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Establishing an airway by means of a surgical approach—incision or percutaneous insertion—is a challenging procedure deployed at high-risk and high-stress moments when basic airway maneuvers have failed. The key is preparation and practice, which means having all equipment ready and available (often in a common cart to ensure consistency) and prior practice in laboratory settings if not recently performed in clinical care. Knowing what options are available and then choosing one and implementing it before respiratory collapse will improve the outcome. The success rates depend largely on the preparedness of the ED and the training of the staff.1,2

Surgical cricothyrotomy refers to incision of the cricothyroid membrane under direct visualization and insertion of a tracheostomy tube either directly through the incision or by using the Seldinger technique. Needle cricothyrotomy is a dated term referring to insertion of a 12- to 16-gauge needle catheter into the trachea and connected to either a bag-valve device or wall oxygen. We do not recommend needle cricothyrotomy. Percutaneous transtracheal jet ventilation uses a 12- to 16-gauge catheter inserted into the cricothyroid membrane and connected to a high-pressure (35 to 50 psi) oxygen source for both oxygenation and ventilation.


The primary indication for surgical airway placement is a "can't intubate, can't ventilate" scenario. Most emergency surgical airways follow a failed attempt to establish an oral endotracheal airway. Cricothyrotomy or jet ventilation can be used before laryngoscopy and direct glottic intubation if the latter is likely to fail because of anatomic impingement or any other cause that impedes visualization, notable blood, secretions, swelling, or foreign matter. It is not necessary to try to intubate once before moving to cricothyrotomy; this often simply enhances the risk of harm.

Difficulty in establishing an airway may be due to anatomy (short, obese neck), a disease state (epiglottitis, laryngeal edema, paralyzed vocal cords, or retropharyngeal abscess), trauma from distortion of the neck by hematoma (cervical fracture or major vessel injury), aspiration of blood (facial trauma), or loss of supporting structures (mandibular fractures). Assess for these factors before any laryngoscopic attempts, have a surgical airway plan in mind, and have equipment ready at the bedside to manage impending or actual respiratory failure.

In a patient with a failed intubation attempt, the best course of action is to use bag-valve mask ventilation to restore or maintain gas exchange while regrouping. If bag mask ventilation is successful, try another attempt at laryngoscopy with a different operator and approach, rather than performing immediate cricothyrotomy. Clinical signs and symptoms of airway obstruction—one common reason to choose a surgical airway—are listed in Table 30-1.

TABLE 30-1Clinical Manifestations Associated with Acute Airway Obstruction

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