Equipment checklist (mandatory)

• Scalpel
• Trachael hook
• Bougie (155mm for adult)
• Size 6.0 tracheostomy tube (portex; obturator removed)
• Tracheostomy ties
• Size 6.0 endotracheal tube
• 10ml syringe

Procedures

1. Ensure anaesthetics have been alerted and are attending
2. If there is time [predicted difficult airway], prepare skin with chlorhexidine, don sterile gloves, mark cricothyroid membrane and skin marker & consider 2% lignocaine / adrenaline 5ml sc local infiltration
3. Identify cricothyroid membrane; stabilize with non-dominant hand
4. With scalpel in dominant hand, incise cricothyroid membrane horizontally using “stab / rocking’” technique. Hold scalpel blade in position
5. With non-dominant hand, insert tracheal hook into incision following line of the scalpel blade; rotate through 90 degrees. Apply caudal (inferior) traction to cricoid cartilage
6. Remove scalpel and insert bougie into trachea. Insert 6.0mm tracheostomy tube over bougie (lubricated if necessary) & into trachea
7. Remove tracheal hook whilst ensuring tracheostomy tube remains fully inserted
8. Remove bougie whilst maintaining tracheostomy tube position
9. 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 used instead of a tracheostomy tube
• If the surgical cricothyroidotomy fails, consider reinserting iGel / LMA for transfer/until further expert assistance arrives