Cricothyroidotomy from scratch to sky

Cricothyroidotomy ( from scratch to sky)

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Cricothyroidotomy is an emergency front-of-neck airway procedure performed when a patient cannot be oxygenated or ventilated by other methods. A full “from scratch to sky” guide can cover:

Core concepts - definition, purpose, anatomy, airway physiology
Indications and decision-making - recognizing a “cannot intubate, cannot oxygenate” emergency
Contraindications and alternatives - including pediatric considerations
Equipment and preparation - scalpel-bougie-tube method and other approaches
Step-by-step procedure - landmarks, incision, membrane entry, tube placement, confirmation
Post-procedure management - ventilation, securing the tube, monitoring, conversion to definitive airway
Complications - bleeding, false passage, laryngeal injury, infection, stenosis, failed access
Special situations - obesity, neck trauma, distorted anatomy, children
Practical learning - algorithms, mnemonics, documentation, simulation tips, viva questions

At a high level, it is a last-resort, time-critical airway intervention, normally taught and performed within formal airway training, simulation, and local emergency protocols. It is not a substitute for hands-on supervised instruction.

Which section should I cover in depth first?

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1. Core concepts of cricothyroidotomy

What it is

Cricothyroidotomy, also called cricothyrotomy, is an emergency procedure that creates an airway through the cricothyroid membrane (CTM). It provides direct access to the trachea below the vocal cords when the upper airway cannot be used.

Other terms occasionally used include coniotomy and minitracheostomy, though “emergency surgical cricothyrotomy” is the clearest term in acute airway care. The procedure typically permits placement of a cuffed airway tube and positive-pressure ventilation.
Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 2405.

The purpose

Its immediate purpose is to restore or maintain:

Oxygenation: getting oxygen into the blood
Ventilation: eliminating carbon dioxide
A route for controlled ventilation when oral, nasal, supraglottic, and mask-based techniques have failed

It is therefore a rescue procedure, not a routine substitute for endotracheal intubation.

When it enters the airway algorithm

The classic trigger is CICO:

Cannot intubate, cannot oxygenate

This means attempts at placing a tracheal tube have failed and adequate oxygenation cannot be achieved by face-mask ventilation or a supraglottic airway device. In such a situation, the priority changes from securing a conventional airway to rapidly restoring oxygen delivery by emergency front-of-neck access.

Current difficult-airway guidance continues to place emergency front-of-neck airway access at the final rescue stage, after failure of intubation, supraglottic rescue, and optimized mask ventilation. The key danger is delay while hypoxia worsens.

Relevant anatomy

From superior to inferior in the anterior midline of the neck:

Hyoid bone
Thyroid cartilage
- Often palpable as the laryngeal prominence or “Adam’s apple”
Cricothyroid membrane
Cricoid cartilage
Tracheal rings

The cricothyroid membrane lies between the inferior border of the thyroid cartilage and the superior border of the cricoid cartilage. It is a fibroelastic membrane overlying the laryngeal mucosa. It is relatively superficial and normally has few major structures immediately anterior to it, which makes it the preferred emergency entry point.
Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 2405; Gray’s Anatomy for Students, section “Cricothyrotomy”.

Why this site is chosen

Compared with an emergency tracheostomy, cricothyroidotomy is generally:

Faster
More superficial
Easier to identify in many adults
More direct in a time-critical oxygenation failure
Less likely to encounter the thyroid isthmus or larger vessels than a lower tracheal approach

In the emergency setting, it is generally considered faster and more straightforward than tracheotomy.
ROSEN’s Emergency Medicine: Concepts and Clinical Practice, p. 42.

Cricothyroidotomy versus tracheostomy

Feature	Cricothyroidotomy	Tracheostomy
Entry site	Cricothyroid membrane	Trachea, usually lower in the neck
Usual role	Emergency rescue airway	Planned or longer-term airway
Speed	Rapid	Usually slower
Technical setting	CICO emergency	Operating room, ICU, or controlled emergency setting
Relationship to thyroid gland	Usually above it	May require dealing with thyroid isthmus

A cricothyroidotomy may later be assessed for conversion to a more definitive airway depending on the clinical situation and local protocol.

Main methods

There are several broad methods:

Surgical scalpel-based technique, commonly described as scalpel-bougie-tube
Large-bore cannula techniques
Needle cricothyroidotomy, usually a temporary oxygenation method rather than a definitive ventilatory airway

For adult emergency front-of-neck access, modern difficult-airway teaching commonly favors a surgical scalpel-based approach because it is more reliable than narrow cannula techniques in many real CICO scenarios. In contrast, needle approaches have a more limited role, particularly in young children.
ROSEN’s Emergency Medicine: Concepts and Clinical Practice, p. 42; Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 2405.

Important limitations

Cricothyroidotomy is not equally suitable for every patient:

Infants and young children: the membrane is small and laryngeal structures are vulnerable. Surgical cricothyroidotomy is generally avoided in young children.
Laryngeal fracture: can make the procedure inappropriate or hazardous.
Distorted anatomy: obesity, neck swelling, hematoma, tumor, prior surgery, radiation, or infection can make landmark identification difficult.
Coagulopathy or local infection: important risks, but in a true CICO emergency these are usually relative, not absolute, concerns.

Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 2405; ROSEN’s Emergency Medicine: Concepts and Clinical Practice, p. 42.

One-sentence exam definition

Cricothyroidotomy is an emergency front-of-neck airway procedure in which the cricothyroid membrane is opened to establish oxygenation and ventilation when intubation and noninvasive rescue oxygenation have failed.

Key takeaways

It is a time-critical rescue airway for CICO.
The target is the cricothyroid membrane, between thyroid and cricoid cartilages.
It is usually preferable to emergency tracheostomy in adults because it is quicker and more direct.
In a genuine CICO event, the goal is oxygenation first, not a perfect conventional airway.
It requires regular supervised simulation training, equipment readiness, clear team communication, and a local emergency-airway protocol.

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https://pmc.ncbi.nlm.nih.gov/articles/PMC12643155

2. Indications and decision-making

The primary indication: CICO

The principal indication for emergency cricothyroidotomy is:

Cannot intubate, cannot oxygenate
also phrased as cannot intubate, cannot ventilate

It means the clinician cannot place a tracheal tube and cannot maintain acceptable oxygenation by less invasive techniques, including optimized face-mask ventilation and a supraglottic airway device.

In this setting, emergency front-of-neck access is not a “last attempt at intubation.” It is a change in objective: rapidly restore oxygen delivery before hypoxic cardiac arrest occurs.
Roberts and Hedges’ Clinical Procedures in Emergency, “Surgical Cricothyrotomy”; Cummings Otolaryngology Head and Neck Surgery, “Indications”.

Practical decision pathway in an adult

Recognize a failed airway early
Intubation attempts are unsuccessful, unsafe to repeat, or impossible because the glottis cannot be reached or visualized.
Optimize oxygenation immediately
Use the best available noninvasive rescue measures:
- Two-person face-mask ventilation with airway maneuvers and adjuncts
- Supraglottic airway device
- Oxygen delivery during airway attempts, where appropriate
- Call for expert help and bring the emergency front-of-neck airway equipment
Declare the emergency explicitly
Clear words reduce delay and confusion:

“Cannot intubate, cannot oxygenate. Proceed to emergency front-of-neck airway.”
Proceed when oxygenation cannot be maintained
Do not continue repeated traumatic laryngoscopy attempts while saturation is deteriorating. Repeated attempts cause bleeding, edema, worsened visualization, and further delay.

The 2025 adult difficult-airway approach retains a staged sequence: intubation, supraglottic airway, face-mask oxygenation, then emergency front-of-neck airway. It emphasizes moving through failed stages promptly rather than persisting with ineffective attempts. Summary of the 2025 DAS update

Clinical situations that can lead to CICO

Cricothyroidotomy is indicated by the failure to oxygenate, rather than by a diagnosis alone. Common situations that may evolve into CICO include:

Severe maxillofacial trauma with blood, disrupted anatomy, or inability to obtain a mask seal
Acute upper-airway obstruction from edema, burns, anaphylaxis, infection, tumor, or foreign body
Massive vomitus, blood, or secretions preventing laryngoscopic visualization
Expanding neck hematoma
Severe airway distortion due to trauma, surgery, radiation, or mass
Laryngospasm or airway edema after induction of anesthesia when rescue ventilation has failed

Anticipated versus unanticipated difficult airway

Unanticipated CICO

This is the classic emergency indication. A conventional airway plan unexpectedly fails, then rescue oxygenation also fails. Cricothyroidotomy is a rescue procedure.

Anticipated failure of oral or nasal access

Occasionally, severe obstruction or anatomy makes oral/nasal intubation predictably impossible. A clinician may plan an invasive airway before complete airway loss, typically with specialist involvement if time allows. This is a different scenario from a crashing CICO emergency.

The key distinction is:

Situation	Main priority
Difficult intubation but adequate oxygenation	Pause, optimize, use another noninvasive strategy, obtain help
Failed intubation plus effective mask/SGA oxygenation	Do not rush to cricothyroidotomy; maintain oxygenation and reassess
Failed intubation plus ineffective mask/SGA oxygenation	Emergency front-of-neck airway

“Difficult intubation” alone is not the indication

A cricothyroidotomy is not automatically indicated simply because intubation is hard. If the patient can still be oxygenated by face mask or a supraglottic device, there is time for a structured reassessment, altered technique, awakening the patient when feasible, or an alternative definitive-airway plan.

The trigger is failure of oxygenation, not failure of one particular device or operator.

How to recognize impending failure

Warning signs include:

Falling oxygen saturation despite optimized efforts
Absent or inadequate chest rise with mask ventilation
Inability to achieve effective capnography with attempted ventilation
Severe airway obstruction with progressive fatigue, cyanosis, or reduced consciousness
A supraglottic airway that cannot be placed or does not provide effective ventilation
Blood, swelling, secretions, or anatomy making repeated laryngoscopy progressively less likely to work

Do not wait for saturation to reach zero or for cardiac arrest to begin. The decision must account for the trajectory: rapidly falling oxygenation, the cause of obstruction, and whether any remaining noninvasive method can realistically work.

Context-specific point: trauma

With major facial trauma, oral/nasal intubation and mask ventilation may both fail. With an open laryngeal disruption, direct placement of a tube into the distal tracheal segment through the wound may be possible, so the approach must be tailored to the injury.
Tintinalli’s Emergency Medicine: A Comprehensive Study, “Airway”.

Adult versus pediatric decision

This discussion is principally for adults. In infants and younger children, the small and vulnerable laryngeal anatomy makes open surgical cricothyroidotomy unsuitable or relatively contraindicated in many protocols. Pediatric rescue-airway plans differ by age, size, available expertise, and local guidelines.
Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 2405; Tintinalli’s Emergency Medicine, “Surgical Airway Management”.

Exam-ready answer

Emergency cricothyroidotomy is indicated in an adult CICO situation: failure of tracheal intubation combined with inability to maintain adequate oxygenation or ventilation with face-mask and supraglottic-airway rescue measures. It may also be considered when upper-airway obstruction or severe anatomical disruption makes conventional airway access impossible and a definitive airway is urgently required.

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3. Contraindications and alternatives

First principle

In a true adult CICO event, there are very few absolute contraindications to emergency cricothyroidotomy. If the patient cannot be oxygenated by noninvasive means, restoring oxygenation takes priority over risks such as bleeding, infection, or difficult landmarks.

Most “contraindications” are therefore relative. They signal that the procedure may be technically difficult, hazardous, or that another airway route is preferable if oxygenation can still be maintained.

Contraindications to surgical cricothyroidotomy

1. Ability to oxygenate by a less invasive method

This is the most important practical contraindication.

If effective face-mask ventilation or a supraglottic airway is providing oxygenation, do not perform a rushed surgical airway. Pause and move to a safer airway plan, such as awakening the patient where feasible, expert intubation, fiberoptic techniques, or a planned tracheostomy.

Difficult intubation alone is not an indication.
Failure of oxygenation is the trigger.

2. Young children

Open surgical cricothyroidotomy is generally avoided in infants and younger children because:

The cricothyroid membrane is very small
The larynx is more mobile and easily injured
A standard tracheal tube may be too large for the membrane
Cartilage damage and later airway stenosis are particular concerns

However, the exact age threshold differs among sources and protocols:

Source or approach	Age guidance
Barash anesthesia text	Contraindicated below about 6 years
Cummings otolaryngology	Relative contraindication below 10 years
Tintinalli emergency medicine	Surgical technique contraindicated below 10 years
Recent pediatric guidance	Favors age- and expertise-specific eFONA plans rather than relying only on one cutoff

Therefore, follow local pediatric difficult-airway guidance and obtain pediatric anesthesia or ENT support immediately when possible. A recent pediatric guideline states that surgical and commercial cannula cricothyrotomy are generally contraindicated in children because of the small membrane and risk of traumatic injury; it proposes needle CTM puncture for ages 5-12 years in its own protocol. AIDAA pediatric airway guideline

3. Laryngeal or laryngotracheal fracture/transection

A known or strongly suspected laryngeal fracture, laryngotracheal transection, or severe disruption of the subglottic airway is a major concern.

Why?

Passing a tube through the cricothyroid membrane may worsen disruption.
The tube may enter a false passage.
The obstruction or injury may lie below the proposed entry site.

If there is an open laryngeal wound, direct intubation through the wound into the identifiable distal trachea may be possible in selected trauma situations. Otherwise, specialist surgical airway management is needed.

4. Subglottic pathology

Cricothyroidotomy may not bypass the problem if there is obstruction or disease below the vocal cords, for example:

Subglottic tumor
Severe subglottic stenosis
Major laryngeal infection or structural disease extending below the CTM

When there is time and oxygenation is preserved, awake tracheostomy is often a more appropriate definitive plan.
Cummings Otolaryngology Head and Neck Surgery, “Indications”.

5. Distorted neck anatomy or inability to locate landmarks

Examples:

Marked obesity
Large neck mass
Prior neck surgery or radiotherapy
Severe congenital deformity
Burns, edema, cellulitis, or infection
Extensive trauma
Expanding neck hematoma

These conditions increase the risk of wrong-site incision, bleeding, false passage, and failure. They do not preclude cricothyroidotomy in a genuine CICO emergency. A vertical skin incision and an anatomy-guided approach may help when landmarks are impalpable, but this must be part of trained emergency-airway practice.

6. Coagulopathy or anticoagulation

Coagulopathy increases bleeding risk, but it is a relative contraindication only. In CICO, an airway takes precedence. Control bleeding after oxygenation is restored.

7. Local skin infection

Pre-existing infection at the intended entry site increases infectious complications. It matters in non-emergency planning, but it should not delay lifesaving front-of-neck access in an adult who cannot be oxygenated.
ROSEN’s Emergency Medicine: Concepts and Clinical Practice, p. 42.

Alternatives

The alternative depends on whether the patient can still be oxygenated.

If oxygenation is adequate

Use a safer, deliberate strategy:

Optimize face-mask ventilation
- Two-person technique
- Head and neck positioning as appropriate
- Oropharyngeal or nasopharyngeal airway adjuncts
- Suction blood, vomitus, or secretions
Use a supraglottic airway device
- A rescue option after failed intubation
- If ventilation is successful, stop repeated intubation attempts and reassess
Awake tracheal intubation
- Often with flexible endoscopy when there is predicted difficulty and time permits
- Best undertaken by an experienced team with a backup surgical-airway plan
Awake tracheostomy
- Particularly appropriate for anticipated upper-airway obstruction, subglottic disease, or when cricothyroidotomy is unsuitable but the patient remains oxygenated
Wake the patient
- In an anesthesia setting, if the procedure is non-emergent and reversal/awakening is feasible

If oxygenation is failing: emergency alternatives

Situation	Potential approach
Adult CICO, CTM accessible	Surgical cricothyroidotomy is generally preferred
Adult CICO, CTM difficult to identify	Trained eFONA approach using a vertical incision to identify the membrane
CICO with experienced ENT/surgeon immediately present	Emergency tracheostomy may be considered, but it is usually slower
Pediatric CICO	Age-specific plan: often needle CTM puncture, surgical tracheostomy by an expert, or another locally specified pediatric eFONA technique
Open laryngotracheal trauma	Direct airway placement through the wound into distal trachea may be possible in selected cases

Needle cricothyroidotomy can provide temporary oxygenation but is not a reliable definitive ventilatory airway in adults. It requires a patent route for expiration and carries risks of barotrauma, catheter kinking, and inadequate carbon dioxide clearance. Modern adult emergency-airway teaching typically favors a surgical airway approach rather than narrow-bore needle ventilation.
ROSEN’s Emergency Medicine: Concepts and Clinical Practice, p. 42; Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 2405.

Exam-ready summary

Absolute practical contraindication: the airway can be safely secured or oxygenation maintained by less invasive means.

Relative contraindications: young age, laryngeal fracture or transection, subglottic pathology, inability to identify neck landmarks, distorted neck anatomy, expanding hematoma, local infection, and coagulopathy.

In adult CICO, none of these should delay lifesaving emergency front-of-neck access. The choice of alternative depends on whether oxygenation is maintained, the patient’s age, airway pathology, available expertise, and local protocol.

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4. Equipment and preparation

Cricothyroidotomy should be performed only by trained clinicians in a CICO emergency, using a prepared emergency front-of-neck airway kit and local protocol.

Core adult surgical kit: scalpel-bougie-tube

A minimal, practical kit contains:

Item	Purpose
Personal protective equipment	Gloves, eye/face protection, gown as conditions permit. Blood and secretions are common.
Suction	Clears blood, vomitus, and secretions. It should be on and immediately accessible.
Oxygen source and bag-valve device	Continue oxygenation attempts before access and ventilate after tube placement.
Scalpel	Typically a No. 10 blade, with some kits using No. 11. The No. 10 blade is broad and can help create and maintain the opening.
Tracheal bougie / introducer	Guides the tube into the trachea. A coude-tip bougie is commonly used.
Cuffed endotracheal tube	Commonly a 6.0 mm internal-diameter cuffed tube for an adult emergency cricothyroidotomy. Keep a smaller tube available.
10 mL syringe	Inflates the cuff.
Waveform capnography	Confirms tracheal ventilation after placement.
Tube securing materials	Tape, ties, cloth ribbon, and ideally sutures if a tracheostomy tube is used.
Dressing and hemostatic supplies	Gauze, suction, and materials to manage bleeding after oxygenation is restored.

Tintinalli’s Emergency Medicine: A Comprehensive Study, Table 30-3, “Equipment Needed to Perform a Surgical Cricothyrotomy”.

The essential “four-item” emergency setup

For an adult scalpel-bougie-tube technique, the most important items are:

Scalpel
Bougie
6.0 cuffed endotracheal tube
Capnography plus a means of ventilation

Everything else supports safety, confirmation, and securing the airway. The equipment should be pre-packed, immediately available, and familiar to the team.

Why this method is favored

The scalpel-bougie-tube technique uses readily available tools and is commonly taught for adult emergency front-of-neck access. Emergency medicine and anesthesia texts describe it as faster and more successful than some needle or Seldinger-based alternatives, particularly where landmarks are poor.
ROSEN’s Emergency Medicine: Concepts and Clinical Practice, p. 42.

Current difficult-airway teaching emphasizes standardizing the emergency kit and practicing one familiar approach rather than depending on an unfamiliar proprietary device. A difficult-airway cart should include a dedicated eFONA kit alongside oxygenation and rescue-airway equipment. Difficult-airway equipment summary

Optional or backup items

Item	When useful
Smaller cuffed ETT or tracheostomy tube	If the standard 6.0 tube does not pass
Tracheal hook or dilator	May help maintain or widen access, depending on the local kit and operator training
Hemostat or Kelly forceps	Can assist with widening an incision in some techniques
Ultrasound	Can identify and mark the CTM before induction in anticipated difficult anatomy, if time permits
Local anesthetic, antiseptic, sterile drapes	Useful in a controlled or semi-elective procedure, but must not delay access in CICO
Flexible endoscope	May be used after stabilization to assess the airway, not as a reason to delay rescue oxygenation

Preparation before an anticipated difficult airway

If difficulty is predicted, prepare before induction:

Assign a team leader and declare the airway plan.
Allocate roles: intubator, assistant, drug administrator, suction, airway cart, and person ready for eFONA.
Check oxygen supply, suction, capnography, bag-mask device, supraglottic devices, and eFONA kit.
Locate and, when appropriate, mark the cricothyroid membrane before edema, bleeding, loss of landmarks, or patient positioning makes it difficult.
Consider ultrasound marking in obesity, neck mass, prior radiation/surgery, or impalpable landmarks when time permits.
Have senior anesthesia, emergency medicine, ENT, or surgical support available early where feasible.

The CTM can often be identified with ultrasound in adults, but it must not delay a true CICO rescue intervention.
Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 2406.

Positioning and environment

For an adult emergency airway:

Place the patient supine if feasible.
Use neck extension only when it is safe, and avoid it when cervical-spine movement is contraindicated.
Continue attempted oxygenation while the front-of-neck airway is being prepared.
Ensure strong lighting, suction, and a clear team declaration.
In a rapidly deteriorating CICO event, a formal sterile setup must not delay oxygenation.

Confirmation equipment

After emergency airway placement, rely on:

Continuous waveform capnography: preferred confirmation of ventilation
Visible chest movement
Improvement in oxygen saturation
Bilateral chest assessment
Chest radiograph and/or endoscopic assessment after stabilization, when indicated

Clinical examination or chest radiography alone is not sufficiently reliable to confirm tube placement.
The Washington Manual of Medical Therapeutics, p. 283.

Needle cricothyroidotomy equipment

Needle techniques are distinct from the adult surgical approach. They may require:

Large-bore, non-kinking catheter designed for airway use
Syringe for air aspiration confirmation
Appropriate oxygen delivery and pressure-regulated ventilation system
A plan that allows adequate expiration and avoids barotrauma

Ordinary IV catheters may kink and improvised ventilation connectors can be unreliable. Needle techniques are generally a temporary oxygenation measure and have a more limited role in adult CICO compared with surgical front-of-neck access.
Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 2405.

Equipment readiness checklist

Before any high-risk airway attempt, ask:

Is suction working?
Is oxygen connected and flowing?
Is waveform capnography available?
Is a second-generation supraglottic airway available?
Is the eFONA kit physically present and opened or immediately accessible?
Are scalpel, bougie, 6.0 cuffed tube, syringe, and securing materials present?
Has the CTM been identified or marked if time allows?
Does every team member know the threshold for declaring CICO?

Exam-ready answer

The standard adult emergency cricothyroidotomy setup is a scalpel-bougie-tube kit: PPE, suction, oxygen and bag-valve device, scalpel, tracheal bougie, 6.0 mm cuffed endotracheal tube with a smaller backup, cuff syringe, waveform capnography, and materials to secure the tube. In anticipated difficult airway cases, the CTM should be identified or marked in advance and roles, backup oxygenation devices, and emergency front-of-neck access plans should be explicitly prepared.

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5. Step-by-step procedure: adult emergency surgical cricothyroidotomy

This is a CICO rescue procedure for trained clinicians: cannot intubate and cannot oxygenate. Use local emergency-airway protocol and call for help, but do not delay lifesaving oxygenation for the arrival of help.

Modern adult practice favors a vertical-incision scalpel-bougie-tube approach. The 2025 DAS guideline retains this vertical eFONA technique and standardizes it as the emergency front-of-neck approach. DAS 2025 guideline

Equipment at hand

No. 10 scalpel
Coudé-tip bougie
Lubricated 6.0 mm cuffed endotracheal tube
10 mL syringe
Bag-valve device with high-flow oxygen
Suction
Continuous waveform capnography
Tape or ties to secure the tube

Miller’s Anesthesia, 10e, p. 5959.

Procedural sequence

1. Declare CICO and prepare in parallel

State the situation clearly:

“Cannot intubate, cannot oxygenate. Emergency front-of-neck airway now.”

Call for help.
Allocate roles: operator, oxygenation/ventilation, suction, drugs/monitoring.
Continue any potentially effective mask or supraglottic oxygenation while access is being established.
Turn on suction.
Open the eFONA kit.

2. Position the patient

Place supine if feasible.
Extend the neck only if it is safe to do so.
Do not delay for ideal positioning in a rapidly desaturating patient.
In suspected cervical-spine injury, minimize movement but prioritize oxygenation.

3. Identify and stabilize the larynx

With the non-dominant hand:

Palpate the thyroid cartilage.
Move inferiorly into the depression between the thyroid cartilage and the cricoid cartilage.
This depression is the cricothyroid membrane.
Stabilize the larynx firmly in the midline throughout the procedure.

If the CTM is impalpable, as in obesity, hematoma, edema, or distorted anatomy, proceed with a midline vertical skin incision to expose and identify the laryngeal structures by blunt dissection. Textbook guidance describes an approximately 8-10 cm vertical incision when the membrane cannot be palpated.
Miller’s Anesthesia, 10e, p. 5959.

4. Make a vertical midline skin incision

Make a vertical incision in the anterior neck midline, centered over the presumed CTM location.

Purpose:

Exposes the laryngeal framework
Helps maintain orientation if the membrane is difficult to feel
Gives access for blunt dissection and re-identification of the CTM

Use fingers to separate soft tissue and re-palpate the thyroid cartilage, cricoid cartilage, and membrane. Keep the larynx stabilized.

5. Enter the cricothyroid membrane

Once the CTM is located:

Hold the scalpel perpendicular to the skin.
Make a transverse stab incision through the CTM into the airway.
Keep control of blade depth to limit posterior-wall injury.
Rotate the scalpel 90 degrees so its cutting edge points caudally and its handle remains upright, maintaining the opening.

The 90-degree rotation widens the opening and creates a guide for bougie passage.
Miller’s Anesthesia, 10e, pp. 5959-5960.

6. Pass the bougie

Keep traction on the scalpel to maintain the opening.
Pass the coudé tip of the bougie down the side of the scalpel blade that is furthest from you and into the trachea.
Direct the bougie caudally, toward the feet.
Advance gently into the trachea, usually about 10-15 cm.
Never force the bougie.

A feeling of tracheal “clicks” may be felt but is not required. Lack of resistance and appropriate direction matter more than any single tactile sign.

7. Remove scalpel and railroad the tube

Remove the scalpel while maintaining control of the bougie.
Railroad the lubricated 6.0 mm cuffed endotracheal tube over the bougie.
Rotate the tube gently if needed while advancing.
Avoid advancing too deeply because endobronchial placement can occur.
Remove the bougie once the tube is seated.

Miller’s Anesthesia, 10e, p. 5960.

8. Inflate, ventilate, confirm

Inflate the cuff.
Connect the bag-valve device or ventilator.
Ventilate with oxygen.
Confirm successful tracheal placement with continuous waveform capnography.

Also assess:

Visible chest rise
Improving oxygen saturation
Bilateral breath sounds
Absence of major air leak, rapidly expanding neck emphysema, or gastric insufflation

Sustained waveform capnography is the preferred confirmation method.
Miller’s Anesthesia, 10e, p. 5960.

9. Secure and manage after access

Once oxygenation is restored:

Secure the tube firmly with tape, ties, or sutures as locally practiced.
Reassess tube depth, ventilation, oxygenation, hemodynamics, and complications.
Obtain chest imaging and airway review once the patient is stabilized.
Arrange transfer to an appropriate critical-care, anesthesia, ENT, or surgical team.
Plan subsequent management of this temporary emergency airway according to local protocol.

Cricothyroidotomy is not generally considered a permanent airway; a subsequent plan for removal or conversion to formal tracheostomy may be necessary.
Miller’s Anesthesia, 10e, p. 5958.

Quick cognitive aid: “Cut - bougie - tube - capnography”

Cut: vertical skin incision, identify CTM, transverse membrane incision
Bougie: insert caudally into trachea
Tube: railroad 6.0 cuffed tube
Capnography: confirm ventilation, then secure the airway

If the tube will not pass

Do not repeatedly force it.

Reconfirm that the bougie is in the trachea.
Maintain the opening with the scalpel or a finger only if trained to do so.
Use gentle rotation while advancing the tube.
Consider a smaller cuffed tube if immediately available.
Continue the team’s oxygenation strategy and follow the local failed-eFONA rescue algorithm.

Common critical errors to avoid

Delaying the decision while oxygenation is failing
Repeated laryngoscopy attempts after CICO has been established
Losing midline orientation in a difficult neck
Blind deep cutting or uncontrolled scalpel depth
Directing the bougie posteriorly rather than caudally
Forcing the bougie or tube against resistance
Advancing the tube too far into a main bronchus
Treating visual chest movement alone as confirmation instead of using waveform capnography
Failing to secure the tube after successful ventilation

This procedure should be learned and maintained through supervised simulation, not from written instructions alone.

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Quick answer

6. Post-procedure management after cricothyroidotomy

Once the airway has been placed, the immediate priorities are to confirm ventilation, secure the tube, stabilize the patient, identify complications, and arrange definitive airway care.

1. Confirm that the tube is in the trachea

Use continuous waveform capnography as the primary confirmation method.

Also assess:

Bilateral chest rise
Improvement in oxygen saturation
Bilateral breath sounds
Absence of marked gastric insufflation
Ventilator pressures and delivered tidal volumes
Clinical improvement in cyanosis, consciousness, and hemodynamics where relevant

Chest auscultation or chest radiography alone should not be relied on to confirm placement. If capnography is absent or inconsistent, suspect displacement, false passage, obstruction, or peri-arrest low pulmonary blood flow.

2. Ventilate and oxygenate

Connect to a bag-valve device or ventilator with high-concentration oxygen initially.
Set ventilation appropriate to the patient’s condition and monitor oxygenation and end-tidal CO2.
Avoid excessive pressures, especially if there is concern for malposition, barotrauma, or airway obstruction.
Suction the tube if blood or secretions are likely.

3. Secure the tube immediately

An emergency cricothyroidotomy tube can be easily displaced.

Secure it with commercial tube ties, tape, or sutures according to local protocol.
Record the visible tube depth and reassess it after transfers, repositioning, imaging, or transport.
Apply an appropriate dressing around the entry site.
Avoid excessive tube movement while the patient is being stabilized.

4. Reassess for immediate complications

Look actively for:

Finding	Possible concern
No or poor capnography	Displacement, false passage, obstruction, arrest/very low perfusion
Subcutaneous emphysema	Air leak, false passage, tracheal injury
High airway pressures or poor chest rise	Tube obstruction, kinking, mainstem placement, pneumothorax, severe bronchospasm
Unilateral breath sounds	Endobronchial tube placement or pneumothorax
Hypotension or sudden deterioration	Tension pneumothorax, persistent hypoxia, hemorrhage, peri-arrest state
Ongoing bleeding	Soft-tissue or vascular injury
Persistent hypoxemia	Incorrect placement, tube obstruction, underlying lung pathology, inadequate ventilation

If ventilation suddenly fails, treat it as an airway emergency. Check the circuit, tube position, patency, capnography, and chest movement, and consider pneumothorax or false passage.

5. Continue resuscitation and treat the cause

Cricothyroidotomy restores an airway. It does not treat the underlying problem. Continue management of the precipitating cause, such as:

Anaphylaxis
Facial or neck trauma
Expanding hematoma
Inhalation injury or burns
Upper-airway infection or edema
Foreign-body obstruction
Tumor-related obstruction
Massive bleeding or aspiration

Provide analgesia, sedation, and ongoing critical-care support once oxygenation and circulation permit.

6. Obtain specialist review and plan definitive airway care

Notify anesthesia, ENT, trauma surgery, emergency medicine, or intensive care specialists as appropriate.

Cricothyroidotomy is usually regarded as a temporary emergency airway, not a long-term solution. After stabilization, the team should decide whether to:

Retain the cricothyroidotomy temporarily
Convert to a formal tracheostomy
Establish a conventional oral/nasal tracheal tube if safely possible
Remove the device when no longer needed

The timing and need for conversion are individualized. Do not manipulate or exchange a functioning emergency airway casually before an experienced team and full backup are available.

7. Imaging and airway assessment after stabilization

Once the patient is stable, consider:

Chest radiograph to check tube depth and detect pneumothorax
Flexible endoscopic airway assessment when indicated
CT imaging in major laryngeal or neck trauma, if clinically safe
Documentation of laryngeal injury, bleeding, emphysema, and tube position

8. Documentation and debrief

Document clearly:

CICO declaration and time of decision
Indication for cricothyroidotomy
Technique and device/tube size used
Number of attempts
Confirmation by waveform capnography
Tube depth and securing method
Complications and corrective actions
Subsequent airway plan and named responsible team

A team debrief is useful after the event. It addresses clinical learning, equipment issues, human factors, and staff support after a high-stress emergency.

Post-procedure checklist

Capnography - Ventilate - Secure - Reassess - Treat cause - Call specialists - Plan definitive airway - Document

Exam-ready answer

Following cricothyroidotomy, confirm tracheal ventilation with continuous waveform capnography, ventilate with oxygen, secure the tube, and monitor oxygenation, ventilation, hemodynamics, and complications such as bleeding, false passage, tube displacement, subcutaneous emphysema, pneumothorax, and endobronchial intubation. Obtain specialist review and formulate a plan for definitive airway management, including possible conversion to tracheostomy.

6. Post-procedure management

A successful cricothyroidotomy is only the start of airway care. Once ventilation is restored, priorities are confirmation, stabilization, ongoing resuscitation, surveillance for complications, and planning definitive airway management.

1. Confirm tracheal placement immediately

Use continuous waveform capnography as the primary confirmation method.

Also assess:

Bilateral chest rise
Improvement in oxygen saturation
Bilateral breath sounds
Absence of epigastric insufflation
Tube depth and signs of excessive air leak
Hemodynamic response

Clinical examination and chest radiography alone are not reliable enough to prove correct airway placement. Persistent waveform capnography with effective ventilation is the key confirmation.

2. Ventilate and oxygenate

Connect the tube to a bag-valve device or ventilator with oxygen.
Use lung-protective ventilation when stabilized, tailored to the underlying illness or injury.
Titrate oxygen to adequate saturation once the immediate crisis has resolved.
Obtain arterial blood gas analysis when clinically appropriate, especially after prolonged hypoxia, hypercapnia, or resuscitation.

If ventilation is inadequate, consider:

Tube obstruction by blood, secretions, or kinking
Displacement or false passage
Cuff leak
Right mainstem bronchial intubation from excessive tube depth
Pneumothorax, including tension pneumothorax
Severe ongoing airway or pulmonary pathology

3. Secure the tube

The cricothyroidotomy tube is highly prone to accidental displacement.

Secure it with tape, ties, or sutures according to local practice.
Avoid excessive movement during transfer.
Mark and document tube depth.
Recheck waveform capnography after every move, handover, or deterioration.
Keep suction immediately available.

4. Treat the cause of the airway emergency

The emergency airway does not treat the underlying problem. Continue targeted care, for example:

Cause	Ongoing priorities
Anaphylaxis	Intramuscular or intravenous epinephrine as appropriate, fluids, adjunctive therapy, observation
Trauma	Hemorrhage control, cervical-spine considerations, imaging, trauma-team management
Neck hematoma	Surgical review and hemostasis
Infection or airway edema	Antimicrobial therapy, anti-inflammatory therapy where appropriate, ENT/anesthesia assessment
Foreign body	Definitive removal once oxygenation is secure
Tumor or stenosis	ENT/thoracic airway planning and definitive management

5. Sedation, analgesia, and paralysis if needed

Once oxygenation is secured, provide adequate analgesia and sedation. The awake or partially awake patient may experience pain, coughing, agitation, and risk of tube displacement.

Choice of medication depends on blood pressure, neurological status, injury pattern, and available monitoring. Ongoing paralysis may be needed for controlled mechanical ventilation, but only after confirming a functioning airway and ensuring adequate sedation and analgesia.

6. Monitor for early complications

Monitor continuously in a resuscitation area, operating theatre, or ICU.

Early complications include:

Hemorrhage
Tube displacement or accidental decannulation
False passage
Subcutaneous emphysema
Pneumomediastinum or pneumothorax
Posterior tracheal-wall injury
Tube obstruction by blood or secretions
Inadequate ventilation or hypoxemia
Mainstem bronchial intubation
Aspiration
Hemodynamic collapse related to preceding hypoxia

A sudden loss of capnography or chest rise after initial success should be treated as tube displacement or obstruction until proved otherwise.

7. Imaging and airway assessment after stabilization

Once the patient is stable:

Obtain chest radiography to assess tube position and look for pneumothorax or other thoracic complications.
Consider flexible endoscopic examination where indicated.
Assess for laryngeal, tracheal, vascular, or esophageal injury, especially after trauma or difficult placement.
In trauma, imaging must follow the patient’s overall stability and trauma protocol.

8. Decide on definitive airway management

Cricothyroidotomy is generally considered a temporary emergency airway, not necessarily a long-term definitive airway.

Early involvement of anesthesia, ENT, trauma surgery, or critical care is appropriate to decide whether to:

Keep the cricothyroidotomy temporarily
Remove it after a secure conventional airway is established
Convert to a formal tracheostomy
Proceed with oral or nasal endotracheal intubation when safe and appropriate

The need and timing of conversion vary with the reason for airway failure, airway injury, expected ventilation duration, local protocol, and specialist assessment. Do not remove or exchange a functioning emergency airway without a clear backup plan.

Miller’s Anesthesia, 10e, p. 5958.

9. Documentation and debrief

Document:

Indication and CICO declaration
Time of decision and procedure
Technique and equipment used
Tube type and size
Confirmation method, especially capnography
Oxygenation and hemodynamic status before and after placement
Complications and interventions
Definitive airway plan and responsible specialty

A structured team debrief is useful after this high-stress event, both for staff support and system improvement.

Exam-ready summary

After cricothyroidotomy, confirm ventilation with continuous waveform capnography, oxygenate and ventilate, secure the tube, provide analgesia and sedation, monitor for bleeding, displacement, barotrauma and tube obstruction, treat the original cause of airway failure, obtain imaging and specialist review after stabilization, and plan removal or conversion to a definitive airway such as tracheostomy when indicated.

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10. Conversion to tracheostomy: avoid a rigid rule

Traditional teaching often advised conversion of every cricothyroidotomy to a tracheostomy within 72 hours because of concern about subglottic stenosis. The evidence supporting a mandatory time-based conversion is limited.

A systematic review found comparable complication rates for emergency cricothyroidotomy and emergency tracheostomy, and concluded that more evidence is needed to define whether conversion is always needed and, if so, when. Systematic review of surgical airways

Therefore:

Do not automatically convert solely because a fixed number of hours has passed.
Obtain early ENT, anesthesia, trauma, or critical-care input.
Base the decision on airway injury, expected duration of ventilation, need for further neck surgery, tube stability, laryngeal pathology, and local protocol.
If conversion is planned, it must occur in a controlled setting with a backup airway plan.
Never remove a working cricothyroidotomy before another secure airway is confirmed.

Miller’s Anesthesia, 10e, p. 5958, states that a plan for removal or conversion to formal tracheostomy should be made after placement.

Tube-care priorities during transfer and ICU care

A cricothyroidotomy tube can dislodge easily because it is shallow and placed through an emergency incision.

Secure and reassess frequently

Secure the tube with appropriate ties, tape, and where practiced, sutures.
Document the tube type, internal diameter, visible depth, cuff status, and capnography.
Keep the neck accessible. Do not bury the site under bulky dressings.
Have suction, bag-valve ventilation, oxygen, capnography, and re-airway equipment immediately available during transport.
Confirm waveform capnography after repositioning, transfer, or any deterioration.

Cuff pressure

Check cuff pressure after stabilization and at intervals.
Use the lowest pressure that provides a seal, following local critical-care practice.
Overinflation may worsen mucosal injury; underinflation causes an air leak and loss of effective ventilation.

Humidification and secretion management

Use humidified gas when ongoing ventilation is required.
Suction through the tube as needed using sterile technique.
Be alert to obstruction from clot, thick secretions, or kinking.

If ventilation suddenly fails after initially successful placement

Treat this as an emergency. Use a structured assessment:

DOPES approach

D - Displacement: tube has moved out or into a false passage
O - Obstruction: clot, mucus, kink, or biting
P - Pneumothorax: especially tension pneumothorax after difficult access or positive-pressure ventilation
E - Equipment failure: disconnected circuit, oxygen failure, capnography issue
S - Stacked breaths / severe bronchospasm: high intrathoracic pressure or obstructive physiology

Immediate actions include:

Call for help and give 100% oxygen.
Check the circuit and bag manually.
Assess waveform capnography and chest movement.
Pass a suction catheter to check tube patency if appropriate.
Look for neck swelling, bleeding, air leak, or subcutaneous emphysema.
Assess for pneumothorax and decompress immediately if tension pneumothorax is suspected clinically.
If displacement is suspected, do not repeatedly blindly reinsert through the same tract. Follow the local failed-eFONA rescue plan with senior airway and surgical assistance.

Post-event investigation and specialty review

After stabilization, consider the following according to the scenario:

Chest radiograph for pulmonary complications and tube position assessment
Flexible bronchoscopy or laryngoscopy if airway injury, tube malposition, aspiration, or retained blood/foreign material is suspected
CT neck/chest in stable trauma patients or when laryngotracheal injury is suspected
ENT review for laryngeal trauma, fracture, tumor, stenosis, prolonged airway need, or planned conversion
Trauma-team review for penetrating or blunt neck injury

A cuffed tracheal tube placed through a surgical cricothyroidotomy permits conventional low-pressure ventilation, facilitates capnographic confirmation, and allows expiration, unlike narrow-bore needle approaches. Review of eFONA techniques

Handover checklist

A safe handover should state:

Why the airway failed and when CICO was declared
Exact time and method of cricothyroidotomy
Tube type, size, depth, cuff status, and method of securing
Evidence of correct placement: sustained waveform capnography
Current ventilator settings, oxygen requirement, blood gas results, and hemodynamic status
Drugs administered, including sedatives, analgesics, paralytics, antibiotics, and resuscitation medications
Known or suspected complications: bleeding, aspiration, emphysema, pneumothorax, airway trauma
Plan for ENT/anesthesia/ICU review and possible definitive-airway management

Key post-procedure principle

A functioning cricothyroidotomy must be protected as the patient’s lifesaving airway. Confirm it with waveform capnography, secure it, ventilate appropriately, investigate complications, manage the original cause of obstruction, and make an individualized specialist plan for definitive airway care.

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7. Complications of cricothyroidotomy

Complications arise from the emergency context itself, difficult anatomy, hypoxia before access, and mechanical injury during or after tube placement. In a true CICO emergency, these risks do not outweigh the need to restore oxygenation.

A systematic review of 1,219 emergency cricothyrotomies found that early complications included failure to obtain an airway (1.6%), injury to cartilaginous structures (1.6%), hemorrhage (0.7%), and pneumothorax (0.2%). Late airway stenosis occurred in about 1.1% in the pooled data, although reported rates varied across studies. Emergency surgical-airway review

A. Immediate and early complications

Complication	Mechanism or clues	Prevention / response
Failure to establish an airway	Unable to find CTM, enter trachea, pass bougie, or pass tube	Declare CICO early, use a practiced technique, maintain midline orientation, call for help, follow a failed-eFONA rescue plan
False passage / paratracheal tube placement	No sustained capnography, poor chest movement, neck swelling, subcutaneous emphysema	Do not force the bougie or tube; confirm with waveform capnography; reassess urgently
Hemorrhage	Skin, thyroid, vascular, or traumatic neck bleeding obscures landmarks	Firm laryngeal stabilization, midline approach, suction, direct pressure after oxygenation is achieved
Laryngeal or tracheal cartilage injury	Deep, off-midline, or excessively large incision	Controlled blade depth, correct identification of the CTM, avoid forceful dilatation
Posterior tracheal-wall injury	Excessive depth of scalpel, bougie, dilator, or tube	Keep the scalpel controlled and perpendicular; do not force instruments
Tube obstruction	Blood clot, secretions, kinking, or cuff/tube problem	Suction, assess circuit and capnography, replace or revise only with an airway backup plan
Tube displacement / accidental decannulation	Sudden loss of capnography or chest rise, air leak, inability to ventilate	Secure well, minimize handling, reassess after all transfers or repositioning
Mainstem bronchial intubation	Unilateral breath sounds, high airway pressure, reduced contralateral ventilation	Avoid excessive advancement; reassess depth and withdraw if needed
Subcutaneous emphysema	Neck swelling and crepitus, often from malposition or air leak	Check tube position and integrity; seek pneumothorax and false passage
Pneumomediastinum or pneumothorax	Worsening hypoxia, hypotension, high airway pressures, unilateral absent breath sounds	Consider especially after difficult access or positive-pressure ventilation; immediately decompress suspected tension pneumothorax
Aspiration	Gastric contents, blood, or secretions in airway	Suction, cuffed tube, lung-protective ventilation, supportive treatment
Hypoxic brain injury or cardiac arrest	Usually from delay before successful oxygenation, rather than the incision itself	Early recognition of CICO and prompt front-of-neck access

Acute complications described in anesthesia texts include pneumothorax, subcutaneous and mediastinal emphysema, bleeding, esophageal puncture, aspiration, and respiratory acidosis.
Morgan and Mikhail’s Clinical Anesthesiology, 7e, Airway section.

B. Problems especially associated with needle or jet ventilation

Needle cricothyroidotomy and transtracheal jet ventilation carry specific risks because gas may enter under pressure while expiration is restricted.

Potential consequences include:

Barotrauma
Pneumothorax, including bilateral tension pneumothorax
Pneumomediastinum
Subcutaneous emphysema
Hypercapnia due to poor carbon dioxide clearance
Catheter kinking or migration
Paratracheal insufflation from misplaced cannula

Barotrauma is particularly dangerous if the upper airway is fully obstructed and exhalation cannot occur. This is one reason surgical scalpel-bougie-tube access is often favored for adult CICO: a cuffed tube allows conventional low-pressure ventilation and expiration.

C. Late complications

Complication	Clinical relevance
Subglottic or tracheal stenosis	Scar-related narrowing can present later with exertional dyspnea, stridor, or recurrent respiratory symptoms
Tracheomalacia	Weakness or collapse of tracheal wall, uncommon but possible after injury or prolonged airway instrumentation
Voice change / dysphonia	May follow laryngeal trauma, scarring, nerve injury, or altered vocal-cord function
Dysphagia or swallowing dysfunction	May result from local trauma, edema, scarring, or coexisting airway injury
Peristomal infection	Erythema, purulent discharge, fever, local pain
Granulation tissue	May form around the stoma and contribute to bleeding, obstruction, or later stenosis
Persistent stoma or scar	Usually minor but may require follow-up
Aspiration pneumonia	May occur after the emergency, especially with initial aspiration, impaired laryngeal function, or prolonged ventilation

Late complications listed in Miller’s Anesthesia, 10e include swallowing dysfunction, infection, voice changes, and tracheal stenosis. It reports tracheal stenosis in roughly 2%-8% of adults, particularly where trauma or infection already exists.
Miller’s Anesthesia, 10e, p. 5960.

Stenosis: important, but do not exaggerate the risk

Subglottic stenosis has historically been the complication most associated with cricothyroidotomy. Modern evidence suggests that the risk is lower than traditional teaching implied, especially when the procedure is performed as a short-term emergency intervention rather than prolonged airway management. The systematic review cited above found reported airway-stenosis rates ranging from 0.22%-7.0% across included studies. Review findings

The possibility of future stenosis should prompt airway follow-up when appropriate. It must never delay an emergency procedure in a patient who cannot be oxygenated.

D. Risk factors for complications

Complications become more likely with:

Delay in declaring CICO
Repeated failed intubation attempts causing edema and bleeding
Obesity, large neck circumference, neck mass, hematoma, or distorted anatomy
Prior neck surgery, radiation, burns, or infection
Laryngeal trauma or fracture
Coagulopathy or anticoagulant therapy
Inexperienced operator or unfamiliar equipment
Poorly secured tube during transfer
Needle-based ventilation with inadequate exhalation
Pediatric age and small laryngeal anatomy

E. Red flags after placement

Urgently reassess if any of the following occur:

No sustained waveform capnography
Sudden fall in oxygen saturation
Absent chest rise
Worsening neck swelling or crepitus
Rapid air leak
Bleeding that obscures the airway
High airway pressures
Unilateral breath sounds
Hypotension or cardiac arrest after ventilation begins

Think of: displacement, obstruction, pneumothorax, equipment failure, or severe bronchospasm/air trapping.

Exam-ready classification

Immediate complications: failure to obtain the airway, hemorrhage, false passage, cartilage or posterior tracheal-wall injury, esophageal injury, tube obstruction or displacement, aspiration, subcutaneous emphysema, pneumomediastinum, pneumothorax, and persistent hypoxia.

Late complications: infection, granulation tissue, dysphagia, dysphonia, vocal-cord dysfunction, tracheomalacia, and subglottic or tracheal stenosis.

Most important preventable factor: early CICO recognition, prompt use of a practiced technique, capnographic confirmation, and secure post-procedure tube care.

8,9

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8. Special situations

A. Obesity or impalpable neck landmarks

Obesity creates two related risks:

Mask ventilation and supraglottic rescue may be more difficult.
The cricothyroid membrane may be deep and difficult to palpate.

Preparation for a predicted difficult airway:

Position appropriately, commonly with head and torso elevation or a ramped position for oxygenation.
Identify and mark the cricothyroid membrane before induction, ideally while the patient is awake and landmarks are not distorted.
Use ultrasound when palpation is uncertain and time permits.
Ensure a dedicated eFONA kit is immediately accessible, with a team plan and assigned roles.

The DAS 2025 guidance supports identifying the CTM during airway assessment using visual inspection, palpation, or ultrasound. DAS guidance on CTM identification

If CICO occurs:

Do not waste time repeatedly searching for a small “perfect” landmark.
Use the trained vertical midline incision approach to expose and identify laryngeal anatomy.
Expect a greater skin-to-airway distance and the need for more blunt dissection.
Maintain firm, continuous laryngeal stabilization.

ROSEN’s Emergency Medicine: Concepts and Clinical Practice, “Difficult Cricothyrotomy: SMART”.

B. Neck trauma, hematoma, burns, or distorted anatomy

Cricothyroidotomy may be technically difficult when landmarks are obscured by:

Expanding hematoma
Penetrating neck injury
Massive edema
Surgical emphysema
Neck mass or tumor
Prior neck surgery
Radiation scarring
Local infection or abscess
Burns

The mnemonic SMART helps identify a potentially difficult cricothyroidotomy:

S - Surgery or scarring
M - Mass or hematoma
A - Access problem, including trauma or radiation
R - Radiation or related distortion
T - Tumor or trauma

Different versions exist, but the central message is to anticipate difficulty when anterior neck access is limited or laryngeal landmarks are obscured.

In trauma:

Continue manual in-line stabilization when cervical-spine injury is possible, but do not allow this to prevent lifesaving oxygenation.
If there is an obvious open laryngotracheal wound, a tube may sometimes be placed directly into the distal tracheal segment by an experienced clinician.
Suspected laryngeal fracture or transection makes standard cricothyroidotomy hazardous. Obtain surgical help immediately if possible, but in CICO the oxygenation emergency remains paramount.

C. Upper-airway edema and infection

Examples include anaphylaxis, inhalation injury, angioedema, epiglottitis, deep-neck infection, and severe laryngeal edema.

Key points:

Airway deterioration may be rapid and intubation can become progressively harder after repeated attempts.
Seek expert airway and ENT support early if oxygenation is still preserved.
A controlled awake airway plan may be safer than induction in selected patients.
If CICO occurs, proceed to emergency front-of-neck access according to protocol.

For deep-neck infection, anatomy may be distorted and local infection raises procedural risk, but these concerns are secondary to the need to establish oxygenation in a true CICO emergency.

D. Laryngeal tumor, stenosis, or obstruction below the CTM

A cricothyroidotomy only bypasses obstruction that is above the membrane. It may fail if disease lies at or below the entry site, such as:

Subglottic stenosis
Laryngeal or subglottic tumor
Major laryngotracheal injury

If time and oxygenation permit, specialist-led awake tracheostomy is often more suitable. If the patient cannot be oxygenated, emergency airway decisions must be individualized with immediate surgical assistance.

E. Pediatric airway emergency

Pediatric eFONA is fundamentally different from adult practice.

Infants and young children have a very small cricothyroid membrane and mobile laryngeal structures.
A standard surgical cricothyroidotomy may cause severe laryngeal injury.
Protocols vary in age cutoffs and preferred technique.
Pediatric CICO should prompt immediate senior pediatric anesthesia, ENT, and surgical support.

There is no universal age threshold across all guidelines. Many sources avoid open surgical cricothyroidotomy in young children and favor age-specific alternatives such as needle CTM puncture or surgical tracheostomy by an experienced operator. Pediatric eFONA guidance

Do not apply the adult scalpel-bougie-tube technique automatically to a child.

9. Practical learning, algorithms, and viva points

The key cognitive sequence

Oxygenate - recognize CICO - declare CICO - perform eFONA - confirm with capnography - secure - hand over

A practical adult airway sequence is:

Plan	Goal
Plan A	Tracheal intubation
Plan B	Oxygenation via supraglottic airway
Plan C	Optimized face-mask oxygenation
Plan D	Emergency front-of-neck airway

The important behavioral skill is moving on promptly when a plan fails, rather than repeating ineffective attempts while the patient becomes hypoxic.

Suggested spoken crisis script

A clear, standardized declaration helps the team transition:

“This is a CICO situation. Stop further intubation attempts. Call for help. Bring and open the eFONA kit. Continue oxygenation attempts. I am proceeding to emergency front-of-neck airway.”

Then, after tube placement:

“Ventilate and confirm continuous waveform capnography. Secure the tube. Notify ENT, anesthesia, ICU, or trauma team. Document and plan definitive airway management.”

Adult scalpel-bougie-tube memory aid

Skin - membrane - bougie - tube - capnography

Or:

Cut - bougie - tube - CO₂

This is an educational aid, not a replacement for formal hands-on training.

Pre-intubation “FONA-ready” checklist

For any predicted difficult airway, ask:

Is the cricothyroid membrane identifiable and, if indicated, marked?
Is suction working?
Is oxygen available and are backup oxygenation devices prepared?
Are scalpel, bougie, 6.0 cuffed tube, syringe, and capnography ready?
Are team roles assigned?
Has the threshold for CICO and eFONA been discussed?
Is senior help available or being called early?

Training principles

Because emergency cricothyroidotomy is rare but time-critical, competence cannot depend on experience alone.

Training should include:

Repeated simulation on an appropriate airway trainer or cadaveric model where permitted
Use of the exact eFONA kit available in the clinician’s workplace
Both palpable and impalpable-landmark scenarios
Obesity, neck hematoma, bleeding, secretions, and trauma simulations
Team communication, role allocation, and explicit CICO declaration
Capnography confirmation and tube-securement practice
Post-event handover, documentation, and debriefing

Anesthesia guidance recommends regular training because this skill decays without practice.
Miller’s Anesthesia, 10e, p. 5960.

High-yield viva questions

1. What is the indication?
Adult CICO: failed tracheal intubation plus inability to maintain oxygenation by face mask or supraglottic airway.

2. What structure is entered?
The cricothyroid membrane, between the thyroid cartilage and cricoid cartilage.

3. What is the preferred adult emergency approach?
A trained, standardized surgical scalpel-bougie-tube eFONA approach.

4. What are the essential items?
Scalpel, coudé-tip bougie, 6.0 mm cuffed ETT, oxygen/ventilation equipment, suction, waveform capnography, and tube-securing materials.

5. What confirms placement?
Sustained waveform capnography, with clinical evidence of effective ventilation.

6. What is the commonest reason for death in CICO?
Delay in recognizing failed oxygenation and delay in proceeding to emergency front-of-neck access.

7. What major complications must be mentioned?
Failure, hemorrhage, false passage, cartilage or posterior-wall injury, tube obstruction or displacement, pneumothorax, subcutaneous emphysema, aspiration, infection, dysphonia, dysphagia, and later subglottic/tracheal stenosis.

8. Is it appropriate in children?
Not as a direct copy of the adult technique. Pediatric rescue-airway management is age-, anatomy-, expertise-, and protocol-dependent.

9. Does every cricothyroidotomy need immediate conversion to tracheostomy?
No fixed time rule should replace specialist assessment. A functioning emergency airway must be protected while the definitive-airway plan is individualized.

Final exam summary

Cricothyroidotomy is an emergency rescue airway for adult CICO. The most important factors are early recognition, clear declaration, immediate access to a standardized scalpel-bougie-tube kit, continuous waveform capnography to confirm ventilation, tube security, management of complications, and structured specialist follow-up. The procedure must be practiced in supervised simulation and performed according to local difficult-airway protocols.

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mkdir -p "/tmp/workspace/cricothyroidotomy-study-note/src" "/tmp/workspace/cricothyroidotomy-study-note/output" && python - <<'PY' from reportlab.lib import colors from reportlab.lib.enums import TA_CENTER from reportlab.lib.pagesizes import A4 from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.units import cm from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, PageBreak, Table, TableStyle, KeepTogether from reportlab.pdfbase.pdfmetrics import stringWidth from reportlab.pdfbase.ttfonts import TTFont from reportlab.pdfbase import pdfmetrics from reportlab.lib.colors import HexColor from reportlab.pdfbase.pdfmetrics import registerFontFamily from xml.sax.saxutils import escape out='/tmp/workspace/cricothyroidotomy-study-note/output/Cricothyroidotomy_Study_Guide.pdf' styles=getSampleStyleSheet() styles.add(ParagraphStyle(name='TitleCustom', parent=styles['Title'], fontName='Helvetica-Bold', fontSize=24, leading=29, alignment=TA_CENTER, textColor=HexColor('#123047'), spaceAfter=12)) styles.add(ParagraphStyle(name='SubTitle', parent=styles['Normal'], fontSize=11.5, leading=16, alignment=TA_CENTER, textColor=HexColor('#445B69'), spaceAfter=18)) styles.add(ParagraphStyle(name='H1C', parent=styles['Heading1'], fontName='Helvetica-Bold', fontSize=16, leading=20, textColor=HexColor('#0B4F6C'), spaceBefore=12, spaceAfter=8, keepWithNext=True)) styles.add(ParagraphStyle(name='H2C', parent=styles['Heading2'], fontName='Helvetica-Bold', fontSize=12.5, leading=16, textColor=HexColor('#123047'), spaceBefore=8, spaceAfter=5, keepWithNext=True)) styles.add(ParagraphStyle(name='BodyC', parent=styles['BodyText'], fontName='Helvetica', fontSize=9.5, leading=13.4, spaceAfter=5)) styles.add(ParagraphStyle(name='BulletC', parent=styles['BodyText'], fontName='Helvetica', fontSize=9.3, leading=12.5, leftIndent=14, firstLineIndent=-8, spaceAfter=2.5)) styles.add(ParagraphStyle(name='Callout', parent=styles['BodyText'], fontName='Helvetica-Bold', fontSize=10.5, leading=14, textColor=HexColor('#6C2B11'), backColor=HexColor('#FFF1E8'), borderColor=HexColor('#E89D6B'), borderWidth=0.7, borderPadding=8, spaceBefore=7, spaceAfter=8)) styles.add(ParagraphStyle(name='Small', parent=styles['BodyText'], fontName='Helvetica', fontSize=8.1, leading=10.5, textColor=HexColor('#465A64'), spaceAfter=3)) def p(text, style='BodyC'): return Paragraph(text, styles[style]) def bullets(items): return [p('• '+x, 'BulletC') for x in items] def table(headers, rows, widths=None): data=[[p(h,'Small') for h in headers]]+[[p(str(c),'Small') for c in row] for row in rows] t=Table(data, colWidths=widths, repeatRows=1, hAlign='LEFT') t.setStyle(TableStyle([ ('BACKGROUND',(0,0),(-1,0),HexColor('#0B4F6C')),('TEXTCOLOR',(0,0),(-1,0),colors.white), ('FONTNAME',(0,0),(-1,0),'Helvetica-Bold'),('VALIGN',(0,0),(-1,-1),'TOP'), ('GRID',(0,0),(-1,-1),0.35,HexColor('#B9CBD3')),('ROWBACKGROUNDS',(0,1),(-1,-1),[colors.white,HexColor('#F3F7F8')]), ('LEFTPADDING',(0,0),(-1,-1),5),('RIGHTPADDING',(0,0),(-1,-1),5),('TOPPADDING',(0,0),(-1,-1),4),('BOTTOMPADDING',(0,0),(-1,-1),4), ])) return t def footer(canvas, doc): canvas.saveState() canvas.setStrokeColor(HexColor('#B9CBD3')); canvas.line(1.6*cm,1.35*cm,A4[0]-1.6*cm,1.35*cm) canvas.setFont('Helvetica',8); canvas.setFillColor(HexColor('#526A75')) canvas.drawString(1.6*cm,0.85*cm,'Cricothyroidotomy Study Guide | Educational reference only') canvas.drawRightString(A4[0]-1.6*cm,0.85*cm,f'Page {doc.page}') canvas.restoreState() doc=SimpleDocTemplate(out,pagesize=A4,rightMargin=1.6*cm,leftMargin=1.6*cm,topMargin=1.55*cm,bottomMargin=1.75*cm,title='Cricothyroidotomy Study Guide',author='Orris') story=[] story += [Spacer(1,1.2*cm),p('CRICOTHYROIDOTOMY', 'TitleCustom'),p('A structured study guide: from core concepts to practical learning', 'SubTitle'),p('Safety notice. This is an educational note for trained healthcare professionals and students. Cricothyroidotomy is a time-critical emergency front-of-neck airway procedure. It must be learned through supervised training, simulation, local protocols, and appropriate clinical governance, not written material alone.', 'Callout')] story += [p('Scope', 'H2C'),p('This guide consolidates nine study areas: core concepts; indications and decision-making; contraindications and alternatives; equipment and preparation; adult procedure overview; post-procedure management; complications; special situations; and practical learning/viva review.'),Spacer(1,10)] story += [p('Quick emergency principle', 'H2C'),p('CICO = cannot intubate, cannot oxygenate. The decisive priority is restoring oxygenation. Do not persist with repeated unsuccessful airway attempts while hypoxia worsens.', 'Callout'),PageBreak()] # 1 story += [p('1. Core concepts', 'H1C'),p('Cricothyroidotomy, also called cricothyrotomy, is an emergency front-of-neck airway that establishes an air passage through the cricothyroid membrane (CTM). It permits ventilation below the vocal cords when conventional airway access has failed.'),p('The CTM is a fibroelastic membrane between the inferior border of the thyroid cartilage and the superior border of the cricoid cartilage. In the anterior midline, the relevant superior-to-inferior surface anatomy is: hyoid bone, thyroid cartilage, CTM, cricoid cartilage, then tracheal rings.'),p('In adults it is usually quicker and more direct than emergency tracheostomy. It is a rescue procedure rather than a routine substitute for tracheal intubation.'),table(['Cricothyroidotomy','Tracheostomy'],[['Through CTM','Through lower trachea'],['Typical role: emergency rescue','Typical role: planned or longer-term airway'],['Rapid, superficial access','Usually slower and deeper']],[8.4*cm,8.4*cm]),p('Exam definition', 'H2C'),p('An emergency airway procedure in which the cricothyroid membrane is opened to restore oxygenation and ventilation when intubation and noninvasive rescue oxygenation have failed.','Callout')] #2 story += [p('2. Indications and decision-making', 'H1C'),p('The primary adult indication is CICO: failure to place a tracheal tube combined with failure to maintain adequate oxygenation by optimized face-mask ventilation and a supraglottic airway device.'),p('A difficult intubation by itself is not an indication. If the patient can be oxygenated, pause, reassess, improve technique, obtain expert help, or awaken the patient when appropriate.'),p('Decision pathway', 'H2C')] + bullets(['Recognize failed or unsafe intubation early.', 'Optimize rescue oxygenation: two-person mask ventilation, airway adjuncts, suction, supraglottic airway.', 'State the crisis explicitly: “Cannot intubate, cannot oxygenate. Emergency front-of-neck airway now.”', 'Proceed promptly if oxygenation cannot be maintained. Do not repeat ineffective laryngoscopy attempts.']) + [p('Clinical contexts that may lead to CICO include major maxillofacial trauma, blood or secretions obscuring the airway, severe upper-airway edema or obstruction, expanding neck hematoma, major anatomical distortion, and airway collapse after induction.')] #3 story += [p('3. Contraindications and alternatives', 'H1C'),p('First principle: in a true adult CICO emergency, most contraindications are relative. Bleeding risk, infection, difficult landmarks, and distorted anatomy must not delay lifesaving oxygenation.'),table(['Issue','Practical implication'],[['Patient can be oxygenated by less invasive means','Do not rush to surgical airway. Use a deliberate airway strategy.'],['Young children','Do not copy adult scalpel-bougie-tube technique. Use age-specific pediatric eFONA protocol and expert support.'],['Laryngeal fracture or laryngotracheal disruption','May make standard CTM entry hazardous; involve surgeons immediately if possible.'],['Subglottic stenosis/tumor','CTM access may not bypass the obstruction; controlled awake tracheostomy may be better if oxygenation permits.'],['Distorted neck, infection, coagulopathy','Higher technical or bleeding risk, but relative in adult CICO.']],[5.1*cm,11.7*cm]),p('Alternatives depend on oxygenation. If oxygenation is maintained, consider optimized face-mask ventilation, a supraglottic airway, awake intubation, awake tracheostomy, or waking the patient in a non-emergent anesthetic setting. In CICO, emergency front-of-neck access is required.')] #4 story += [p('4. Equipment and preparation', 'H1C'),p('The standard adult rescue setup is commonly called scalpel-bougie-tube. Departments should standardize the kit and clinicians should train with the actual equipment stocked in their workplace.'),table(['Core item','Purpose'],[['PPE, suction','Protect staff; clear blood, secretions, vomitus.'],['Oxygen and bag-valve device','Ventilation after tube placement and continued rescue oxygenation.'],['No. 10 scalpel','Skin and CTM entry.'],['Coudé-tip bougie','Guides tube into trachea.'],['6.0 mm cuffed ETT plus smaller backup','Emergency tracheal conduit.'],['10 mL syringe','Cuff inflation.'],['Waveform capnography','Primary confirmation of ventilation.'],['Tape/ties/sutures','Secure the tube.']],[5.1*cm,11.7*cm]),p('For anticipated difficulty, assign roles, check suction/oxygen/capnography, ensure eFONA kit accessibility, and identify or mark the CTM before induction when time permits. Ultrasound can assist landmark identification in obesity, prior neck surgery, mass, or radiation, but must never delay a CICO rescue.')] #5 story += [PageBreak(),p('5. Adult emergency surgical procedure overview', 'H1C'),p('For trained clinicians only, using local protocol. Current adult teaching commonly uses a vertical-incision scalpel-bougie-tube approach.'),p('Sequence', 'H2C')] steps=[('1. Declare and prepare','Declare CICO, summon help, open eFONA kit, turn on suction, and continue any effective oxygenation attempt.'),('2. Position','Supine if feasible. Extend the neck only when safe. Do not delay for ideal positioning.'),('3. Identify and stabilize larynx','Use the non-dominant hand to locate thyroid cartilage, CTM, and cricoid. Hold the larynx in the midline.'),('4. Vertical skin incision','Make a midline vertical incision centered on the presumed CTM. Bluntly dissect and re-identify laryngeal landmarks if needed.'),('5. Enter the CTM','Make a controlled transverse CTM incision. Rotate the blade as taught locally to maintain the opening and guide introducer passage.'),('6. Bougie','Pass the coudé-tip bougie caudally into the trachea. Advance gently. Never force against resistance.'),('7. Tube','Railroad a lubricated 6.0 cuffed tube over the bougie. Avoid excessive depth. Remove bougie.'),('8. Confirm and secure','Inflate cuff, ventilate, confirm sustained waveform capnography, then secure the tube and organize definitive care.')] story += [table(['Step','Key action'],steps,[4.2*cm,12.6*cm]),p('Avoid deep uncontrolled cutting, losing the midline, forcing the bougie/tube, or considering chest rise alone as proof of placement. Sustained waveform capnography is the preferred confirmation.', 'Callout')] #6 story += [p('6. Post-procedure management', 'H1C'),p('A functioning cricothyroidotomy is a lifesaving airway that must be protected. Immediate priorities are confirmation, ventilation, securement, monitoring, treatment of the cause, and an individualized definitive-airway plan.'),p('Immediate checklist', 'H2C')] + bullets(['Confirm sustained waveform capnography, chest rise, oxygenation response, bilateral chest assessment, and absence of major air leak.', 'Connect to bag-valve device or ventilator with oxygen. Obtain blood gases when clinically appropriate.', 'Secure the tube firmly. Recheck capnography after transfers, repositioning, or deterioration.', 'Provide appropriate analgesia, sedation, and if necessary paralysis only after a functioning airway is confirmed.', 'Treat the underlying cause: trauma, hematoma, edema/anaphylaxis, infection, foreign body, tumor, etc.', 'Monitor for bleeding, obstruction, displacement, emphysema, pneumothorax, aspiration, and hemodynamic instability.', 'Arrange ICU, anesthesia, ENT, trauma, or surgical review. Obtain imaging/endoscopic assessment after stabilization when indicated.']) + [p('Conversion to tracheostomy', 'H2C'),p('Cricothyroidotomy is generally a temporary emergency airway. Make an early specialist plan for removal, conversion, or ongoing use. Do not automatically convert based only on a fixed time rule, and never remove a functioning airway without a confirmed backup. The decision depends on injury, expected ventilatory duration, airway pathology, tube stability, and local protocol.'),p('If ventilation fails after initial success, consider DOPES: Displacement, Obstruction, Pneumothorax, Equipment failure, Stacked breaths/severe bronchospasm.', 'Callout')] #7 story += [p('7. Complications', 'H1C'),table(['Timing','Complications'],[['Immediate/early','Failure to obtain airway, hemorrhage, false passage, cartilage injury, posterior tracheal wall injury, esophageal injury, tube obstruction/displacement, mainstem intubation, aspiration, subcutaneous emphysema, pneumomediastinum, pneumothorax, ongoing hypoxia.'],['Late','Infection, granulation tissue, dysphonia, dysphagia, vocal-cord changes, tracheomalacia, subglottic or tracheal stenosis, scar/persistent stoma.'],['Needle/jet ventilation specific','Barotrauma, hypercapnia, catheter kinking/migration, paratracheal insufflation, tension pneumothorax when expiration is inadequate.']],[4.0*cm,12.8*cm]),p('Red flags after placement: no sustained capnography, falling saturation, absent chest rise, neck swelling/crepitus, severe air leak, high airway pressures, unilateral breath sounds, hypotension, or cardiac arrest.', 'Callout'),p('The key preventable contributor to harm is delay: delayed recognition of CICO and delayed transition to emergency front-of-neck access.')] #8 story += [p('8. Special situations', 'H1C'),p('Obesity / impalpable landmarks', 'H2C'),p('Anticipate difficult mask ventilation and difficult CTM palpation. Use ramped positioning and CTM marking/ultrasound in advance if time permits. In CICO, use the trained vertical midline approach, expect greater skin-to-airway depth, and use blunt dissection to locate the laryngeal framework.'),p('Neck trauma, hematoma, burns, or distorted anatomy', 'H2C'),p('Prior surgery, radiation scarring, mass, hematoma, abscess, edema, local trauma, obesity, and subcutaneous air can obscure landmarks. Continue cervical-spine precautions where appropriate, but do not permit them to prevent lifesaving oxygenation. Major laryngeal fracture or transection requires immediate surgical involvement when possible.'),p('Edema, infection, tumor, or stenosis', 'H2C'),p('Seek expert help early while oxygenation is preserved. A controlled awake airway or tracheostomy may be preferable for predictable obstruction. CTM entry may not bypass pathology at or below the CTM.'),p('Pediatrics', 'H2C'),p('Pediatric eFONA is not a scaled-down adult procedure. The membrane is small, the larynx is vulnerable, and protocols vary. Promptly use local age-specific guidance and obtain pediatric anesthesia/ENT/surgical support. Do not automatically use adult scalpel-bougie-tube technique in a child.')] #9 story += [p('9. Practical learning, algorithms, and viva points', 'H1C'),p('Emergency mental model', 'H2C'),p('Oxygenate - recognize CICO - declare CICO - perform eFONA - confirm with capnography - secure - hand over.', 'Callout'),table(['Plan','Goal'],[['A','Tracheal intubation'],['B','Oxygenation by supraglottic airway'],['C','Optimized face-mask oxygenation'],['D','Emergency front-of-neck airway']],[3*cm,13.8*cm]),p('Suggested spoken script', 'H2C'),p('“This is a CICO situation. Stop further intubation attempts. Call for help. Bring and open the eFONA kit. Continue oxygenation attempts. I am proceeding to emergency front-of-neck airway.”'),p('Pre-intubation FONA-ready check', 'H2C')] + bullets(['Can the CTM be identified or marked?', 'Are suction, oxygen, capnography, supraglottic rescue devices, and the eFONA kit ready?', 'Are roles assigned and senior help called early?', 'Has the team agreed on the threshold for CICO and eFONA?']) + [p('High-yield viva answers', 'H2C'),table(['Question','Answer'],[['Indication?','Adult CICO: failed intubation plus inability to maintain oxygenation by mask or supraglottic airway.'],['Target structure?','Cricothyroid membrane, between thyroid and cricoid cartilages.'],['Preferred adult rescue approach?','A trained, standardized scalpel-bougie-tube eFONA technique.'],['How confirm?','Sustained waveform capnography, supported by clinical assessment.'],['Important complications?','Failure, bleeding, false passage, injury, displacement, pneumothorax, emphysema, infection, dysphonia/dysphagia, stenosis.'],['Children?','Use age-specific protocol; do not automatically apply adult technique.']],[5.0*cm,11.8*cm]),p('Training standard', 'H2C'),p('Regular multidisciplinary simulation should include the exact local eFONA kit, decision-making under time pressure, both palpable and impalpable landmarks, obesity/hematoma/bleeding scenarios, capnography confirmation, tube securement, post-event handover, documentation, and debriefing.')] story += [PageBreak(),p('Selected sources used for this study guide', 'H1C'),p('Textbook sources', 'H2C'),p('• Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, pp. 2405-2410. • Miller’s Anesthesia, 10e, pp. 5958-5960. • ROSEN’s Emergency Medicine: Concepts and Clinical Practice, p. 42 and airway sections. • Tintinalli’s Emergency Medicine: A Comprehensive Study, surgical airway sections. • Roberts and Hedges’ Clinical Procedures in Emergency, surgical cricothyrotomy sections. • Morgan and Mikhail’s Clinical Anesthesiology, 7e, airway section. • Gray’s Anatomy for Students, “Cricothyrotomy.”'),p('Evidence and guidance', 'H2C'),p('• Difficult Airway Society 2025 guideline on management of unanticipated difficult tracheal intubation in adults. • Best practices for emergency surgical airway: a systematic review, Laryngoscope Investigative Otolaryngology, 2020. • Emergency front-of-neck access in airway management, BJA Education, 2021.'),p('Educational disclaimer', 'H2C'),p('This document is a study aid, not a clinical protocol or authorization to perform the procedure. Follow local emergency-airway guidelines, professional scope of practice, and supervision requirements. In an actual emergency, activate local emergency response and expert airway support immediately.', 'Callout')] doc.build(story,onFirstPage=footer,onLaterPages=footer) print(out) PY python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/cricothyroidotomy-study-note/output/Cricothyroidotomy_Study_Guide.pdf' r=PdfReader(p) text='\n'.join(page.extract_text() or '' for page in r.pages) print('pages',len(r.pages),'bytes',__import__('os').path.getsize(p)) for required in ['1. Core concepts','2. Indications','3. Contraindications','4. Equipment','5. Adult emergency','6. Post-procedure','7. Complications','8. Special situations','9. Practical learning']: print(required, required in text) PY

Cricothyroidotomy Study Guide

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