Surgical Cricothyrotomy
3160531600wRVU: 5.42 — Conversion to formal open tracheostomy (separate encounter)31603wRVU: 5.85 — Emergency tracheostomy
Cannot-intubate, cannot-oxygenate (CICO) emergency [/ failed airway / massive facial trauma / angioedema with complete airway obstruction / laryngeal fracture]
Same
Emergency surgical cricothyrotomy
[Attending name], MD/DO
[Resident/PA name / other provider]
None [/ brief IV sedation / local infiltration with 1% lidocaine with epinephrine]
The patient presented with [cannot-intubate, cannot-oxygenate (CICO) scenario / failed [X] intubation attempts / progressive airway obstruction from [angioedema / hematoma / facial trauma / foreign body]] with [oxygen saturation falling to [X]% / complete loss of oxygenation]. Standard intubation techniques including direct laryngoscopy, video laryngoscopy, and fiberoptic intubation were [attempted and failed / not feasible]. Emergency surgical cricothyrotomy was performed as a lifesaving airway intervention.
The cricothyroid membrane was [palpable / identified by [external landmarking / ultrasound guidance]]. The thyroid notch and cricoid cartilage were used as anatomic landmarks. The membrane was [thin / indurated / obscured by [obesity / hematoma / edema]]. The airway was entered successfully on the [first] attempt. [Confirmation: end-tidal CO2 detected, bilateral breath sounds confirmed, oxygen saturation improved to [X]%.]
The procedure was performed with the patient supine and the neck extended when possible. [Local anesthetic (1% lidocaine with epinephrine) was infiltrated over the cricothyroid membrane if time permitted.]
The larynx was stabilized with the non-dominant hand using the laryngeal handshake technique: the thumb and middle finger stabilized the thyroid cartilage laterally while the index finger palpated the cricothyroid membrane in the midline inferior to the thyroid notch.
A [vertical / horizontal] skin incision was made over the lower half of the cricothyroid membrane with a [#20 / #10] scalpel blade. The subcutaneous tissue was divided. A horizontal stab incision was made through the inferior portion of the cricothyroid membrane with the scalpel. A tracheal hook was placed through the incision and used to provide caudal traction on the cricoid cartilage, stabilizing the airway.
[STANDARD TECHNIQUE:] A [Trousseau dilator] was inserted to dilate the opening. A [size 6.0 cuffed endotracheal tube / size 6.0 cuffed tracheostomy tube] was inserted into the airway through the cricothyrotomy site, directed caudally. The cuff was inflated.
Ventilation was confirmed by bilateral breath sounds, [chest rise], and [end-tidal CO2 waveform]. Oxygen saturation improved to [X]%. The tube was secured with [ties / tape / sutures to the skin].
A post-procedure chest radiograph was obtained to confirm tube position. Conversion to formal tracheostomy is planned when the patient is clinically stable — timing is based on clinical judgment (typically within 24–72 hours when feasible) to reduce the risk of subglottic stenosis from prolonged cricothyrotomy. No fixed conversion window is mandated by current DAS/ASA guidelines.
None [/ describe]
None
Minimal
None
The patient was transferred to the [ICU / trauma bay / OR] with the cricothyrotomy tube in place on [mechanical ventilation / supplemental oxygen]. Conversion to formal tracheostomy was planned within 24–72 hours.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: CICO emergency / failed airway / ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Emergency surgical cricothyrotomy
ATTENDING/PROVIDER: ***, MD/DO
ANESTHESIA: None / local
INDICATIONS: .PTAGE-year-old .PTSEX with [CICO / failed airway / ***]. [*** intubation attempts failed: direct laryngoscopy ***, video laryngoscopy ***, fiberoptic ***.] O2 sat ***%. Emergency surgical cricothyrotomy performed as lifesaving airway.
FINDINGS: Cricothyroid membrane ***. Thyroid cartilage and cricoid palpable/identified. Airway entered successfully on first attempt. ETCO2 confirmed; bilateral breath sounds; O2 sat improved to ***%.
PROCEDURE:
Supine, neck extended. Laryngeal handshake stabilization. [Local: 1% lidocaine/epi infiltrated.] [Vertical/horizontal] skin incision over inferior cricothyroid membrane. Horizontal stab incision through inferior membrane. Tracheal hook on cricoid, caudal traction. Trousseau dilator inserted. Size *** cuffed ETT/trach tube inserted caudally. Cuff inflated. Bilateral breath sounds confirmed. ETCO2 confirmed. O2 sat *** %. Tube secured with ***. CXR obtained: tube position confirmed.
EBL: Minimal
COMPLICATIONS: None
PLAN: Conversion to formal tracheostomy within 24–72 hours.
Signed: .ME, .MYDEGREE
.TODAYVariants
Scalpel-Finger-Bougie Technique (DAS Guidelines)
The scalpel-finger-bougie technique was used per Difficult Airway Society (DAS) guidelines for emergency front-of-neck access (FONA). A single bold horizontal stab incision was made through the skin and cricothyroid membrane simultaneously with a #10 blade. The non-dominant finger was inserted into the trachea to confirm position and maintain the tract. A gum elastic bougie was railroaded alongside the finger into the trachea. A [size 6.0 cuffed ETT] was then railroaded over the bougie into the trachea. The bougie was removed. Ventilation was confirmed as described. This technique is the preferred DAS/ASA emergency approach due to its reliability and speed.
Conversion to Formal Tracheostomy
Given the requirement for ongoing mechanical ventilation and the known risk of subglottic stenosis from prolonged cricothyrotomy, formal open tracheostomy was performed [X hours / X days] after the initial cricothyrotomy. The cricothyrotomy tube was removed during the tracheostomy procedure. A new tracheostomy was placed at the second-third tracheal ring level as described in the open tracheostomy template. Bill 31600 (formal tracheostomy) at the separate encounter.
Charting Tips
- Document the CICO scenario and failed airway attempts. The clinical indication for cricothyrotomy must be explicit: 'cannot intubate, cannot oxygenate' with documentation of what was attempted (DL, VL, LMA, fiberoptic). This is a medicolegally high-stakes procedure — the note must justify the emergent intervention and show that standard methods were exhausted.
- Document airway confirmation immediately after tube placement. End-tidal CO2 waveform is the gold standard. Document bilateral breath sounds, chest rise, and improvement in oxygen saturation. If ETCO2 was not available, document the alternative confirmation method. Esophageal tube placement in a CICO situation is catastrophic.
- Plan for conversion to tracheostomy. Document in the operative note or a separate order that conversion to formal tracheostomy is planned within 24–72 hours. Prolonged cricothyrotomy (>72 hours) significantly increases subglottic stenosis risk. The conversion note should reference the original cricothyrotomy date and indication.
- Cricothyroid membrane anatomy: the membrane is approximately 9 × 30 mm in adults, located between the inferior border of the thyroid cartilage and the superior border of the cricoid. The inferior third is the target to avoid the cricothyroid arteries that run along the superior border. Document that the inferior membrane was targeted.
Billing Tips
- Surgical cricothyrotomy: 31605 (6.29 wRVU, 0-day global). Use for any surgical entry through the cricothyroid membrane to establish an emergency airway. The 0-day global period means all follow-up services are separately billable from the date of the procedure.
- Emergency tracheostomy: 31603 (5.85 wRVU, 0-day global). Use for emergent surgical entry through the trachea (not the cricothyroid membrane). Use 31603 when formal tracheal entry below the cricoid was performed emergently; use 31605 when entry was through the cricothyroid membrane specifically.
- Conversion to formal tracheostomy: planned surgical conversion of a cricothyrotomy to a formal tracheostomy at a later date uses 31600 (5.42 wRVU, 0-day global) as a new procedure at a separate encounter. The 0-day global on 31605 means 31600 is separately billable. Document conversion in the new operative note.
- Needle cricothyrotomy (14-gauge angiocatheter): this is a temporizing measure, not the same procedure as surgical cricothyrotomy. There is no specific CPT for needle cricothyrotomy — it may be reported under unlisted codes or as part of airway management in an E/M context. It does not use 31605.