6.2 Needle Cricothyrotomy

 (Approved for Paramedics Only)

The following is a general description of one of several accepted techniques being used throughout the Commonwealth, and may be used as a guideline. Due to differences in medical devices used by individual systems, the procedure may vary slightly. Refer to your local and regional guidelines for the technique and equipment used in your system.

Note: Appropriate body substance isolation precautions are required whenever caring for the trauma patient.

Indications: The indications for performing a needle Cricothyrotomy on a patient will be:

1. The patient is in imminent danger of death.

2. No alternative airway device/maneuver has been successful.

3. The patient cannot be oxygenated or ventilated by any other means

The affiliate hospital medical director has appropriately trained and authorized the treating Paramedics. 

Examples of types of patients potentially meeting the above criteria include (but are not limited to):

1. Patients suffering traumatic arrest

2. Patients suffering multiple traumatic injuries

3. Patients suffering an upper airway obstruction

Recognizing the time critical nature of the emergency, Needle Cricothyrotomy will be a Standing Order for Paramedics authorized in accordance with lthe above criteria.

Procedure:

1. Assemble and prepare oxygen tubing by cutting a hole toward one end of the tubing.  Connect the other end of the oxygen tubing to an oxygen source, capable of delivering 50 psi or greater at the nipple, and assure free flow of oxygen through the tubing.

2. Place the patient in a supine position.

3. Assemble a #12 or 14-gauge, 8.5 cm, over-the-needle catheter to a 6- to 12-mL syringe.

4. Clean the neck with an aseptic technique, using antiseptic swabs.

5. Palpate the cricothyroid membrane, anteriorly, between the thyroid cartilage and cricoid cartilage.  Stabilize the trachea with the thumb and forefinger of one hand to prevent lateral movement of the trachea during the procedure.

6. Puncture the skin midline with the needle attached to a syringe, directly over the cricothyroid membrane (i.e., mid-saggital).  

7. Direct the needle at a 45 degree angle caudally, while applying negative pressure to the syringe.

8. Carefully insert the needle through the lower half of the cricothyroid membrane, aspirating as the needle is advanced.

9. Aspiration of air signifies entry into the tracheal lumen.

10. Remove the syringe and withdraw the stylet while gently advancing the catheter downward into position, being careful not to perforate the posterior wall of the trachea,

11. Attach the oxygen tubing over the catheter needle hub (you may use a 3.0-4.0 ET tube connector), and secure the catheter to the patient's neck.

12. Intermittent ventilation can be achieved by occluding the open hole cut into the oxygen tubing with your thumb for one second and releasing it for four seconds.  After releasing your thumb from the hole in the tubing, passive exhalation occurs.  Note: Adequate PaO2, can be maintained for only 30 to 45 minutes.

13. Continue to observe lung inflations and auscultate the chest for adequate ventilation.

Complications of Needle Cricothyrotomy

1. Asphyxia

2. Aspiration

3. Cellulitis

4. Esophageal perforation

5. Exsanguinating hematoma

6. Hematoma

7. Posterior tracheal wall perforation

8. Subcutaneous and/or mediastinal emphysema

9. Thyroid perforation

10. Inadequate ventilations leading to hypoxia and death