CICO: Scalpel Technique

airway emergency airway management cico difficult airway hypoxia oxygenation scalpel scalpel technique Jul 30, 2024
CICO: Scalpel Technique

The Scalpel Technique for CICO is a daunting prospect. If it is not the first option for front of neck access, it should still remain as the backup option if the cannula technique is unsuccessful. The scalpel is relatively unfamiliar to the anaesthetic team, however, the rest of the kit is made up of common pieces of anaesthesia equipment 👩‍⚕️👨‍⚕️

Here’s what you need to know:

Equipment:
- Size 10 Broad Blade Scalpel
- Frova intubating bougie
- 6.0mm cuffed ETT
- 10ml syringe

Procedure:
1️⃣ Allocate roles 👥

2️⃣ Prepare equipment 🧰
- Open each item onto a large stable surface that can be placed next to the patient

3️⃣ Prepare the neck
- Extend the neck and swab the area with an alcohol swab 🧼
- Identify cricothyroid membrane +/- inject adrenaline-containing solution

4️⃣ Access trachea 🫁
- Make a transverse incision through the cricothyroid membrane, ensuring the tip of the scalpel enters the trachea. Ideally, the scalpel should be cutting towards the operator.
- The scalpel blade is then turned 90 degrees, which provides a small opening for the bougie to pass through

5️⃣ Insert bougie ➡️
- Place the tip of the bougie into the hole created and direct it towards the carina and ensure the scalpel is placed in a safe area.

6️⃣ Insert ETT ➡️
- Thread the ETT over the bougie, anticipating significant resistance at the point of entry. A twisting motion may be needed.
- Remove the bougie, inflate the cuff, and connect the circuit.

7️⃣ Confirm position ✅
- Gently ventilate manually using the circuit and confirm end-tidal CO2 in a square waveform.
- Secure the ETT using a tie.

8️⃣ Oxygenate 📈
- Once confirmed, switch the ventilator and ensure settings are appropriate.

9️⃣ Green Zone discussion 🟢
- Confirm your team is in the Green Zone and take the opportunity to pause and discuss the next steps 🗣️.

Note: Periop Concepts supports training and education using the Royal Perth Hospital/Andy Heard technique for both cannula and scalpel cricothyroidotomy.

Ref: [Vortex Approach](https://vortexapproach.org/neckrescueemergency)

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