6.7     Surgical Cricothyrotomy 

This Protocol includes:

(1) requirements for participation in the Surgical Cricothyrotomy Program 

(2) guidelines on initial and continued education and procedure competency; 

(3) guidelines for quality assurance and data collection; and 

(4) an updated protocol for the use of advanced airway management, necessary equipment and backup equipment, and patient monitoring guidelines.

Criteria for participation: The Affiliate Hospital Medical Director has appropriately trained and authorized the treating Paramedics.  Ongoing training and equipment requirements are met.

Indications:  

1. The patient is in imminent danger of death due to airway compromise.

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

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

PARAMEDIC STANDING ORDERS:

Surgical Cricothyrotomy Procedure:

1. Position the patient in a neutral position.

2. Identify and palpate landmarks. Palpate thyroid 

              and cricoid cartilage then palpate cricothyroid membrane.

3. Clean area using antiseptic swabs.

4. Make a 2-3 cm midline vertical incision through the skin over the 

              cricothyroid membrane.

5. Make a 1-2 cm horizontal incision though the cricothyroid membrane.

6. Prior to removing scalpel, insert the tracheal hook(optional) and pull it cephalad pulling 

               against the caudal end of the thyroid cartilage.

7. Cannulate the trachea.

8. Inflate cuff.

9. Confirm placement with ETC02 and lung sounds.

1. Guideline for a Surgical Cricothyrotomy Program

Surgical Cricothyrotomy is an invasive procedure performed only when a patient is in imminent danger of death due to airway compromise which cannot be alleviated by other means. Needle 

cricothyrotomy is the preferred procedure in children under the age of 8 years old.

2. Quality Assurance of a Surgical Cricothyrotomy Program:

Quality assurance review will be performed by each service on every case of attempted or successful 

intubation, including surgical and needle cricothyrotomy. The Affiliate Hospital Medical Directors and the service’s Director of CQI, or their designee, will review each case individually and keep a written record of their review. Each case and its appropriate information will be available within a standard database including: age, sex, indication for intubation (or cricothyrotomy), provider information, medications used, number of attempts, successful/unsuccessful intubation, adjuncts/backups used, and complications of intubation (ex-failed airway, cricothyrotomy required, bradycardia, hypoxemia, esophageal intubation). 

3. Requirements for Participation in a Surgical Cricothyrotomy Program:

The service and its affiliate hospital medical director are committed to the Surgical Cricothyrotomy Program and participation in the Quality Assurance program. This program includes review of each individual surgical cricothyrotomy case and the specified training requirements. The service (Director of CQI) or designee must collect required data for each surgical cricothyrotomy and entered it into a database and be available for review by the Department.

4. Contraindications: No absolute contraindication relative to the given situation.

5. Education Requirements/Training Guidelines  of a Surgical Cricothyrotomy Program:

The initial educational program for this program consists of didactic lectures, skills labs and simulation. It is expected that the initial program takes at least four hours to complete.

1. Didactic classroom

1.1. Anatomy and physiology

1.2. Advanced airway management - including: 

1.2.1.  Necessary equipment

1.2.2. BVM technique

1.2.3. Standard intubation technique and backup techniques (bougie, cric, BVM, video        

               assisted laryngoscopy)

1.2.4. Difficult airway algorithms 

1.2.5    Identifying correct airway placement

1.2.6. Necessary monitoring equipment, including 02 sat monitor,   

               cardiac monitoring, continuous end-tidal C02

1.2.7. Review of recent evidence- based medicine on prehospital airway management    

               including issues with pediatric intubation and head trauma patients.

2. Skills lab for difficult airway & surgical cricothyrotomy

2.1. Review of necessary equipment

2.2. Review of Standard BVM technique .

2.3. Review of standard direct laryngoscopy intubation technique

2.4       Animal tracheas or equivalent used for skill development 

2.5. Use of case based scenarios

3. Simulation Participation for difficult airway and surgical cricothyrotomy

3.1. Intubation technique

3.2. Airway equipment and backup equipment

3.3. Monitoring equipment

                                  3.4. Participation in advanced airway management of patient under the supervision of               

                                              simulation staff

4. Successful signoff by the Medical Director or designee.

6. Continuing Education for Difficult Airway and Surgical Cricothyrotomy Program:

A refresher training program for this specific skill must be conducted at minimum every six months and must have a hands-on practical component-adding simulations well as trachea cannulations.  The Affiliate Hospital Medical Director or designee must then sign off on each Paramedic’s continuation in the program.

100% Continuing Quality Improvement (CQI) must be performed on all intubations and cricothyrotomies.