Article Data

  • Views 5196
  • Dowloads 769


Open Access Special Issue

Cricothyroidotomy in the emergency setting: indications, techniques and outcomes

  • Federico Mazza1
  • Massimiliano Venturino1
  • Davide Turello1
  • Alberto Gorla1
  • Cristina Degiovanni2
  • Alessandro Locatelli2
  • Giulio Melloni1

1Department of Thoracic Surgery, A.O. S. Croce e Carle, 12100 Cuneo, Italy

2Department of Anaesthesia and Intensive Care, A.O. S. Croce e Carle, 12100 Cuneo, Italy

DOI: 10.22514/sv.2021.063 Vol.17,Issue 3,May 2021 pp.31-41

Submitted: 26 January 2021 Accepted: 04 March 2021

Published: 08 May 2021

*Corresponding Author(s): Giulio Melloni E-mail:


Cricothyroidotomy is a lifesaving procedure performed in acute respiratory failure secondary to upper airway obstruction to restore a patent airway. Emergency cricothyroidotomy is considered to be the technique of choice to provide oxygenation to patients in “Can’t Intubate, Can’t Oxygenate” (CICO) scenario. In this study, we describe and discuss indications, different techniques and complications of cricothyroidotomy performed for establishing an airway in the emergency setting from a multidisciplinary point of view.


Cricothyroidotomy; Emergency; Airway; CICO

Cite and Share

Federico Mazza,Massimiliano Venturino,Davide Turello,Alberto Gorla,Cristina Degiovanni,Alessandro Locatelli,Giulio Melloni. Cricothyroidotomy in the emergency setting: indications, techniques and outcomes. Signa Vitae. 2021. 17(3);31-41.


[1] Melachuri V, Ince M. Emergency front of neck access. Indian Journal of Respiratory Care. 2017; 6: 793.

[2] Schroeder AA. Cricothyroidotomy: when, why, and why not? American Journal of Otolaryngology. 2000; 21: 195–201.

[3] Brantigan CO, Grow JB. Cricothyroidotomy: elective use in respiratory problems requiring tracheotomy. The Journal of Thoracic and Cardiovas-cular Surgery. 1976; 71: 72–81.

[4] McKenna P, Desai NM, Morley EJ. Cricothyrotomy. StatPearls Publish-ing. 2020.

[5] Šimunjak T, Goranović T, Šimunjak B. Cricothyrotomy - urgent access to the airway, when and how? Acta Medica Croatica. 2018; 72: 57–62.

[6] Hessert MJ, Bennett BL. Optimizing emergent surgical cricothyrotomy for use in austere environments. Wilderness & Environmental Medicine. 2013; 24: 53–66.

[7] Langvad S, Hyldmo P, Nakstad A, Vist G, Sandberg M. Emergency cricothyrotomy - a systematic review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2013; 21: 43.

[8] DiGiacomo C, Neshat KK, Angus LDG, Penna K, Sadoff RS, Shaftan GW. Emergency cricothyrotomy. Military Medicine. 2003; 168: 541–544.

[9] Rao S, Mendoca C. Airway emergency - management of can’t intubate can’t oxygenate scenario. Journal of Anaesthesia Practice. 2006.

[10] Civitarese F. Cricothyrotomy (CT) as a primary airway maneuver vs. an airway salvage technique. emDOCs. 2015.

[11] NAP4, Executive summary - The Royal College of Anaesthetists. Major complications of airway management in the United Kingdom. 2011. Available at: (Accessed: 07 March 2021).

[12] Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. British Journal of Anaesthesia. 2011; 106: 632–642.

[13] Cook TM, Woodall N, Frerk C. A national survey of the impact of NAP4 on airway management practice in United Kingdom hospitals: closing the safety gap in anaesthesia, intensive care and the emergency department. British Journal of Anaesthesia. 2016; 117: 182–190.

[14] Govender V. Cricothyroidotomy and the difficult airway. Anaesthetics. 2016.

[15] Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia. 2016; 115: 827–848.

[16] Drew T, McCaul CL. Laryngeal handshake technique in locating the cricothyroid membrane: a non-randomised comparative study. British Journal of Anaesthesia. 2018; 121: 1173–1178.

[17] Nagaro T, Yorozuya T, Sotani M, Adachi N, Tabo E, Arai T, et al. Survey of patients whose lungs could not be ventilated and whose trachea could not be intubated in university hospitals in Japan. Journal of Anesthesia. 2003; 17: 232–240.

[18] Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcames of impossible mask ventilation: a review of 50.000 anesthetics. Anestesiology. 2009; 110: 891–897.

[19] Tachibana N, Niiyama Y, Yamakage M. Incidence of cannot intubate-cannot ventilate (CICV): results of a 3-year retrospective multicenter clinical study in a network of university hospitals. Journal of Anesthesia. 2015; 29: 326–330.

[20] Timmermann A, Chrimes N, Hagberg CA. Need to consider human factors when determining first-line technique for emergency front-of-neck access. British Journal of Anaesthesia. 2016; 117: 5-7.

[21] Ono Y, Yokoyama H, Matsumoto A, Kumada Y, Shinohara K, Tase C. Surgical airways for trauma patients in an emergency surgical setting: 11 years’ experience at a teaching hospital in Japan. Journal of Anesthesia. 2013; 27: 832–837.

[22] Brown III C, Cox K, Hurwitz S, Walls R. 4,871 Emergency airway en-counters by air medical providers: a report of the air transport emergency airway management (NEAR VI: “A-TEAM”) project. Western Journal of Emergency Medicine. 2014; 15: 188–193.

[23] Boon JM, Abrahams PH, Meiring JH, Welch T. Cricothyroidotomy: a clinical anatomy review. Clinical Anatomy. 2004; 17: 478–486.

[24] Kwon YS, Lee CA, Park S, Ha SO, Sim YS, Baek MS. Incidence and outcomes of cricothyrotomy in the “cannot intubate, cannot oxygenate” situation. Medicine. 2019; 98: e17713.

[25] Asai T. Surgical cricothyrotomy, rather than percutaneous cricothyro-tomy, in “cannot intubate, cannot oxygenate” situation. Anesthesiology. 2016; 125: 269–271.

[26] Walls R, Murphy M. Chapter 7: identification of the difficult airway. Manual of Emergency Airway Management. 3rd edn. Lippincott Williams & Wilkins. 2008.

[27] Dover K, Howdieshell TR, Colborn GL. The dimensions and vascular anatomy of the cricothyroid membrane: Relevance to emergent surgical airway access. Clinical Anatomy. 1996; 9: 291–295.

[28] Nutbeam T, Clarke R, Luff T, Enki D, Gay D. The height of the cricothyroid membrane on computed tomography scans in trauma patients. Anaesthesia. 2017; 72: 987–992.

[29] Bennett JD, Guha SC, Sankar AB. Cricothyrotomy: the anatomical basis. Journal of the Royal College of Surgeons of Edinburgh. 1996; 41: 57–60.

[30] Dixit A, Ramaswamy KK, Perera S, Sukumar V, Frerk C. Impact of change in head and neck position on ultrasound localisation of the cricothyroid membrane: an observational study. Anaesthesia. 2019; 74: 29–32.

[31] Lamb A, Zhang J, Hung O, Flemming B, Mullen T, Bissell MB, et al. Accuracy of identifying the cricothyroid membrane by anesthesia trainees and staff in a Canadian institution. Canadian Journal of Anesthesia. 2015; 62: 495–503.

[32] Kristensen MS, Teoh WH, Rudolph SS, Tvede MF, Hesselfeldt R, Børglum J, et al. Structured approach to ultrasound-guided identification of the cricothyroid membrane: a randomized comparison with the palpation method in the morbidly obese. British Journal of Anaesthesia. 2015; 114: 1003–1004.

[33] Aslani A, Ng S, Hurley M, McCarthy KF, McNicholas M, McCaul CL. Accuracy of identification of the cricothyroid membrane in female subjects using palpation. Anesthesia & Analgesia. 2012; 114: 987–992.

[34] Levitan RM. Tips and tricks for performing cricothyrotomy. ACEP Now. 2014.

[35] Elliott DSJ, Baker PA, Scott MR, Birch CW, Thompson JMD. Accuracy of surface landmark identification for cannula cricothyroidotomy. Anaesthesia. 2010; 65: 889–894.

[36] Hiller KN, Karni RJ, Cai C, Holcomb JB, Hagberg CA. Comparing success rates of anesthesia providers versus trauma surgeons in their use of palpation to identify the cricothyroid membrane in female subjects: a prospective observational study. Canadian Journal of Anesthesia. 2016; 63: 807–817.

[37] You-Ten KE, Desai D, Postonogova T, Siddiqui N. Accuracy of conven-tional digital palpation and ultrasound of the cricothyroid membrane in obese women in labour. Anaesthesia. 2015; 70: 1230–1234.

[38] Yıldız G, Göksu E, Şenfer A, Kaplan A. Comparison of ultrasonography and surface landmarks in detecting the localization for cricothyroidotomy. The American Journal of Emergency Medicine. 2016; 34: 254–256.

[39] Hsiao J, Pacheco-Fowler V. Videos in clinical medicine. Cricothyroido-tomy. The New England Journal of Medicine. 2008; 358: e25.

[40] Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identification of the cricothyroid membrane: best evidence, techniques, and clinical impact. British Journal of Anaesthesia. 2016; 117: i39–i48.

[41] Mallin M, Curtis K, Dawson M, Ockerse P, Ahern M. Accuracy of ultrasound-guided marking of the cricothyroid membrane before simulated failed intubation. The American Journal of Emergency Medicine. 2014; 32: 61–63.

[42] Siddiqui N, Arzola C, Friedman Z, Guerina L, You-Ten KE. Ultrasound improves cricothyrotomy success in cadavers with poorly defined neck anatomy: a randomized control trial. Anesthesiology. 2015; 123: 1033–1041.

[43] Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia. 2004; 59: 675–694.

[44] Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia. 2015; 115: 827–848.

[45] Scrase I, Woollard M. Needle vs surgical cricothyroidotomy: a short cut to effective ventilation. Anaesthesia. 2006; 61: 962–974.

[46] Coté CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children? Pediatric Anesthesia. 2009; 19: 66–76.

[47] Fagan J. Cricothyroidotomy & needle cricothyrotomy. The open access atlas of otolaryngology, Head & Neck Operative Surgery. Johan Fagan. 2016. Available at:

[48] Bould MD, Bearfield P. Techniques for emergency ventilation through a needle cricothyroidotomy. Anaesthesia. 2008; 63: 535–539.

[49] Schaefer R, Hueter L, Preussler N, Schreiber T, Schwarzkopf K. Percutaneous transtracheal emergency ventilation with a self-made device in an animal model. Paediatric Anaesthesia. 2007; 17: 972–976.

[50] Price RJ, Laird C. A survey of surgical airway experiences and equipment among immediate care doctors. Emergency Medicine Journal. 2009; 26: 438–441.

[51] Metterlein T, Frommer M, Ginzkey C, Becher J, Schuster F, Roewer N, et al. A randomized trial comparing two cuffed emergency cricothyrotomy devices using a wire-guided and a catheter-over-needle technique. The Journal of Emergency Medicine. 2011; 41: 326–332.

[52] Wong DT, Mehta A, Tam AD, Yau B, Wong J. A survey of Canadian anesthesiologists’ preferences in difficult intubation and “cannot intubate, cannot ventilate” situations. Canadian Journal of Anesthesia. 2014; 61: 717–726.

[53] American College of Surgeons Commitee on Trauma. Advanced Trauma Life Support Program for Doctors. 9th edn. American College of Surgeons. 2012.

[54] Fennessy P, Drew T, Husarova V, Duggan M, McCaul CL. Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length. British Journal of Anaesthesia. 2019; 122: 263–268.

[55] Wang EE, Quinones J, Fitch MT, Dooley-Hash S, Griswold-Theodorson S, Medzon R, et al. Developing technical expertise in emergency medicine-the role of simulation in procedural skill acquisition. Academic Emergency Medicine. 2008; 15: 1046–1057.

[56] Chan TC, Vilke GM, Bramwell KJ, Davis DP, Hamilton RS, Rosen P. Comparison of wire-guided cricothyrotomy versus standard surgical cricothyrotomy technique. The Journal of Emergency Medicine. 1999; 17: 957–962.

[57] DiGiacomo JC, Angus LD, Gelfand BJ, Shaftan GW. Cricothyrotomy technique: standard versus the rapid four step technique. The Journal of Emergency Medicine. 1999; 17: 1071–1073.

[58] Eisenburger P, Laczika K, List M, Wilfing A, Losert H, Hofbauer R, et al. Comparison of conventional surgical versus Seldinger technique emergency cricothyrotomy performed by inexperienced clinicians. Anes-thesiology. 2000; 92: 687–690.

[59] Hill C, Reardon R, Joing S, Falvey D, Miner J. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Academic Emergency Medicine. 2010; 17: 666–669.

[60] Holmes JF, Panacek EA, Sakles JC, Brofeldt BT. Comparison of 2 cricothyrotomy techniques: standard method versus rapid 4-step technique. Annals of Emergency Medicine. 1998; 32: 442–446.

[61] Johnson DR, Dunlap A, McFeeley P, Gaffney J, Busick B. Cricothy-rotomy performed by prehospital personnel: a comparison of two techniques in a human cadaver model. The American Journal of Emergency Medicine. 1993; 11: 207–209.

[62] Keane M, Brinsfield K, Dyer K, Roy S, White D. A laboratory comparison of emergency percutaneous and surgical cricothyrotomy by prehospital personnel. Prehospital Emergency Care. 2004; 8: 424–426.

[63] Murphy C, Rooney SJ, Maharaj CH, Laffey JG, Harte BH. Comparison of three cuffed emergency percutaneous cricothyroidotomy devices to conventional surgical cricothyroidotomy in a porcine model. British Journal of Anaesthesia. 2011; 106: 57–64.

[64] Salah N, Mhuircheartaigh RN, Hayes N, McCaul C. A comparison of four techniques of emergency transcricoid oxygenation in a manikin. Anesthesia and Analgesia. 2010; 110: 1083–1085.

[65] Schaumann N, Lorenz V, Schellongowski P, Staudinger T, Locker GJ, Burgmann H, et al. Evaluation of Seldinger technique emergency cricothyroidotomy versus standard surgical cricothyroidotomy in 200 cadavers. Anesthesiology. 2005; 102: 7–11.

[66] Schober P, Hegemann MC, Schwarte LA, Loer SA, Noetges P. Emergency cricothyrotomy-a comparative study of different techniques in human cadavers. Resuscitation. 2009; 80: 204–209.

[67] Sulaiman L, Tighe SQM, Nelson RA. Surgical vs wire-guided cricothy-roidotomy: a randomised crossover study of cuffed and uncuffed tracheal tube insertion. Anaesthesia. 2006; 61: 565–570.

[68] Chua H, Wong T, Lim WY, Wong P. Emergency front-of-neck airway in the COVID-19 patient: Cannula or surgical cricothyroidotomy?Anaesthesia Critical Care & Pain Medicine. 2020; 39: 475–477.

[69] Bribriesco A, Patterson GA. Cricothyroid approach for emergency access to the airway. Thoracic Surgery Clinics. 2018; 28: 435–440.

[70] Heard A, Gordon H, Douglas S, Grainger N, Avis H, Vlaskovsky P, et al. Front-of-neck airway rescue with impalpable anatomy during a simulated cannot intubate, cannot oxygenate scenario: scalpel-finger-cannula versus scalpel-finger-bougie in a sheep model. British Journal of Anaesthesia. 2020; 125: 184–191.

[71] Umek N, Hodzovic I, Damjanovska M, Cvetko E, Zel J, Seliskar A, et al. Rescue oxygenation success by cannula or scalpel-bougie emergency front-of-neck access in an anaesthetised porcine model. PLoS ONE. 2020; 15: e0232510.

[72] Heymans F, Feigl G, Graber S, Courvoisier DS, Weber KM, Dulguerov P. Emergency cricothyrotomy performed by surgical airway-naive medical personnel: a randomized crossover study in cadavers comparing three commonly used techniques. Anesthesiology. 2016; 125: 295–303.

[73] Paix BR, Griggs WM. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ’scalpel-finger-tube’ method. Emergency Medicine Australasia. 2012; 24: 23–30.

[74] Hubble MW, Wilfong DA, Brown LH, Hertelendy A, Benner RW. A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates. Prehospital Emergency Care. 2010; 14: 515–530.

[75] Wong DT, Prabhu AJ, Coloma M, Imasogie N, Chung FF. What is the minimum training required for successful cricothyroidotomy? A study in mannequins. Anesthesiology. 2003; 98: 349–353.

[76] Walls RM. Cricothyroidotomy. Emergency Medicine Clinics of North America. 1988; 6: 725–736.

[77] Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB. Management of difficult tracheal intubation. Anesthesiology. 2019; 131: 818–829.

[78] Bair AE, Panacek EA, Wisner DH, Bales R, Sakles JC. Cricothyrotomy: a 5- year experience at one institution. The Journal of Emergency Medicine. 2003; 24: 151–156.

[79] American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologist Task Force on management of the difficult airway. Anesthesiology. 2003; 98: 1269–1277.

[80] Lockey D, Crewdson K, Weaver A, Davies G. Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians. British Journal of Anaesthesia. 2014; 113: 220–225.

[81] Mabry RL. An analysis of battlefield cricothyrotomy in Iraq and Afghanistan. Journal of Special Operations Medicine. 2012; 12: 17–23.

[82] Pracy JP, Brennan L, Cook TM, Hartle AJ, Marks RJ, McGrath BA, et al. Surgical intervention during a can’t Intubate can’t Oxygenate (CICO) event: emergency Front-of-neck Airway (FONA)? Clinical Otolaryngology. 2016; 41: 624–626.

[83] Atkins JH, Rassekh CH. Multidisciplinary airway response teams: concept, structure & implementation. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2020; 31: 105–110.

[84] Mark L, Lester L, Cover R, Herzer K. A decade of difficult airway response team. Critical Care Clinics. 2018; 34: 239–251.

[85] Atkins JH, Rassekh CH, Chalian AA, Zhao J. An airway rapid response system: implementation and utilization in a large academic trauma center. Joint Commission Journal on Quality and Patient Safety. 2017; 43: 653–660.

[86] Panda N, Donahue DM. Acute airway management. Annals of Cardio-thoracic Surgery. 2018; 7: 266–272.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 1.0 (2022) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time