STP 31-18D34-SM-TG

Perform a Cricothyroidotomy
081-833-4528

Conditions: Given a casualty with a totally obstructed airway that cannot be cleared or a casualty in
respiratory arrest who cannot be intubated, cutting instrument (scalpel, knife blade), airway tube
(endotracheal [ET] tube, cannula, or any noncollapsible tube), hemostats, needle holders, suture material,
suctioning apparatus, povidone-iodine, knife handle, blanket, gloves, and tape. A cricothyroidotomy
needle is unavailable, or performing a needle cricothyroidotomy is not effective.

Standards: Establish an emergency airway without causing unnecessary injury to the casualty.
Complete steps 3 through 10 in order.

Performance Steps
CAUTION: Consider only casualties with a total upper airway obstruction or casualties with inhalation
burns for a surgical cricothyroidotomy.
1. Gather cricothyroidotomy kit or minimum essential equipment.
NOTE: Because of the need for speed, every medic should have an easily accessible cricothyroidotomy
kit that contains all required items. Do no delay getting an airway established for lack of nonessential
equipment.
a. Cutting instrument: Number 10 or 11 scalpel or knife blade.
b. Airway tube: ET tube, cannula, or any noncollapsible tube that will allow enough airflow to
maintain oxygen saturation.
NOTE: In a field setting, an ET tube is preferred because it is easy to secure. Use a size 6 or 7 ET tube,
and ensure the cuff will hold air.
2. Hyperextend the casualty’s neck.
WARNING: Do not hyperextend the casualty’s neck if a cervical injury is suspected.
a. Place the casualty in the supine position.
b. Place a blanket or poncho rolled up under the casualty’s neck or between the shoulder blades
so the airway is straight.
3. Put on gloves.
4. Locate the cricothyroid membrane.
a. Place a finger of the nondominant hand on the thyroid cartilage (Adam’s apple), and slide the
finger down to the cricoid cartilage.
b. Palpate for the "V" notch of the thyroid cartilage.
c. Slide the index finger down into the depression between the thyroid and cricoid cartilage.
d. Prepare the skin over the membrane with povidone-iodine.
e. Raise the skin to form a tentlike appearance over the cricothyroid space, using the index finger
and thumb.
5. With a cutting instrument in the dominant hand, make a 1 1/2-inch horizontal incision through the
raised skin to the cricothyroid space.
CAUTION: Do not cut the cricothyroid membrane with this incision.
6. Relocate the cricothyroid space by touch and sight.
7. Stabilize the larynx with one hand and cut or poke through the cricothyroid membrane.
NOTE: A rush of air may be felt through the opening.
a. If using a number 10 blade or knife blade, make a 1/2-inch horizontal incision through the
elastic tissue of the cricothyroid membrane.
b. If using the number 11 blade, poke through the cricothryroid membrane.
8. Insert the tips of a hemostat or needle holder through the opening, and open the jaws to make a
larger opening.

3 - 1055
STP 31-18D34-SM-TG

Performance Steps
9. Insert the end of the ET tube or cannula between the jaws. The tube should be in the trachea and
directed toward the lungs. Inflate the cuff with 5 to 10 cubic centimeters (cc) of air.
NOTE: Do not advance the tube more than 2 to 3 inches, as this could result in the intubation of only 1
main stem broncus.
10. Check for air exchange and placement of the tube.
a. Air exchange.
(1) Listen and feel for air passing in and out of the tube.
(2) Look for bilateral rise and fall of the chest.
b. Placement of the tube.
(1) Connect the Ambu bag to the tube or have someone perform mouth-to-tube respirations.
(2) As someone pumps or blows air into the tube, ascualtate the abdomen and both lung
fields while observing for bilateral rise and fall of the chest.
(3) If there are bilateral breath sounds and bilateral rise and fall of the chest, the tube is
properly placed and may be secured.
(4) If there is unilateral rise and fall of the chest, absent or unilateral breath sounds, epigastric
gurgling, air escaping from the casualty’s mouth or from around the tube, or air infiltrating
into the tissues of the neck or chest, the tube is improperly placed and corrective action
must be initiated immediately.
( a) Unilateral breath sounds and unilateral rise and fall of the chest indicate that the tube
is past the carina. Deflate the cuff, retract the tube 1 to 2 inches, and recheck air
exchange and placement.
( b) Air coming out of the casualty’s mouth indicates the tube is pointed away from the
lungs. Remove the tube, reinsert, and recheck for air exchange and placement.
( c) Any other problem is indicative of the tube not being in the trachea. Remove the
tube, reinsert, and recheck for air exchange and placement.
11. If the tube is correctly placed but the casualty is not breathing, direct someone to perform rescue
breathing.
a. Connect the tube to an Ambu bag, with oxygen if available, and have the casualty ventilated at
the rate of about 20 breaths per minute.
b. If no Ambu bag is available, have someone perform mouth-to-tube resuscitation at 20 breaths
per minute.
c. Once rescue breathing has started, secure the tube.
12. Suction the casualty’s airway, as necessary.
a. Insert the suction catheter 4 to 5 inches into the tube.
b. Apply suction only while withdrawing the catheter.
c. Administer 1 cc of saline solution into the airway to loosen secretions, and help facilitate
suctioning.
NOTE: Allow the casualty to take several breaths between suctionings.
13. Apply a dressing to further protect the tube and incision by using one of the following techniques.
a. Cut two 4- x 4-inch or 4- x 8-inch gauze pads halfway through. Place them on opposite sides
of the tube so that the tube comes up through the cut and the gauze overlaps. Tape securely.
b. Apply a sterile dressing under the casualty’s tube by making a V-shaped fold in a 4- x 8-inch
gauze pad and placing it under the edge of the cannula to prevent irritation to the casualty.
Tape securely.
14. Monitor casualty’s respirations on a regular basis.
a. Reassess air exchange and placement every time the casualty is moved.
b. Assist respirations if respiratory rate falls below 12 or rises above 20 per minute.

Evaluation Preparation: Setup: For training and evaluation, use a mannequin or have another soldier
act as the casualty. Under no circumstances will the skin be incised. Have the soldier demonstrate and
explain what he or she would do.

3 - 1056
 STP 31-18D34-SM-TG

Brief soldier: Tell the soldier to perform a surgical cricothyroidotomy.

Performance Measures GO NO GO
1. Gathered cricothyroidotomy kit or minimum essential equipment. —— ——
2. Hyperextended the casualty's neck. —— ——
3. Put on gloves. —— ——
4. Located the cricothyroid membrane. —— ——
5. With a cutting instrument in the dominant hand, made a 1 1/2-inch horizontal —— ——
incision through the raised skin to the cricothyroid space.
6. Relocated the cricothyroid space by touch and sight. —— ——
7. Stabilized the larynx with one hand and cut or poked through the cricothyroid —— ——
membrane.
8. Inserted the tips of a hemostat or needle holder through the opening and opened —— ——
the jaws to make a larger opening.
9. Inserted the end of the ET tube or cannula between the jaws. The tube should be —— ——
in the trachea and directed toward the lungs.
10. Checked for air exchange and placement of the tube. —— ——
11. When the tube was correctly placed but the casualty was not breathing, had —— ——
someone perform rescue breathing.
12. Suctioned the casualty's airway, as necessary. —— ——
13. Applied a dressing to further protect the tube and incision —— ——
14. Monitored casualty's respirations on a regular basis. —— ——

Evaluation Guidance: Score the soldier go if all steps are passed. Score the soldier no-go if any step is
failed. If the soldier fails any step, show what was done wrong and how to do it correctly.

References
Required Related
EMT-P, BRADY 3RD ED. 1997

3 - 1057