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Technique

  1. Cleanse and anesthetize the skin if the clinical situation allows (see Video 22.11).

  2. If right hand dominant, stand on the patient’s right side (see Fig. 22.82).

  3. With the nondominant hand, identify the thyroid cartilage and stabilize with the long finger and thumb (see Fig. 22.83).

  4. With the nondominant index finger, identify the cricothyroid membrane and cricoid cartilage (see Fig. 22.84).

  5. With the dominant hand, make a vertical (north to south) incision through the skin from the bottom of the thyroid cartilage to the top of the cricoid cartilage (see Fig. 22.85).

  6. With the nondominant hand index finger, through the north to south incision, reconfirm the cricothyroid membrane (see Fig. 22.86).

  7. Using a stab incision, incise the cricothyroid membrane horizontally (east to west) (see Fig. 22.87).

  8. Rotate the scalpel 180 degrees to fully extend the cricothyroid membrane incision (see Fig. 22.88).

  9. Firmly place the dominant hand small finger into the trachea directed caudally and blunt dissect to allow passage of an ETT (see Fig. 22.89).

  10. Place a bougie in the trachea directed caudally (see Fig. 22.90).

  11. Insert a 6.0-mm ID ETT over the bougie and into the trachea until the top of balloon is at least 3 cm below the level of the skin (see Fig. 22.91).

  12. Inflate the ETT cuff (see Fig. 22.92).

  13. Remove bougie while holding ETT in the trachea.

  14. Initiate ventilation.

  15. Confirm tube placement with end-tidal carbon dioxide detector.

  16. Secure ETT using institutionally accepted method.

FIGURE 22.82

Cricothyrotomy Landmarks. Stand on the side of the patient of your hand dominance. (Photo Contributor: Lawrence B. Stack, MD.)

FIGURE 22.83

Stabilize the Thyroid Cartilage. Identify the thyroid and cricothyroid cartilages with the nondominant hand. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.84

Cricothyroid Membrane Identification. Using the index finger of the nondominant hand, palpate and identify the cricothyroid membrane. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.85

Vertical (North-South) Skin Incision Over the Cricothyroid Membrane. Make a generous midline vertical incision through the skin over the cricothyroid membrane. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.86

Reconfirm Cricothyroid Membrane. Place nondominant index finger into North-South incision to confirm by palpation the cricothyroid membrane. (Photo Contributor: Lawrence B. Stack, MD.)

FIGURE 22.87

Horizontal (East-West) Incision Through the Cricothyroid Membrane. Make a horizontal (East-West) stab incision through the cricothyroid membrane. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.88

Horizontal (West-East) ...

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