Surgical Airway/Cricothyroidotomy: How to

This video is a supplement to training and is neither comprehensive nor a replacement for proper instruction.

A surgical airway/cricothyroidotomy is the advanced airway of choice in combat, due to the types of injuries encountered. Severe maxofacial trauma secondary to blasts are common and may require more invasive treatment when neither the recovery position nor NPA nor King Oropharyngeal Airway (King-LTD) will suffice. It is important to note that only airway management is generally best left to the Tactical Field Care (TFC) phase of treatment. Furthermore, less than 1% of trauma casualties require an airway, so prudence is required when deciding to intervene. The indications and contraindication are as follows:


–Airway obstruction due to maxillofacial trauma that cannot be corrected by positioning or a nasopharyngeal airway
–Anaphylaxis that is or is about to compromise the airway
–Inhalation burns injury
–Where other means to secure the airway have failed


–Airway can be maintained by other means

Please note that we illustrate a vertical incision instead of the traditional horizontal, because we feel it is the preferred method in the tactical environment. First, a vertical incision minimizes the risk of involving (e.g., cutting) the vascular structure of the neck. Second, it creates a larger “window,” thereby simplifying landmark identification. Finally, a vertical incision allows one to select a different location above or below the initial site, if one should misplace the initial cut, due to lack of familiarity with the procedure.

Three-Step Cric?

Below you will find an article published in Military Medicine. It argues that traditional ways of providing a surgical airway in a tactical environment are flawed. Therefore, the authors continue, a new approach is needed. Three-step Cric

Objective: Surgical cricothyroidotomy is the airway of choice in combat. It is too dangerous for combat medics to perform orotracheal intubation, because of the time needed to complete the procedure and the light signature from the intubation equipment, which provides an easy target for the enemy. The purpose of this article was to provide a modified approach for obtaining a surgical airway in complete darkness, with night-vision goggles. Methods: At our desert surgical skills training location at Nellis Air Force Base (Las Vegas, Nevada), Air Force para-rescue personnel received training in this technique using human cadavers. This training was provided during the fall and winter months of 2003-2006. Results: Through trial and error, we developed a “quick and easy” method of obtaining a surgical airway in complete darkness, using three steps. The steps involve the traditional skin and cricothyroid membrane incisions but add the use of an elastic bougie as a guide for endotracheal tube placement. We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal. Conclusion: Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.