Cricothyrotomy: Assisting

  1. Perform hand hygiene and apply clean gloves. 
  2. Assess the patient's need for the procedure. 
  3. Assess anterior neck for landmarks:  Cricothyroid membrane and  Thyroid cartilage 
  4. Assess patient for crush injuries to anterior neck. 
  5. Assess patient for expanding hematomas that may alter the anatomy. 
  6. Place the patient in a supine position with the neck in a neutral position. 
  7. Cleanse the anterior neck with antiseptic solution. 
  8. Drape the neck with sterile towels. 
  9. If the patient is conscious, the physician or advanced practice nurse anesthetizes the skin and also the airway by injecting lidocaine through a transcricothyroid membrane puncture. 
  10. The physician or advanced practice nurse manually stabilizes the thyroid cartilage and incises the skin vertically, in the midline anterior neck, over the cricothyroid membrane.

Surgical Technique

  1. The physician or advanced practice nurse incises the cricothyroid membrane, inserts the tracheal hook in the inferior aspect of the thyroid cartilage, and gently pulls the airway up and out of the skin. The physician or advanced practice nurse then dilates the incision with a hemostat or tracheal spreader. 
  2. The physician or advanced practice nurse inserts a cuffed endotracheal tube or tracheostomy tube into the cricothyroid membrane incision, directing the tube caudally into the trachea. 
  3. Inflate the tube cuff, and ventilate the patient with a bag-mask device. 
  4. Observe for chest rise and fall and for presence of end-tidal carbon dioxide (ETCO2) on either a colorimetric device or capnograph. Auscultate for bilateral breath sounds. 
  5. Secure the tube with tape or ties. If using an endotracheal tube, note and document the centimeter marking at the skin incision line. 
  6. Place a sterile dressing around the incision area.

Melker Technique

Note: The Melker emergency cricothyrotomy catheter set is designed to establish emergency airway access by using a percutaneous entry via Seldinger technique through the cricothyroid membrane with subsequent dilatation of the tracheal entrance tract and passage of either a cuffed or uncuffed airway catheter.

  1. The physician or advanced practice nurse places a 6-ml syringe containing saline solution on the 18-G catheter and needle introducer.
  2. The physician or advanced practice nurse advances the 18-G catheter and needle introducer through the incision and through the cricothyroid membrane at a 45-degree angle caudally. Proper placement within the trachea is confirmed by aspiration of air bubbles into the saline-filled syringe.
  3. The physician or advanced practice nurse removes the syringe and needle while leaving the catheter in place. The physician or advanced practice nurse then advances the guidewire through the catheter several centimeters into the airway.
  4. The physician or advanced practice nurse removes the catheter over the guidewire, leaving the guidewire in place.
  5. The physician or advanced practice nurse advances the dilator and airway catheter combination over the guidewire and through the cricothyroid membrane.
  6. Once the airway catheter is in place, the physician or advanced practice nurse removes the guidewire and the dilator together. The physician or advanced practice nurse inflates the cuff if using the cuffed version of the Melker tray.
  7. Ventilate the patient with a bag-mask device.
  8. Observe for chest rise and fall and for presence of end-tidal carbon dioxide (ETCO2) on either a colorimetric device or capnograph. Auscultate for bilateral breath sounds.
  9. Secure the tube with tape or ties. If using an endotracheal tube, note and document the centimeter marking at the skin incision line.
  10. Place a sterile dressing around the incision area.

Post Procedure

1.  Ensure the airway adjunct is adequately secured.

2.  Discard supplies, remove gloves, and perform hand hygiene.
3.  Anticipate that a chest x-ray will be performed to evaluate tube placement.
4.  Reevaluate the patient periodically.
5.  Document the procedure in the patient's record.

 

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