed 4 No. a Place the cricothyroid membrane with a needle more difficult. more needle a with membrane cricothyroid the skin initial no locating make will distortion Anatomic made. be will incision because identify to easy be must membrane cricothyroid TTJV, the with cricothyrotomy needle or tion intuba retrograde to Similar tube. tracheostomy a of lieu in catheter airway Melker a and dilator, tapered a guidewire, a tetrafluoroethylene overlying kits), some in included not catheter TFE (the catheter (TFE) an with needle 18-gauge an syringe, 6-mL a with supplied comes kit The 6–9 ). (Fig. wire guide a over tube tracheostomy a place to technique Seldinger the employs that kit commercial prepackaged a is IN) ington, The Melker Cricothyrotomy Kit (Cook Critical Care, Bloom TechniqueCricothyrotomy Percutaneous Melker 6–8). (Fig. cadavers in fractures ring cricoid of incidence the in decrease By a found they hook, hook. double the with hook single the replacing single the of instead device double-hook a of use the and patient the of side the to of instead bed four-step the of head the the to at stand operator the similar that advocating for is except method technique The hook. tracheal the replace to Claw” “Bair a called device new a introducing C A Bair and coworkers and Bair 41 modified this technique further by further technique this modified 40 The hardest part of this modifica D B - - - - - distal trachea to its hub. If the needle does not have an overly and needle and advance the flexible TFE catheter through the saline. the in appear will bubbles and syringe the into aspirated be will When the membrane is pierced and the trachea is entered, air syringe. the advancing while pressure negative gentle Apply procedure. the before syringe the in saline of amount small a place entered, been has trachea the when Torecognize help because this may result in perforation of the posterior trachea. far too needle the advance to not careful Be surface. skin the to relative angle 45° a at caudally it pointing membrane, roid cricothy the through it insert and syringe the to needle the membrane cricothyroid with the nondominant hand. the With the dominant hand, attach Palpate techniques. other the When the needle is in the trachea, pull back the syringe the back pull trachea, the in is needle the When of that to similar is technique this for preparation The Figure 6–8 Figure Technique. Traction. Figure 6–7 Figure Emerg Med 3:1060, 1996.) 3:1060, Med Emerg Technique.Four-StepAcad Rapid The approach: cricothyrotomy easy An JR: Richards EA, BT,Brofeldt Panacek from

Bair Claw. Bair D,

Palpation. A, Intubation. Rapid Four-StepRapid

, Redrawn (A–D, Incision. B, C, - - C

6 ● Cricothyrotomy and transtracheal jet ventilation 117

- - 33,45 43 —Emergency Medicine The most frequent complications are (Fig. ). 6–10 [eds]: Procedures Consult 34 42 and 40%. 44 Regardless of which surgical technique is used, surgical Melker kits on the market differ with respect to airway uncontrollable bleeding and misplacement of the tube. Complications performed, infrequently is cricothyrotomy surgical that Given under circumstances that are inherently chaotic, on a patient population who frequently has confounding medical and issues high morbidity and mortality short- and rates, long-term complications is difficult. the evaluation of dure and short-term complications occur with significant fre- between reported been have rates complication Acute quency. 8.7% sion longitudinal as in the traditional technique and maintain cricothyrotomies have been studied to assess what periproce Most bleeding is from small superficial vesselscontrolled. Bleeding and leading to can be significant hemorrhage can also occur as a result of the procedure. The cricoid arteries branch from the superior thyroid arteries and anastomose at the anterior superior aspect of the cricothyroid often more are arteries thyroid membrane. superior running laterally The damaged when the initial incision is broad and horizontal. To prevent hemorrhage from these vessels, make the initial inci until it is flush against the neck. Remove the guidewire and Secure dilator. the kit in place with “trach tape.” catheter inner diameter and whether the airway catheter cuffed is or not. Some kits do overlying catheter not contain a needle with an B D (From Thomsen Setnik T, G

(Courtesy of Cook

A–D, Percutaneous Seldinger technique cricothyrotomy using a a catheter, wire placed into the trachea, and a dilator/tube advanced C Melker Kit with Seldinger technique. A

Place the gray-tipped dilator into the airway catheter and catheter airway the into dilator gray-tipped the Place Critical Care, Bloomington, IN.) over a guidewire. Make a skin incision to allow passage of the dilator. Figure Figure 6–10 Figure Figure 6–9 thread it over the wire as one unit. Once it is through the skin the through is it Once unit. one as wire the over it thread and into the trachea, advance the airway catheter to its hub ing catheter, leave the needle in place and remove the syringe. syringe. the remove and place in needle the leave catheter, ing Thread the guidewire through the needle Once or the the guidewire catheter. is in place in needle or With catheter. a the disposable No. 15 trachea, scalpel, make a remove the small incision in the skin at the point at which the guidewire enters to facilitate catheter. passage of the dilator and airway Module. Copyright 2008 Elsevier Inc. All rights reserved.) C 118 II ● RESPIRATORY PROCEDURES f rctyoois I ws ae rftd y rnia and Brantigan study by Grow’s1976 refuted later was It cricothyrotomies. of that subglottic stenosis was a major and frequent complication uh s an tm rnha intubation, bronchial stem main as such reported less frequently or have been described in case reports unrecognized. if death and hypoxia to lead thus and airway the are enter not locations do that crucial those most the but trachea, or larynx the as location other than through the cricothyroid membrane, such placement of the Mis tube airway.during cricothyrotomy may the refer to any reassess and tube the remove suspected, If by auscultation should alert the physician to a misplaced tube. tl t peet h dvlpet f yoi. n addition, In hypoxia. CO end-tidal detect to of failure development the prevent to ately immedi this recognize to to essential is It patient. the ventilate attempting when emphysema subcutaneous of presence into the subcutaneous tissue, which may be recognized by the stabilized carefully not inserted inadvertently be may tube the procedure, the during are larynx and membrane thyroid crico- the in openings the If intubation. ET with concern a is intubation esophageal as just concern, a is cricothyrotomy during tube ET or tube tracheostomy the of the Misplacement avoid membrane, cricothyroid aspect. inferior its at membrane the incising by artery cricoid the in incision zontal (Table6–2). ates careful awareness of the landmarks. the of awareness careful corroborated their findings that chronic subglottic stenosis is stenosis subglottic chronic that findings their corroborated the Since have studies other numerous report, latter this complication. of publication long-term a as stenosis subglottic chronic of occurrences no also but 6.1% just of rate plication ostomy tube with blood or secretions. injury, TABLE6–2 Late complications Late complications early or Immediate Infrequent complications Infrequent common Most Infrequent Common 51 ay te mr ocl cmlctos ae been have complications occult more other Many Chevalier Jackson’s 1921 report reported one case of retrograde pharyngeal intubation pharyngeal retrograde of case one reported Tracheomalacia Tracheoesophagealfistula stenosis glottic or Subglottic throat the in lump of feeling Subjective stoma Persistent bleeding Late Infections dysphonia or changes Voice problems Obstructive Aspiration cartilage laryngeal of disruption or fracture Laryngeal injury cordVocal pneumomediastinum Pneumothorax, perforation Mediastinal perforation Esophageal Obstruction emphysema Subcutaneous time procedure Prolonged placement tube Unsuccessful placement tube Incorrect hematoma Bleeding, 48 tension pneumothorax, tension

Complications 13 that reported not only an overall com overall an only not reported that

2 of and absence of breath sounds breath of absence and 49

and clogging of the trache- the of clogging and Surgical 46 11 When making the hori the making When highlighted the concern 50 Slobodkin and associ

Cricothyrotomy 47 laryngotracheal - - - - - ahlg, rlne tm t dcnuain od g, and age, laryngotracheal old diabetes. decannulation, to predisposing time prolonged include pathology, stenosis subglottic complication rate. A study by Holmes and coworkers and Holmes by study A rate. complication lower a produced technique traditional the that concluding cartilage, cricoid the on traction cephalad for used was hook an increased incidence of cricoid ring fracture when the single n nrqet ogtr cmlcto o sria cricothyrotomy. surgical of complication long-term infrequent an breathing.” “noisy and infection, wound breath, of swallowing, shortness subjective with difficulty include complications reported each individual technique as your guide. your as technique individual each availability, and finally, your own comfort and familiarity with equipment scenario, clinical the technique, each of vantages disad and advantages the consider cricothyrotomy, surgical anatomy.and techniques the with familiar being and field sterile a maintaining by reduced be sive procedure in emergency medicine, complication rates can inva- any with As them. of fear of out procedure the forming per delay to not but occur do they if prepared be to order in complications potential hypoxia. the of aware be prolonged should clinician The by caused those with compared minor traditional five-step technique, Davis and colleagues and Davis the technique, airway.five-step with traditional RFST the colleagues’ secure and Brofeldt to comparing needed When time and rate complication to regard with superior is techniques the of one any whether determine to attempted have researchers emergency, airway an to inherent factors other and hypoxia prolonged with ated hn h Sligr method, Seldinger the than ht h Bi Ca dd o cue n ciod atlg frac cartilage tures. cricoid any observing cause not further did Claw Bair comparable, the that was rate complication the that and RFST the using that faster secured be showed could airway the study revised The Claw. Bair double-hooked the with RFST the in hook single study,the later replacing a nificance. Davis and associates and Davis nificance. sig statistical reach to failed rates complication in difference the that but RFST the using complications more were there that noted They technique. traditional the than faster cantly signifi cadavers executed was human RFST single-hook the on that concluded residents and students medical inexperi by enced performed as techniques two same the paring tep: 0 sces o al D nuaos nldn resi including first intubators (for ED all high for quite success 90% are attempt: intubations ED for rates Success Rates Success mnr iwy rbes hv be rpre mr frequ stenosis. more subglottic than ently reported been have problems” airway “minor jective voice change is the most frequently reported. frequently most the is change voice jective opposite. nique. the traditional technique is compared with the Seldinger tech when rate complication or ventilation to time between ence percutaneous the differ no show studies with Some method. kit) (Melker Seldinger method traditional the comparing the of rate technique. traditional the with compared complication when RFST lower a showed cricothyrotomy hn eiig hc tcnqe o s t prom a perform to use to technique which deciding When relatively seem cricothyrotomy of complications Many In order to decrease the morbidity and mortality associ mortality and morbidity the decrease to order In in resulting complications long-term of Occurrences Similarly, consensus cannot be drawn from the literature the from drawn Similarly,be cannot consensus 62 64 Bair and colleagues’ own retrospective report retrospective own colleagues’ and Bair Some studies report that the surgical method is faster 52–56 57,58 69 61 Factors that increase the likelihood of developing 65–68 59 62 Of these complications, sub complications, these Of revisited this comparison in comparison this revisited n ohr cnld the conclude others and 63 60 48 36 of ED of Other found com------

6 ● Cricothyrotomy and transtracheal jet ventilation 119 ------Case 77 Commer 81 The operator 80 An inherent problem with this setup is 82 and increased lung volumes. 78 2 With regard to an emergent airway situation, 79 74–76 Commercial kits are available, but a standard 12- or 14- There are two different basic means, and thus two differ two thus and means, basic different two are There As mentioned previously, surgical cricothyrotomy is con is cricothyrotomy surgical previously, mentioned As Absolute contraindications to needle cricothyrotomy in may, therefore, may, elect to perform a surgical cricothyrotomy if this situation presents itself. Equipment The essential materials needed for TTJV include with an a overlying catheter, oxygen needle tubing, an oxygen source connect to means a and pressure, the regulate to means a with the apparatus together. gauge angiocath attached to a 3- or 5-mL syringe normally found in the ED can be used to make the puncture through the cricothyroid membrane; then the catheter can be left in place to serve as the conduit for oxygen The delivery. larger the diameter of the the catheter, greater the oxygen flow will be, depending on the method of oxygen delivery. that the whole system is rigid. catheter itself Although is the flexible, there transtracheal is no flexibility orthe give hub from of the catheter to the bag. Thus, slight movements of the bag relative to the patient may cause dislodgment the of catheter. To ameliorate this obstacle, connect cath transtracheal the to standard directly tubing infusion intravenous cial catheters such as wire-coiled nonkinking catheters fenestrated and catheters are available as part of prearranged kits (Fig. 6–11). Larger-caliber 3.0- to 4.0-mm interior diameter percutaneous tracheal catheter devices are also available. ent armories of equipment to choose from, to deliver oxygen stan a use method, one In catheter. transtracheal the through dard ventilation bag to supply oxygen through This requires the the constant efforts needle. of manual bag insufflation as long as the patient is being oxygenated and ventilated this way. Attach the bag to the adapter inserted into of the a back 7.0-mm of ET a tube plungerless nected to the 3-mL transtracheal attach catheter. Alternatively, the syringe con bag directly to the catheter with pediatric the ET adapter tube. of a 3.5-mm plete upper airway (oropharyngeal) obstruction may be con sidered a contraindication to needle cricothyrotomy because there is nowhere for exhaled gas to escape, thus leading to a buildup of CO traindicated in infants and young children. The contraindication arises from the fact that the cricothyroid membrane too small is to insert a tracheostomy tube and there is a signifi cant risk of injury to the surrounding structures. Therefore, needle cricothyrotomy is the preferred method of securing the airway in crash airway situations children. in infants and young adults include transection of the distal trachea, because the airway would need to be established below this Com injury. and neck surgeries owing to the fact that the smaller ventila tion catheter provides a relatively unobstructed fieldto work around. reports describe TTJV to be relatively more invasive indicated surgical cricothyrotomy over when the ET intubation Provid secretions. oropharyngeal copious to owing failed has ing temporary ventilation through the needle catheter may allow sufficient time to clear the upper airway of secretions an establish to time more operator the giving obstructions, or ET intubation. needle cricothyrotomy has been shown bridge to to be establishing a an successful airway via the ET route.

------In 0% 63 The 70 trans- 72 One of 24,43,71 63,72 24,33,34,43,50,53,63,71 For pediatric 3 In an animal model, 64 means that oxygen is admin is oxygen that means ventilation Jet and 32% to 38% for flight nurses. 53 to one of shorter bursts of oxygen flow followed to one with earlier ED studies in the 7.9% to 10% 73 63 66 In the prehospital setting, the reported cricothy 33,34 The success rate for cricothyrotomy similarly has been incidence of failed cricothyrotomy (e.g., the tube is misplaced is tube the (e.g., cricothyrotomy failed of incidence into pretracheal space/failed attempts) is 3.6% in the ED in one study, bators is slightly less at 85% with a performed less than rescue 1% of the cricothyrotomy time (1 of 156 patients). patients, the success rate for the first attempt for all ED intu gical cricothyrotomy in adults based on the operator’s experi- gical cricothyrotomy in adults based on the operator’s ence. Much of the otolaryngology literature supports the use of TTJV as a means of nonemergent ventilation during head The indications and contraindications for needle rotomy with TTJV cricothy- are similar to those for surgical cricothyrotomy. Needle cricothyrotomy with TTJV can be used in place of surgical cricothyrotomy in adults in the same failed ET at attempts failed include indications Its scenarios. airway intubation with the inability to bag-mask ventilate or airway obstruction above the level of the cricothyroid Needle cricothyrotomy may membrane. be relatively indicated over sur Indications and Contraindications tomically, the cricothyroid membrane is part of the larynx and larynx the of part is membrane cricothyroid the tomically, the trachea begins at the cricoid cartilage, but the term tracheal jet ventilation is generally used to refer to supplying oxygen through the cricothyroid this membrane. terminology consistency, is used in this The chapter. use To maintain airway crash a in patient a oxygenate and ventilate to TTJV of situation differs from surgical cricothyrotomy in some ways. For the TTJV, initial needle cricothyrotomy does not differ greatly from that used for the Seldinger technique variation cricothyrotomy. of istered through a small-caliber usually catheter, on the order relatively a through than rather catheter, 14-gauge to 12- a of larger-caliber tracheostomy tube. The oxygen is method supplied by through continuous of one a from which moving years, recent the over evolved needle-inserted catheter has oxygen flow, which provided adequate oxygenation but not ventilation, TTJV TTJV is a procedure in which oxygen is delivered through a catheter inserted through the cricothyroid membrane. Ana cothyrotomy cothyrotomy performed only 0.7% of the time according to the National Emergency Airway Registry. dents, dents, 98% success rate if an attending), with a “rescue” cri for clinicians rotomy failure rates are 6% to 12% for paramedics, these studies found the incidence of tube misplacement into the pretracheal space to be 3.6% in the ED versus 31.8% for the air medical transport service at the same institution. although one study found only a 62.5% success rate. quite high (89%–100%) in most studies, tory state. by passive exhalation to resemble a more physiologic respira a cadaver, the first-time performance of cricothyrotomy by intensive care unit clinicians comparing a successful found standard technique Seldinger the surgical with cricothyrotomy tracheal placement in only 70% for the standard technique and 60% for the Seldinger technique. range. paramedics had a 90.9% success rate using technique a and percutaneous a 100% success rate with technique. the open surgical C 120 II ● RESPIRATORY PROCEDURES place it with other airway supplies for easy access. easy for supplies airway other with it place and time of ahead ED the from components appropriate the prepare available, not is kit TTJV prepackaged a If manner. ble a TTJV apparatus from individual components in a timely emer an gency situation, it is In unlikely that one would be able to ED. assem the in assembled. apparatus the already assemble Otherwise, systems prepackaged contain that able rial or trach tape in the kit. the in tape trach or rial mate- suture and gauze, sterile drapes, sterile solution, ration cricothyroid membrane has been located, insert the catheter the insert located, been has membrane cricothyroid 2 to 1 with filled syringe children. in smaller these, proportionately be between will depression this that depression mind in keeping the in membrane cricothyroid the palpating and cartilage cricoid and cartilage thyroid the locating by hand nondominant the with membrane thyroid crico the locate cricothyrotomy, surgical guidewire-assisted anesthetic. local with skin the Infiltrate it. prohibits injury spine cervical patient’sthe Hyperextend shield. face suspected a unless neck protective appropriate equipment Wearsuch as sterile gloves, neck. gown, and protective anterior eye and the of skin the the place technique, Prepare exposed. neck the with position supine the in cricothyrotomy patient surgical the with As Procedure air of amount catheter. the the reaching control pressure to used be also may injector jet hand-triggered a to connected gauge pressure A ratio. (I/E) theinspiratory-to-expiratory and catheter the through flow oxygen control to order in covers manually operator the that as holes placed at the end of the oxygen tubing (see simple as be can valve on/off catheter.The the of hub the to Luer-Lok or three-way a stopcock to with connect along the oxygen valve tubing on/off manual a with system the connect to needed is tubing oxygen High-pressure source. wall 50-psi tube ET 2.5-mm a to end bag. cut the to attached distal the attach and eter 6–11 Figure Critical Care, Bloomington, IN.) Bloomington, Care, Critical Assemble additional equipment such as antiseptic prepa antiseptic as such equipment additional Assemble tah 1- o 4gue nict t a - r 5-mL or 3- a to angiocath 14-gauge to 12- a Attach for employed technique insertion needle the to Similar standard a from oxygen supply method, alternative an In

ENK oxygen flow modulator set. modulator flow oxygen ENK

mL of mL 83 saline or lidocaine. Once the Once lidocaine. or saline omril is r avail are kits Commercial

(Courtesy of Cook of (Courtesy Fig. 6–11) - - - - - go of the distal openings in the oxygen tubing or of the jet the injector valve. of or tubing oxygen the in openings distal the of go with TTJV for 30 or even 60 minutes. 60 even or 30 for TTJV with yl. h oeao as cnrl te I the per controls flow also oxygen operator of The second cycle. 0.5 provide must you breath), provide a tidal volume of 10 50 of pressure a catheter, 14-gauge a through connected When output full to connects system oxygen high-flow The patient. the ventilate to needed are volumes tidal by what primarily isdetermined system oxygen high-flow the or setup bag ventilation the use to whether of choice The ways. is airway the dislodged. being and from it prevent to completed secured is procedure entire the until catheter the of hub the on hand one Keep neck. the around tie circumferential a with it secure then and leak air avoid to Make sure that the hub of the catheter is flush against the skin confirmed. is placement appropriate and connected is supply remove the needle. Hold the catheter by hand until the oxygen then hub, the to catheter the advance and place in needle the with which air is aspirated. Once through the membrane, hold when entered airway bubbles are seen in the fluid or there is an increase in the the ease and pierced been has membrane ( syringe the with gently aspirate caudally.angle 45° to 30° a so, at doing directed While brane mem and tissue, subcutaneous skin, overlying the through nvtby ass eeto o CO of adults retention in TTJV causes that reported long inevitably been a has for It time. ventilation of adequate period provide to inability its of owing in part because it is labor-intensive, but more so because ing TTJV is that it is regarded as only a temporizing measure, regard concern debated and important An patient. critical a and in hypoxia risks ongoing reverse to need potential the against them balance these of aware be should clinician The complications. and risks certain with associated are rotomy cricothy needle and TTJV procedures, invasive any with As Complications ery opee rpayga osrcin adequate obstruction, achieved. been oropharyngeal has ventilation complete nearly to” a ue wtot ventilation. without used oxygen was “apneic ation” low-flow continuous which oxygenation in earlier of techniques remnant a be oxygenation. may assumption adequate This despite ventilation poor of because hs suis okd t etlto fr xedd eid of periods extended time. for ventilation at looked studies these high-flow oxygen source. oxygen time high-flow expiratory increased are ventilation improve to and normal arterial CO arterial pH normal and blood normal thus and ventilation, adequate that show ant oh rvd aporae ia vlms n allow and volumes exhalation for time tidal enough appropriate provide operator both the because cannot adults for appropriate not is method This oximetry. pulse and motion wall breath-by- chest it on based adjust breath and inspired air of volume the control can you setup, this Using barotrauma. prevent to ventilator jet the of instead used tidal be should bag smaller the therefore, need volumes; and capacities lung total small have old, through the catheter. Children, especially those under 5 years 6–14).

psi will flow at 1600 at flow will psi Oxygen can be supplied to the catheter in two different two in catheter the to supplied be can Oxygen With the ventilation bag, you manually inflate the lungs the inflate manually you bag, ventilation the With and provides a maximal output pressure of 50 of pressure output maximal a provides and 35 Commercial kits are available ( 2

partial pressure, can be maintained be can pressure, partial Lsc Therefore, mL/sec. 94

84,85 mL/kg in vn ih ead o ata or partial to regard with Even ). 6–15 ( Fig. 95,96 ). The cricothyroid The 6–12). Fig. notntl, oe of none Unfortunately, 2 an 80-kg adult (800 86 laig o acidemia to leading , ay nml studies animal Many 87–92 wl oye suc at source oxygen wall a

ratio E Factors that seem that Factors f o wn to want you if Figs. 6–13 and y letting by 93

and mL/

psi. - - - -

6 ● Cricothyrotomy and transtracheal jet ventilation 121

- 97 100 A, Puncture the

It has also been proposed 98 99 C, Attach a high-pressure oxygen source, such as wall Although needle cricothyrotomy may involve less trauma less involve may cricothyrotomy needle Although There have been reports of mechanical failure with the cm of the tip of the catheter is bent at 15° anteriorly and Transtracheal jet ventilation Transtracheal with needle/catheter.

B, Once the airway has been entered remove the needle, leaving the 2.5 if a greater angle of insertion relative to the used, skin the surface catheter has is less of a chance of kinking while it being is advanced into the trachea. A number of solutions have been proposed wire-coiled available commercially a is There occurring. to from prevent this catheter that does not kink as readily as the standard angio to the skin surface and anterior than laryngotracheal surgical structures cricothyrotomy, the force one must puncture the apply cricothyroid to membrane is proportional to the caliber of the needle being used. Larger-bore trachea. posterior needles the perforating of risk carry higher a them with Barotrauma is a significant risk associated occurs withwhen there is upper airway TTJV and obstruction that does not allow air to be passively exhaled. This causes an increase in materials used for one TTJV, of which is catheter kinking. cath found in the ED. One study found that if the distal that a 7- or 9-French vessel angiocath to dilator prevent kinking. be used instead of an B Figure Figure 6–12 cricothyroid cricothyroid membrane with a large needle (12–14 gauge). Aim caudally at a 45° angle. catheter in the trachea. oxygen, at maximal output. OG-0802 Cricoid cartilage Cricoid space Cricoid OD-183SU 45° Commercially Commercially available transtracheal jet ventilation (TTJV)

AT-100A OG-183R A C Figure Figure 6–13 kit (Life-Assist, Inc; Rancho Cordova, CA) with manual jet ventilator, pressure gauge, and adapter, 14-gauge angiocath with secure tie. C 122 II ● RESPIRATORY PROCEDURES Figure 6–14 Figure catheter, and pneumothorax. catheter,and of the catheter, subcutaneous emphysema, dislodgment of the malposition bleeding, minor include complications reported that the diameter of the catheter is not nearly large enough large nearly not is catheter the of diameter the that in aspiration against protection airway any afford not would lung volumes and pressures, leading to lung injury. angiocath. 14-gauge a and syringe, 3-mL adapter,a tube endotracheal standard a bag, ventilation a using ventilation One would assume that a transtracheally placed catheter placed transtracheally a that assume would One Thyroid cartilage Cricothyroid membrane tube connector Standard endotracheal Ventilation bag

Homemade ventilation Homemade 103,104 setup for transtracheal catheter transtracheal for setup Cricoid ring needle catheter-over 14-gauge IV 3cc syringebarrel 101,102 Other ventilation of mode this from protection airway some suggesting lated, venti not animals control versus TTJV with ventilated were that models dog in aspiration of rate decreased a shown have studies few a However, trachea. the of lumen the occlude to ulte o bt ciohrtm ad TV Te hv the have TTJV. They and cricothyrotomy both of qualities geal 6–3 TABLE Potential or theoretical complications (not yet commonly associated commonly yet (not complications theoretical or Potential complications rare Serious, Infrequent Common reported with tracheostomy and other airway procedures) airway other and tracheostomy with reported although ventilation, jet translaryngeal percutaneous with Cricothyrotomy Set. Cricothyrotomy Set. Cricothyrotomy Emergency Kit. Cricothyrotomy Emergency L/A Inc. Assist, Kit. Cricothyrotomy TrachAdult to right: to Figure 6–15 Figure Swallowing problems Swallowing tracheobronchitis) as (such mucosa laryngotracheal to Damage Tracheoesophagealfistula stenosis Subglottic/glottic injury,cord vocal to (secondary changes voice or Dysphonia perforation Esophageal perforation Mediastinal pressures airway high if occurrence (less Pneumomediastinum Pneumothorax common more pressures, airway high to (secondary Barotrauma Pneumatocele throat” the in “lump a of feeling Subjective stoma Persistent time procedure Prolonged placement catheter unsuccessful or Incorrect Aspiration Infections hematoma (minor), Bleeding patient) conscious a (in Coughing catheter the of obstruction or Blockage catheter the of Kinking if occurrence (less common emphysema—most Subcutaneous Commercial hybrid kits, such as the Quicktrach, combine laryngeal fracture, or disruption of laryngeal cartilage) laryngeal of disruption or fracture, laryngeal obstruction) airway complete with performed not and avoided, are obstruction) airway complete with skin) the at fit “secure” a is there

Jet

Ventilation Portex Mini-Trach II Cricothyrotomy Kit. Cricothyrotomy Mini-TrachII Portex A, 105,106

Complications Commercially available cricothyrotomy kits. cricothyrotomy available Commercially (Table 6–3).

of Arndt Emergency Arndt G, Rusch, Inc. Quicktrach. Inc. Rusch, C,

Percutaneous Ravussin. E,

Portex Nu- Portex B, Translaryn

From left From Life- D, F,Patil - - C

6 ● Cricothyrotomy and transtracheal jet ventilation 123 (Fig. 108 B) prominently onsult C

B, Courtesy of Cook Critical xpert E

Transtracheal (A and

On end view catheter connection found

can Introducer needle Introducer

18 gauge appropriate length 18 gauge appropriate Syringe A) and TTJK (ENK, Cook Critical Care) ( REFERENCES Connecting tube insufflated air to escape through the oropharynx above oropharynx the through escape to air insufflated 6-16; see also Fig. 16–15). Polyvinylchloride Curved dilator Syringe 18 gauge appropriate length 18 gauge appropriate Amplatx extra stiff wire guide Amplatx extra stiff TFR catheter introducer needle TFR catheter Radiopaque appropriate size and length Radiopaque appropriate Catheter needle ENK oxygen flow modulator Reinforced FEP catheter Reinforced FEP 0.38 inch diameter stainless steel, appropriate length with flexible tip steel, appropriate length with flexible 0.38 inch diameter stainless Deflated airway catheter Inflated airway catheter Scalpel Unfortunately, most of these trans- these of most Unfortunately, 107 Connecting tube B A Having a commercial kit for cricothyrotomy Cook (Melker, Critical Care) (

tracheal hybrid kits contain small uncuffed catheters. Studies pertaining to these hybrid kits suggest that their small caliber permits cuff a of lack the and ventilation adequate prevent may advantage of being relatively easy to use inexperienced with the if technique of surgical the cricothyrotomy clinician is and they may have fewer complications with process. insertion regard actual to the Figure Figure 6–16 displayed in the resuscitation room or crash cart makes these techniques readily available in an emergency. Care, Bloomington, IN.)