Equipment checklist (mandatory)

• Scalpel
• Tracheal hook
• Bougie (155mm for adult)
• Size 6.0 Tracheostomy tube (Portex; obturator removed)
• Tracheostomy ties
• Size 6.0 Endotracheal tube
• 10ml Syringe.

Procedures

• Ensure Anaesthetics have been alerted and are attending.
• Unless in emergency, prepare skin with chlorhexidine, don sterile gloves, mark cricothyroid membrane with skin marker & consider infiltration with 2% Lignocaine / Adrenaline 5ml sub-cutaneously.
• Identify cricothyroid membrane; stabilize with non-dominant hand.
• With scalpel in dominant hand, incise cricothyroid membrane horizontally using “stab / rocking’” technique. Hold scalpel blade in position. (Do not remove)
• Insert bougie into trachea with scalpel in place. Insert size 6 tracheostomy tube (or oral endo-tracheal tube) over bougie (lubricated if necessary) into trachea, before removing scalpel.
• Remove bougie whilst maintaining tracheostomy tube position.
• Inflate cuff & verify ventilation and tube position as per standard anaesthesia post-intubation checks. Secure tracheostomy tube with ties.

Modifications

• If the cricothyroid membrane cannot be identified easily using surface landmarks, first use a midline longitudinal incision to identify the underlying structures then proceed with the horizontal incision.
• If there are significant face and neck burns or oedema (e.g., risk of further swelling), a size 6.0 ETT may be chosen instead of a tracheostomy tube.
• If the surgical cricothyroidotomy fails, consider reinserting iGel / LMA for transfer/until further expert assistance arrives.