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22-16: Cricothyrotomy (Seldinger Technique)

Steven J. White; Kevin High; Lawrence B. Stack; Richard M. Levitan

(Figs. 22.73, 22.74, 22.75, 22.76, 22.77, 22.78, 22.79, 22.80, 22.81)

FIGURE 22.73

Melker Cricothyroidotomy Kit. Components of the kit produced by Cook Inc. (www.cookmedical.com). (Photo contributor: Lawrence B. Stack, MD.)

The Melker cricothyroidotomy kit has the following components, shown from left to right: Catheter, thin-walled needle, tracheal hook, two tapered introducers, Seldinger wire, scalpel, cuffed tracheostomy tube, syringe, and trousseau dilator.
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FIGURE 22.74

Identify Landmarks. Palpate thyroid cartilage and cricothyroid cartilage caudally. Angle needle 30 degrees caudad to enter the trachea (Photo contributor: Lawrence B. Stack, MD.)

A patient has their mouth wide open. One gloved hand is raising the cartilage at the top center of the chest, and the other gloved hand has inserted a needle and syringe at a 30-degree angle into the trachea through the chest. A catheter is attached to the needle.
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FIGURE 22.75

Bubbles During Aspiration. Aspiration of bubbles during needle advancement confirms tracheal placement. (Photo contributor: Lawrence B. Stack, MD.)

A photo shows a patient's mouth wide open. One gloved hand inserts a syringe into the trachea. Bubbles entering the syringe are observed.
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FIGURE 22.76

Slide Catheter into Trachea. Carefully slide the catheter off the needle into the trachea. (Photo contributor: Lawrence B. Stack, MD.)

To slide the catheter into the trachea, one gloved hand is raising the cartilage at the top center of the chest, and the other gloved hand is shown sliding a catheter off the needle into the trachea.
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FIGURE 22.77

Confirm Tracheal Placement. Again, aspirate bubbles from the catheter to confirm tracheal placement. (Photo contributor: Lawrence B. Stack, MD.)

To confirm tracheal placement, one gloved hand holds down the needle and catheter on the chest, and the other gloved hand aspirates and drawing bubbles from the trachea.
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FIGURE 22.78

Thread Wire. Lack of resistance during threading of Seldinger wire confirms tracheal placement. (Photo contributor: Lawrence B. Stack, MD.)

Two photos show the use of a thread wire in a tracheal placement.
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FIGURE 22.79

Incision at Wire Entry Site. Remove catheter and make incision at the wire entry site. (Photo contributor: Lawrence B. Stack, MD.)

Two photos show how an incision is made at the Wire Entry Site.
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FIGURE 22.80

Insert Tracheostomy Tube/Introducer. Insert both devices over the wire and into the trachea. (Photo contributor: Lawrence B. Stack, MD.)

To insert the tracheostomy tube or introducer, a gloved hand inserts both a thick Tracheostomy Tube and an elongated Introducer over the wire and into the trachea, via an incision on the chest.
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FIGURE 22.81

Remove Wire and Introducer. Remove these devices together as a single unit. (Photo contributor: Lawrence B. Stack, MD.)

For removal, the wire and the elongated introducer are withdrawn together and only the Tracheostomy Tube remains inserted into the chest. The open end of the Tracheostomy Tube has a flap lid.
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Equipment

The Melker kit manufactured by Cook Medical includes all the equipment necessary: catheter, thin-walled needle, Seldinger wire, cuffed tracheostomy tube 5.0 mm ID, and tapered introducer.

Technique

  1. Identify the thyroid cartilage and the cricothyroid membrane directly caudally.

  2. Prep the neck with suitable antiseptic; anesthetize the skin overlying the cricothyroid membrane with 1% lidocaine.

  3. Isolate the trachea between the thumb and 3rd finger of the sterilely gloved nondominant hand, using the index finger to palpate the cricothyroid membrane landmark. With a syringe attached, preferably containing sterile water or remaining lidocaine, insert the catheter through the cricothyroid membrane at a 30-degree angle to the horizontal, aiming toward the feet. Once through the skin, begin aspirating as the catheter is advanced. Air and bubbles entering the syringe confirm entry into the trachea.

  4. Carefully slide the catheter off of the needle and into the trachea.

  5. Reattach syringe and reconfirm tracheal position.

    ...

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