1. Patient positioning and preparation for the procedure

1. The patient in this situation has likely undergone attempted endotracheal intubation and should already be lying supine.
2. Extend the patient's neck to better assess anatomic landmarks.
3. The cricothyroid membrane is located below the laryngeal prominence ("Adam's apple") and is palpated as a soft indentation in the midline on the anterior neck. The superior thyroid arteries anastomose in the midline inferior to the cricothyroid membrane. The thyroid gland is located inferior to the superior thyroid arteries
4. Gather supplies, including chlorhexidine, a needle cricothyrotomy kit, and airway management supplies (bag-valve-mask device, supplemental oxygen, and suction).
5. There are several pre-packaged percutaneous cricothyrotomy kits available. Standard kits include an introducer needle, a 5mL syringe, a scalpel, a guide wire, a dilator, and an airway catheter, which may be cuffed or uncuffed.
6. Open the needle cricothyrotomy kit and attach the introducer needle to the syringe. Assemble the airway catheter/dilator, prepare the guide wire, and lay out the scalpel for easy access

2. Protocol

The context of this procedure is often the truly emergent situation. In this event, there may not be time for local anesthesia (if the patient is awake) or skin preparation with chlorhexidine. As with all emergent procedures, true sterile technique is sacrificed for rapidity. For example, it is unlikely that the situation that calls for an emergent cricothyrotomy would allow for sterile gowning and gloving.

1. Stand at the head of the bed and identify the patient's anatomy by palpating the laryngeal prominence and moving your fingers inferiorly into the depression below, the cricothyroid membrane.
2. Grab the paratracheal structures and move them around to be certain you can identify the midline. They will move as a unit. It is in the midline of this depression that the practitioner will make the incision and insert the needle.
3. If time allows, the area should be cleaned with chlorhexidine. Ideally, the exam gloves that the practitioner is wearing should be traded for sterile gloves.
4. Make a small (5mm) vertical incision with the scalpel in the midline previously identified.
5. Advance the introducer needle into the neck through the skin incision and through the cricothyroid membrane at a 45° angle toward the patient's feet, withdrawing on the plunger as you advance.
6. When the needle enters into the airway, you will be able to aspirate air. Note that some practitioners prefer to have 2-3 cc saline in the syringe prior to attaching the needle, to aid in identifying the aspiration of air by creating bubbles when the plunger is withdrawn.
7. Remove the syringe from the needle, taking care to keep the needle within the air-filled lumen identified. This is best done by bracing the hand against the patient's neck, so that there is no migration of the needle tip.
8. Advance the guide wire through the needle approximately 15 cm, so that the guide wire is well within the airway.
9. Remove the needle, keeping the guide wire in place
10. Thread the catheter/dilator assembly over the distal end of the guide wire, and advance along the wire
11. Push the catheter/dilator assembly through the skin, anatomically oriented with the airway such that the curve of the catheter matches the curve needed from its entry point into the trachea. Keep pushing until the catheter is fully in place, which means the plastic flange is against the neck.
12. If the catheter is cuffed, fill cuff with air by injecting several milliliters of air into it. Typically 10 mL of air is required. Check the pilot balloon to be sure the cuff is inflated.
13. Remove the dilator and wire from the assembly
14. Attach the catheter to the bag-valve manual resuscitator; auscultate for breath sounds, monitor end-tidal CO₂, and obtain chest X-ray
15. Secure airway catheter with appropriate necktie.

3. Alternative approach for percutaneous cricothyrotomy using Seldinger technique if pre-assembled kit is unavailable

1. Place the patient in supine position as above, with the neck extended.
2. Open central venous catheter tray. Separate out the 5 mL syringe, the introducer needle, the guide wire, and the scalpel.
3. Gather a tracheostomy tube.
4. Attach the introducer needle to an empty 5mL syringe (again, adding water to the syringe first is unnecessary and not advocated by this author).
5. Prepare the guide wire by retracting it in its sheath and straightening out the J tip.
6. Prepare the neck with chlorhexidine if time allows
7. Identify the laryngeal prominence and palpate the depression just caudal to this, the cricothyroid membrane.
8. Grab the laryngeal structures as a unit to be certain the midline is identified.
9. From your position at the head of the bed, advance the introducer needle into the patient's neck, at the point just identified as the cricothyroid membrane. The needle is directed at a 45° angle from the horizontal, in a caudal direction, applying gentle pressure to the plunger of the syringe.
10. Once air is easily aspirated into the syringe, the airway has been identified.
11. Holding the needle steady with your non-dominant hand, remove the syringe with your dominant hand.
12. Advance the guide wire through the introducer needle, to a depth of 15 cm
13. With a #11 scalpel blade, make a 2 cm horizontal incision at the level of the needle. This incision is a complete incision, through both skin and cricothyroid membrane, a depth of approximately 2 cm.
14. The needle is removed with the guide wire left in place
15. Prior to advancing the tracheostomy tube through the neck, it will help if the incision made by the scalpel is dilated open. This can be facilitated with the handle of the scalpel.
16. Retract the blade of the scalpel and advance the handle of the scalpel through the incision
17. With the handle firmly in the incision, rotate the handle 90° so the handle is oriented parallel with the patient's neck and perpendicular to the horizontal incision. This will hold the incision aperture open and allow for easier passage of the tracheostomy tube.
18. Advance the tracheostomy tube over the guide wire. This will assure that the tube follows the correct tract into the airway previously identified by the syringe with air aspiration.
19. Advance the tracheostomy tube into position.
20. Remove the guide wire.
21. Inflate cuff of tracheostomy tube (if cuffed).
22. Attach to appropriate ventilator device as above and secure with neckties.