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M IL IT A RY M E D I C IN E , 1 7 2 , 1 2 : 1 2 2 8 . 2 0 0 7

T hree-Step E mergency C ricothyroidotomyGuarantor: A llan M aclntyre, DOContributors: A llan M aclntyre, D O; M ark K. M arkarian, M D ; D ale C arrison. D O; Jay C oates, DO;D eborah Kuhls. MD : John J . Fildes, M DObjective: Surgical cricothyroidotomy is the airway of choicein combat. It is too dangerous for combat medics to performorotrachea! intubation, because of the time needed to com-plete the procedure and the light signature from the intuba-tion equipment, which provides an easy target for the en-emy. T he purp ose of thi s article was to provide a modifiedapproach for obtaining a surgical airway in complete dark-n e ss , with night-vision goggles. M ethods: A t our de sert sur-gical skills trainin g location at N ellis A ir Force Base (L asVegas, N evada), A ir Force para-rescue person nel receivedtraining in this techniqu e using human ca davers. This train-ing was provided during the fall and winter months of 2 0 0 3 -20 0 6, R esults: T hrough tr ial and error , we developed a"quick and easy" method of obtaining a surgical airway incomplete darkness, using three steps. The steps involve thetraditional skin and cricothyroid membrane incisions butadd the use of an elastic bougie as a guide for endotrachealtube placeme nt. We have discovered th at the bougie not onlyprovides an excellent guide for tube placement but alsoeliminates the use of additional equipment, such as trachealhooks or dilators. Furthermore, the bevel of the endotra-cheal tube displaces the cricothyroid membrane laterally,which allows placement of larger tubes and yields a bettertracheal seal . C onclusions: C ombat medics can perform thethree-step surgical cricothyroidotomy quickly and effi-ciently in complete darkness. An elastic bougie is requiredto place a larger endotracheal tube. No additional surgicalequipment is needed.

IntroductionM ilitary medics need to treat many different types of life-threatening injuries quickly and efficiently while in a combatzone. To increase survival rates, they attend T actical C ombat C a-sualty C are cours es taugh t mon ths before their deployment.'-^T here they leam how to treat the most common preventablecauses of death seen on tbe battlefield, wbile engaging tbe enemy.For example, if the medic is being fired upon, he or she m ust firstsupp ress enemy fire by returning fire, A tter the shooting ceases,the medic takes the casualty to cover and follows the triage mne-monic M AR CH (Table I),-' (1) M assive compressible hemorrhage iscontrolled with the use of pressur e dressings, tourniqu ets, andhemostatie dressings, (2) T he airway is assessed; if compromised,it is mainta ined through placement of a nasopharyngeal airwaywith a jaw -thru st maneuv er. If the airway remain s compromised,then the medic can place a C ombltube (T yco-Kendall, M ansfield.M assachusetts} or perform a cricothyroidotomy.^ (3) R espiratory

D epartment of Surgeiy, U niversity of Nevada School of M edicine. Las Vegas, NV8 9 1 0 2 .Presented at the Annual C linical A ssemhfy of Osteopathi c Specialists M eeting,January 12-14, 2006, Scottsdale. AZ,T his manuscript was received for review in August 2 00 6, TTie revised m anuscriptwas accepted for publication in May 2007,R eprint & C opyright hy A ssociation of M ilitary Surgeons of U , S , , 2 0 0 7 .

emergencies such as tension pneumothorax can be decompresswith needle thoracostomy using a 10 - to 1 4 -gauge BD A ngiocA utoguard angiocatheter (BD Biociences, San Jos e, C alifornia)casualty with a sucking chest w ound is covered with im A shermchest seal or Vaseline gauze, and respiratory effort is monitorclosely, (4) If the patient displays palpable radial pulses and nomal mentation, then no intravenous fluids are given; if these fetures are diminished, then a eontrolled lluid bolus is infused,'^'' (Hypothermia mus t be prevented. If necessary, the casualty mayplaced in a body bag. to prevent evaporative heat loss, and givwarm intravenous fluids. Once the casualties ean be safely rmoved from the battlefield, they are transported to a forward sugical team if they are in u nstable condition or are transported tocombat support hospital if they are in stable condition.If the medic has to perform these lifesa\'ing procedures complete darkness, bowever. then considerable challenges cexist. Over the pas t 3 years at our desert medical training siteN ellis A ir Force B ase, we have developed and modified a tecnique for establishing a surgical airway while in complete darness, with the use of night-vision goggles and an elastic bougas a guide for proper endotracheal tube placement.

M e th o dsThe recommended equipment consists ofa size 10 scalpel, elastic bougie, a cuffed endotraeheal tube (ranging in size fro6 to 8), and night-vision goggles (Fig. lA ). T he three-s tep s urgcal airway procedure is outlined as follows.

Step 1: Skin IncisionQuickly cleanse the neck, and grasp the larynx with the nodominant han d. U se the index finger of the non doniinant hanto identify the thyroid cartilage, ericothyroid membrane, ancricoid ring. Once the underlying structures have been identfied, use the dominant hand to make a vertical incision over thcricothyroid membrane (Fig, IB). Place the nondominani indefinger into the vertical incision a nd move it side to side to clear

feel the cricothyroid m em brane (Fig. I C ).Step 2: Incision of C rieothyroid M embrane

Remove the nondominant index finger from the cricothyromembrane, and make a 5-mm horizontal incision through thcricothyroid membrane (Fig. 2A), Watch the depth of incision, avoid injury to the underlying esophagus. Place the elastic bogie into the defect, and advance it until resistance is appreciate(Fig. 2. B and C ). T his indicates entry into the right main stebronchus.Step 3: E ndotracheal Tube P lacement

A dvance the preselected cuffed endo trachea l tube over thelastic bougie (Fig. 3), up to the cricothyroid m em bran e. E

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Tliree-Step Emergency Cricothyroidotomy 1229TABLE 1

MARCH, TRIAGE MNEMONIC USED IN COMBAT

MARCH

Massive hemorrhageAirwayRespirationCirculationHead injury/hypothemiia

cFig, 2. (A) Horizo ntal incisio n throu gh the cr icothyroid m embra ne. (B) P lace-

m e n t of an elas t ic bougie through the cr icothyroid membrane, iC) P lacemen tof an elas t ic bougie through the cr icothyroid membrane with night-vis ion

r IL;. 1. [A \ Surgical airway procedure being performed with night-vision goggles,(B| Vertical skin incision superficial to the crieothyroid membrane. (C) Nondomi-nant index finger placed into the vertical skin incision, topalpate the cricothyroidmembr ane .

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1230 Three-Step Emergency Cricothyroidotom

Fig, 3, Placement of an endotracheat tube over tbe elastic bougie,sure that the hevel ofthe endolracheal tube is lined up withthe horizontal incision of the cricothyroid membrane beforeadvancing further. Apply gentle pressu re while advancing th eendotracheal tube through the divided cricothyroid mem-brane. As the bevel of the endotracheal tube is passingthrough the membrane, it will push the cricothyroid mem-bra ne laterally. This will open the defect, allowing placem entof the larger endotracheal tube. Once the endotracheal tubecuff has entered the trachea, stop advancing. Remove theelastic bougie, and inflate the endotracheal tube cuff.

DiscussionThere are many benefits of using the three-step approachdescribed above to obtain a su rgical airway. First, a medic canperform this procedure quickly and safely, without the bur-den of any additional equipment (such as a Trousseau dilatoror a trache al hook). This three-ste p airway procedure requiresonly three items, namely, a scalpel, an endotracheal tube,and an elastic bougie. Second, the cricothyroid membrane isdisplaced laterally as the bevel of the endotracheal tube isadvanced into the trachea. This lateral dilation not only re-duces the resistance involved in advancing the endotrachealtube into the trachea but also enables the medic to place atube larger than a standard 6-mm tube. The traditional

teaching is to place a 6-mm endotracheal tube, rather than a>7-mm tube, because ofthe ease of insertion into the narroworifice.^ A iarger endotracheal tube can form a better seal anddecrease airway leaks, both critical issues when dealing withhigher peak airway pressures caused by blast injuries to thelungs. Third, the lateral dilation eliminates the need to use

the back end of the scalpel to increase the diameter of topening, which couid increase the chance of an inadverteairway injury, esophageal injury, or hand injury.The potential drawbacks of the three-step airway proceduInclude those associated with the visual challeng es of working the dark. The use of infrared night-\1sion goggles enab les thmedic to see in complete darkness, but there is a "leamincurve," For example, there is loss of normal multidimensionsight, with visual acuity confined to the color spectm m of greeand black, which would make it difficult to see active bleeding to identify the typical skin color of a hypoxic patient, Howeveone can still readily visualize the neck, important landmarkand one's hand placement throughout the procedure. This reduces the chance of injury from the most dangerous parl ofthprocedure, that is. using the scalpel to make the skin incisioand to divide the cricothyroid membrane. We recommend usina safety scalpel, to keep the blade covered when bringing thscalpel up to the patient's neck. The safety cover can then bretracted to expose the blade and to incise the skin; the samholds true for division of the cricothyroid membrane.

ConclusionsAn efficient easy means of obtaining a surgical airway vicricothyroidotomy is critical in co mba t. We propose a modifcation to the traditional cricothyroidotomy with the followinthree -step airway procedure. Step 1 is the identification olandmark structures and skin incision. Step 2 is cricothyroimembrane incision and insertion of a bougie. Step 3 is insertion of an endotracheal tube and removal of the bougie.The speed, ease, and efficiency of obtaining a surgical airway, in addition to the larger airway provided (compared wit

traditional cricothyroidotomy). have made the three-step airway procedure a key tool for combat em ergency pers onne l. Wexpect it to be ju st as sign ificant an d u seful in the civiliasetting.References

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2. Uw ls N: Tacliral Combat Casualty Care M anual. Ed 1, Washington. DC. U.Army, 2005,

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4. McSwaln N: Military Medicine Prebospital Trau ma Ufc Su ppo n, Ed 4, p 388 . SLouis. MO, Mosby. 2003 .

5. Stem SA, Dronen SC. Biner P, et al: EITect of blood pressure (in hcrnorrhiiRe anvolume and survival in a near fatal hemorrbajie model incorporailng a vasculinjury, Ann Emerg Med 19 93: 22: 1 55- 63,

6- Gross D, Landau EH, Assaiia A. et al: Is hypertonic saline resuscitation safe Iuncontrolled bemorrhagic shock? J Trauma 1988; 28: 751 ,

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