Regional Emergency Medical Advisory Committee of New York City Prehospital Advanced Life Support Protocols Copyright January 1996 (3/96)

1. Confirm the need for Needle Cricothyroidotomy:
   • History suggestive of airway obstruction;
   • Severe respiratory distress or respiratory arrest
     • absent or ineffective respiratory effort,
     • central cyanosis;
   • Absence of air entering
     • lack of air movement at nares,
     • absent breath sounds on both sides of chest; and
   • Failure of basic and advanced life support obstructed airway maneuvers to clear the obstruction.
2. Properly identify the cricothyroid membrane using external landmarks. (The cricothyroid membrane lies just above the cricoid cartilage.)
3. Locate the cricothyroid membrane:
   • By palpating the trachea just above the sternal notch and proceed upward until the prominence of the cricoid cartilage is identified
   • By palpating the thyroid notch and proceeding downward until the prominence of the cricoid cartilage is identified.
4. Palpate the junction of the trachea and the cricothyroid membrane which forms a "T", to insure proper identification of the cricothyroid membrane.
5. Stabilize the larynx with fingers of the non-dominant hand.
6. Cleanse the overlying skin with Povidone Iodine solution.
7. Introduce a l0-l4 gauge over-the-needle catheter attached to a3 ml syringe through the skin just above the cricoid cartilage at a 45° downward angle.
8. Advance the needle into the cricothyroid membrane and into the airway.
9. When air is aspirated, stop advancing the needle, advance the catheter over the needle into the trachea, and remove the needle.
10. Attach the barrel only of the 3 ml syringe to the over-the-needle catheter. Attach a 7.5 mm Endotracheal Tube adapter to the 3 ml syringe barrel.
11. Deliver oxygen at l5 lpm with a Bag-Valve-Device, or via Intermittent Jet Insufflation device capable of delivering oxygen at 60 psi with a timed cycle of 3 seconds "on" followed by 5 seconds "off", and an exhaust port.
12. Auscultate lungs for air entry.
13. Look for chest expansion, and check for egress of air.
14. Rule out possibility of obstruction below the cricothyroid membrane.
15. After completion of the procedure, transport and notify the receiving hospital of the need for surgical airway management.
16. If airway remains obstructed, transport patient immediately, and continue the BLS Obstructed Airway procedures.

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