Last updated: June 13, 2023

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Summarytoggle arrow icon

Cricothyrotomy is the creation of an opening in the cricothyroid membrane (CTM) to establish an effective airway. The primary indication is a cannot intubate-cannot ventilate scenario with actual or impending airway compromise and respiratory failure. Cricothyrotomy may be performed by passing a large bore cannula or needle through the CTM into the trachea (needle cricothyrotomy) or creating an opening through the CTM and passing an endotracheal tube or tracheostomy tube into the trachea (surgical cricothyrotomy). A needle cricothyrotomy is typically paired with jet ventilation to maintain oxygenation and is a temporizing measure because ventilation is often inadequate. Surgical cricothyrotomy is a definitive airway that allows the usage of conventional modes of mechanical ventilation. Contraindications to cricothyrotomy include tracheal transection, tracheal or laryngeal trauma, and/or anatomic distortion. Surgical cricothyrotomy is also contraindicated in infants and young children. Complications include bleeding, airway trauma, and/or incorrect placement.

See also “Surgical airway management.”

Definitiontoggle arrow icon

Indicationstoggle arrow icon

The most common indication is a cannot intubate-cannot ventilate (CICV) scenario (e.g., after failed intubation), however, emergency surgical airways can be considered early in difficult airway management in select situations.

Contraindicationstoggle arrow icon

Needle cricothyrotomy [3]

Surgical cricothyrotomy [2][4][5]

  • Absolute
  • Relative
    • Infection at the site
    • Distorted anatomy

The ability to perform safe and timely endotracheal intubation is a contraindication to cricothyrotomy.

Tracheostomy is preferred for patients who need a permanent surgical airway without imminent signs of airway compromise, or if surgical cricothyrotomy is absolutely contraindicated.

We list the most important contraindications. The selection is not exhaustive.

Equipment checklisttoggle arrow icon

The following applies to stab-twist-bougie-tube cricothyrotomy technique: [2][7]

Preparationtoggle arrow icon

  • Position the patient supine with their neck extended.
  • Provide oxygen to the mouth and nose.
  • Identify the CTM landmarks: the depression between the thyroid cartilage and cricoid cartilage
  • Don PPE and sterile gloves.
  • Perform skin preparation.
  • Apply sterile drape (if time permits).
  • Additional steps for surgical cricothyrotomy:
    • Administer local anesthesia (if the patient is conscious and time permits).
    • Apply a small amount of lubricant to the inside of the tube.

Procedure/applicationtoggle arrow icon

Surgical cricothyrotomy [2][7][11]

There are multiple techniques, e.g., open and percutaneous (using a type of Seldinger technique). The following technique is recommended in the 2015 Difficult Airway Society guidelines: [7]

Surgical cricothyrotomy is contraindicated in infants and very young children. [12]

Stab-twist-bougie-tube cricothyrotomy [2][4][9][10][11]

  1. Grasp the cricoid cartilage between the middle finger and thumb of the nondominant hand.
  2. Locate the CTM with the index finger.
  3. Make an ∼ 1.5 cm-wide transverse incision through the skin, subcutaneous tissue, and CTM.
  4. Turn the scalpel 90° to open the incision.
  5. Insert the bougie (angled end first) directed toward the patient's feet.
  6. Advance the bougie 10–15 cm.
  7. Withdraw the scalpel.
  8. Thread the lubricated tube over the bougie.
  9. Advance the tube just until the cuff is no longer visible.
  10. Inflate the tracheal tube cuff.
  11. Remove the bougie and attach a self-inflating bag.
  12. Verify intratracheal placement with positive EtCO2.

Pitfalls and troubleshootingtoggle arrow icon

Common pitfalls and challenges of cricothyrotomy [2][4][13]
Suggestive features Management
Unable to identify landmarks [2]
  • Distorted anatomy, e.g., edema, scar tissue, overlying masses

Mainstem intubation

(occurs when using ET tubes)

  • Deflate the cuff, pull the ET tube back a short distance, and reassess
Incorrect tube placement
  • Remove the tube and restart the procedure.
Distal airway pathology
  • Consider alternative oxygenation strategies, e.g., ECMO.
Bleeding [4][13]
  • Minor: e.g., oozing
  • Major: e.g., copious and/or pulsatile bleeding
  • Minor: Compress the area with iodoform gauze; consider topical hemostatic agents.
  • Major: Consult the surgical team, as vessel ligation may be required.

Assessment of breath sounds, peak airway pressures, and capnography will help differentiate between common causes of hypoxia and/or inadequate ventilation after a cricothyrotomy.

Postprocedure checklisttoggle arrow icon

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. $Contributor Disclosures - Cricothyrotomy. All of the relevant financial relationships listed for the following individuals have been mitigated: Esther Welzel (illustrator, is an independent contractor for Fluentis Schweiz). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  2. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  3. Mace SE, Khan N. Needle Cricothyrotomy. Emerg Med Clin North Am. 2008; 26 (4): p.1085-1101.doi: 10.1016/j.emc.2008.09.004 . | Open in Read by QxMD
  4. Reichman E. Emergency Medicine Procedures. McGraw-Hill ; 2013
  5. Carretta A, Ciriaco P, Bandiera A, et al. Veno-venous extracorporeal membrane oxygenation in the surgical management of post-traumatic intrathoracic tracheal transection. J Thorac Dis. 2018; 10 (12): p.7045-7051.doi: 10.21037/jtd.2018.11.117 . | Open in Read by QxMD
  6. COTÉ CJ, HARTNICK CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children?. Pediatric Anesthesia. 2009; 19: p.66-76.doi: 10.1111/j.1460-9592.2009.02996.x . | Open in Read by QxMD
  7. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015; 115 (6): p.827-848.doi: 10.1093/bja/aev371 . | Open in Read by QxMD
  8. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  9. Muzyk AJ, Fowler JA, Norwood DK, Chilipko A. Role of α2-Agonists in the Treatment of Acute Alcohol Withdrawal. Ann Pharmacother. 2011; 45 (5): p.649-657.doi: 10.1345/aph.1p575 . | Open in Read by QxMD
  10. Yiannakis CP, Hilmi OJ. Evaluation and management of acute upper airway obstruction. Surgery. 2021; 39 (9): p.598-606.doi: 10.1016/j.mpsur.2021.07.006 . | Open in Read by QxMD
  11. Hill C, Reardon R, Joing S, Falvey D, Miner J. Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab. Acad Emerg Med. 2010; 17 (6): p.666-669.doi: 10.1111/j.1553-2712.2010.00753.x . | Open in Read by QxMD
  12. Watters KF. Tracheostomy in Infants and Children. Respir Care. 2017; 62 (6): p.799-825.doi: 10.4187/respcare.05366 . | Open in Read by QxMD
  13. Kristensen MS, McGuire B. Managing and securing the bleeding upper airway: a narrative review. Can J Anaesth. 2019; 67 (1): p.128-140.doi: 10.1007/s12630-019-01479-5 . | Open in Read by QxMD

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