Transtracheal ventilation – Needle or Knife?

“I Can’t intubate and can’t ventilate. Now what? Surgical cric? That neck seems rather small… what do I do?”

Background

• Transtracheal ventilation is imperative for the EM physician to know how to perform.
• It is faster, easier, less cumbersome and less complications than surgical cricothyrotomy (even
  in adults, but especially in children).
• Infants and children have smaller cricothyroid membranes and the entire larynx is more rostral
  with a more prominent hyoid bone, all of which make the surgical cricothyrotomy more difficult
  in children than adults.
• “Many” state that a surgical cric. is contraindicated in patients less than 5 years of age
  (although, size more than age is the limiting factor).

You will need:

• In-line valve to control gas flow
  • If you are lucky: a commercial device with built in pressure gauge and regulator (like the one we have in the Peds Airway Cart).
  • If you are MacGyver: oxygen tubing with a Y-connector or 3-way stopcock placed in-line as a regulator.
• 16-18 gauge catheter

Recommended Inspiration:Expiration ratios

• Standard – 1:4 to 1:5
• Supraglottic airway obstruction – 1:9 (need more time to let gas escape, otherwise may build up too much pressure in the lungs)

Refereneces:Bould, M.D. and P. Bearfield, Techniques for emergency ventilation through a needle cricothyroidotomy. Anaesthesia, 2008. 63(5): p. 535-9.Mittal, M.K. and J.M. Baren, Percutaneous Transtracheal Ventilation, in Textbook of Pediatric Emergency Procedures, 2nd Edition, C. King and F.M. Henretig, Editors. 2008, Lippincott Williams & Wilkins. p. 237-246.Slutsky, A.S., et al., Tracheal insufflation of O2 (TRIO) at low flow rates sustains life for several hours. Anesthesiology, 1985. 63(3): p. 278-86.