Cricothyrotomy and Jet Ventilation

Dimensions ~1-1.5 cm vertical × 2-3 cm horizontal — small target.

Palpation technique: feel the thyroid notch (laryngeal prominence, more obvious in men), slide a finger down the midline to the soft membrane just below — the next firm cartilage caudally is the cricoid ring.

Membrane is anatomically identifiable by palpation in only 70-80% of necks even in normal anatomy.

Pre-procedure ultrasound localization is the new standard in any anticipated difficult anatomy — mark the membrane before induction.

Target time from CICO declaration to ventilation: ≤90 seconds.

Faster + more reliable than needle cricothyrotomy in adult emergencies.

14-16 gauge IV catheter angled 30-45° caudally through the membrane, aspirate air to confirm tracheal position, advance catheter off needle.

Connect to JET VENTILATOR: high-pressure O₂ at 40-50 psi via Sanders injector, 1-second pulses every 4-5 seconds.

If upper airway completely obstructed (e.g., tumor + edema), jet ventilation is contraindicated; must convert to surgical airway.

Adequate as a bridge for 30-60 minutes until definitive airway placement.

Do NOT keep trying laryngoscopy — each attempt worsens edema + bleeding + raises probability of unrecoverable airway.

Declare CICO VERBALLY to the team ('I am declaring CICO.

Going to FONA now.') and commit to surgical airway.

THE most common error in airway disasters is failure to declare CICO until SpO₂ is <60% — at which point cerebral injury or arrest is imminent.

Practice the verbal declaration in simulation.

Convert to surgical tracheostomy within 24-72 hours — prolonged cricothyrotomy increases the risk of subglottic stenosis from prolonged pressure of the cuff against the cricoid cartilage.

ENT or general surgery performs the conversion in OR semi-electively after the patient is stabilized.

Some institutions accept long-term cricothyrotomy in critically ill patients where conversion poses unacceptable risk; others mandate conversion.

Document the FONA + the conversion plan + responsible service in the chart.

👶Children <8-12 years: needle cricothyrotomy preferred over surgical due to small cricothyroid space (the membrane is tiny + cricoid ring is the narrowest fixed point of the pediatric airway).

18-20G IV catheter through membrane + jet ventilation with PRESSURE-LIMITED settings (start at 10-20 psi for infants, titrate to chest rise).

Barotrauma risk is much higher in peds — limit pulse duration and watch for chest hyperinflation.

Some pediatric difficult-airway algorithms favor proceeding directly to surgical tracheostomy by ENT rather than cricothyrotomy in children.

SIMULATION training is essential — cadaver labs, manikin practice, mental rehearsal.

CRIC CARTS on every anesthesia workstation contain: scalpel #10, bougie, 6.0 cuffed ETT, gauze, suction, scope, capnography filter.

Difficult-airway algorithm cards on the wall serve as cognitive scaffolding during the crisis.

Mental rehearsal before high-risk inductions: 'If I cannot intubate and cannot oxygenate, the cric cart is HERE; I will use scalpel-bougie-tube.' ENT or surgical-airway team paged for ANTICIPATED difficult airway (massive neck tumor, post-radiation, severe sleep apnea, history of failed intubation) — have them in the room scrubbed before induction.

Patient + family debrief with disclosure of events when patient is recovered + capable.