Surgical Cricothyrotomy
Emergency surgical cricothyrotomy
[Cannot intubate, cannot oxygenate after [X] failed intubation attempts / Complete airway obstruction from [angioedema / expanding neck hematoma / massive facial trauma / laryngeal fracture / foreign body]], with SpO2 falling to [X]%, requiring an emergency surgical airway.
[The procedure was emergent and lifesaving, and consent was implied / Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives].
[***, MD/DO]
[Resident/PA name]
[None / Local infiltration with 1% lidocaine with epinephrine / Brief IV sedation]
The cricothyroid membrane was [palpable / identified by ultrasound] and [thin / indurated / obscured by [obesity / hematoma / edema]]. The airway was entered on the [first / second] attempt. Placement was confirmed by end-tidal CO2 waveform, bilateral breath sounds, and chest rise, and SpO2 improved to [X]%. Post-procedure chest radiograph showed [appropriate tube position].
Intubation by [direct laryngoscopy / video laryngoscopy / fiberoptic bronchoscopy] [failed after [X] attempts / was not feasible]. The patient was positioned supine with the neck extended when possible. [Local anesthetic (1% lidocaine with epinephrine) was infiltrated over the cricothyroid membrane.]
The larynx was stabilized with the non-dominant hand using the laryngeal handshake, with the thumb and middle finger holding the thyroid cartilage laterally and the index finger palpating the cricothyroid membrane in the midline below the thyroid notch.
A [vertical / horizontal] skin incision was made over the lower half of the cricothyroid membrane with a [#10 / #20] scalpel blade, and the subcutaneous tissue was divided. A horizontal stab incision was made through the inferior portion of the membrane. A tracheal hook was placed on the cricoid cartilage to provide caudal traction and stabilize the airway.
The opening was dilated with a [Trousseau dilator]. The tube was inserted through the cricothyrotomy, directed caudally, and the cuff was inflated. The tube was secured with [ties / tape / sutures to the skin].
[6.0] mm cuffed [endotracheal / tracheostomy] tube through the cricothyroid membrane[, [X] cm at the skin]
Minimal
None
None
The patient was transferred to the [ICU / trauma bay / OR] on [mechanical ventilation / supplemental oxygen] with the cricothyrotomy tube in place. Conversion to formal tracheostomy is planned [within 24–72 hours / when clinically stable].
Epic SmartPhrase Version
PROCEDURE: Emergency surgical cricothyrotomy
INDICATION: [CICO after *** failed intubation attempts / Complete airway obstruction from ***], SpO2 ***%, requiring emergency surgical airway.
CONSENT: [Emergent and lifesaving, consent implied / Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives].
PERFORMED BY: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: [None / Local: 1% lidocaine with epinephrine / Brief IV sedation]
FINDINGS: Cricothyroid membrane ***. Airway entered on *** attempt. ETCO2 waveform, bilateral breath sounds, and chest rise confirmed. SpO2 improved to ***%. Post-procedure CXR: ***.
PROCEDURE DETAILS:
Intubation by [DL / VL / fiberoptic] [failed after *** attempts / not feasible]. Supine, neck extended. [Local: 1% lidocaine with epinephrine infiltrated.] Laryngeal handshake stabilization. [Vertical / horizontal] skin incision over inferior cricothyroid membrane. Horizontal stab incision through inferior membrane. Tracheal hook on cricoid, caudal traction. Trousseau dilator inserted. Tube inserted caudally, cuff inflated. Secured with ***.
DEVICE PLACED: *** mm cuffed [ETT / tracheostomy tube] through cricothyroid membrane
EBL: Minimal
SPECIMENS: None
COMPLICATIONS: None
POST-PROCEDURE PLAN: Transferred to *** on [mechanical ventilation / supplemental oxygen]. Conversion to formal tracheostomy planned [within 24–72 hours / when clinically stable].
Signed: .ME, .MYDEGREE
.TODAYVariants
Scalpel-Finger-Bougie Technique (DAS Guidelines)
The scalpel-finger-bougie technique was used for emergency front-of-neck access. 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.
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 to third tracheal ring level.
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, so 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, although timing is a clinical judgment and current DAS and ASA guidelines do not mandate a fixed conversion window. 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.
- The scalpel-finger-bougie technique is the preferred emergency front-of-neck access (FONA) approach in the Difficult Airway Society (DAS) guidelines because of its reliability and speed.
- Document the formal tracheostomy after a cricothyrotomy with the open tracheostomy template.
Documentation & Reimbursement Considerations
- Primary service: Report Surgical Cricothyrotomy as the primary service when it is the definitive operation performed.
- Surgical cricothyrotomy (6.29 wRVU, 0-day global) is reported 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 (5.85 wRVU, 0-day global) is a different service, reported when formal tracheal entry below the cricoid was performed emergently rather than through the cricothyroid membrane.
- Planned conversion of a cricothyrotomy to a formal tracheostomy at a later date is a new planned tracheostomy (5.42 wRVU, 0-day global) at a separate encounter, separately billable because the cricothyrotomy has a 0-day global. Document conversion in the new operative note.
- Needle cricothyrotomy (14-gauge angiocatheter) is a temporizing measure, not the same procedure as surgical cricothyrotomy. There is no specific code for needle cricothyrotomy. It may be reported under unlisted codes or as part of airway management in an E/M context, and it is not reported as a surgical cricothyrotomy.