EMCrit Podcast 131 – Cut to Air: Surgical Airway from SMACC Gold


This is the resource page for all things Crics (Cricothyroidotomy)

We spoke a ton about cricothyrotomy way back in episode 24; this is an update

Review Article

Especially keen on the parts of this cricothyrotomy article that discuss the failures of non-surgical techniques

Understand the Surgically Inevitable Airway (thanks, Rich)

In appropriate circumstances (prophylactic cricothyroidotomy) has numerous advantages, not least the potential to secure and check the ‘rescue airway’ in a calm and unhurried manner, without hypoxia, before an emergency arises

— NAP4 Study


Use a Checklist so you are Ready!


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Here was the original CricCON Wee

Which Trach Should you use?

Needle Cric

I don’t recommend this method, but some just will never feel comfortable cutting the neck

My Current Cric Method

Other Cricothyrotomy Lecture Videos

Build a Cric Trainer

Here are My Slides

Now on to the Video…

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  1. Do you still use a tracheostomy tube if available? I’ve only used ET tubes for crics, mainly due to availability and also being more flexible. I once tried to replace a regular trach over a bougie and found the rigidity made it difficult. On the other hand it can be challenging to secure an ETT in a cric and they easily migrate into the mainstem. Has anyone tried using a soft silicone trach tube over a bougie?

  2. I recorded a real life surgical airway from the TV show Inside Combat Rescue (NATGEO). I use that video on my classes.
    If you want me to send you the video email me to Sebastian@mayanz.cl

  3. Scott,

    Great episode- it’s great that we are embracing the fact that performing a surgical airway isn’t a failure and sometimes it should be the primary technique.

    You mentioned in the updated CriCon that you only mark the neck and have the cric kit at bedside for the anticipated “risky” airways. Why not mark the neck and have the cric kit within arm’s reach for all airways? I started routinely marking the neck on every airway and I have gotten feedback from the other docs and nursing staff that they like this approach. They have seen too many airways go south due to a lack of adequate preparation and equipment availability. I know it seems like overkill but I think it sends a powerful message to everyone in the room that we are mentally prepared to do a cric if needed.

    True story- I was working at a community ED when I was called up to the ICU to intubate. As I am preparing my equipment one of the nurses says “What’s the scalpel for” I said “That’s in case this airway goes south” HIs response “Why doesn’t everyone do this?” Good question! (And, of course- the airway was a chip shot…)


    • Steve,
      got no problem with that–but if you feel the neck, have the kit in the room, and announce the end of the airway plan is cric, that seems enough for most situations. if you want to mark everyone, i say go for it.

  4. Hi Scott,

    Thanks for a fantastic talk. I completely agree that just by picking up a laryngoscope you are commiting to a cric if need be.
    Speaking as someone who’s never done one in anger, is the longitudinal incision necessary? If you can feel the anatomy, why cant you just do the transverse incision to save time and cut down on bleeding (even though as you say, the bleeding it’s self is no big problem). What problem would i create for myself by doing this?


    Anesthesia/ICU resident, Stockholm, Sweden

    • we generally advocate to train for how you fight. this seems like a perfectly rational idea now (and it is), however when you have to actually do this you will fall back to how you trained. you should train just one way and do it continuously. hence the lack of an option to diverge based on anatomy.

  5. Great talk, Scott. We use at fast stepwise approach to locate the cricothyroid membrane by US egen we are in CRICON yellow.


    We feel this ads substantially to Safety during airway management.

    • like it! the ultrasound podcast guys did a whole series on this

      • Scott- awesome talk. Amazing how it doesn’t matter how many times I have heard you speak about a topic, always seem to pick up on new subtle things. Wondering if you have ever personally incorporated u/s into your cric, or at least used it for your cric planning/marking in the morbidly obese pt..?

  6. I like the subtle removal of the glasses. Great talk!

  7. Michael Fullenkamp MD says:

    I’m going to ask what may be a very silly question. Once the cric is completed, and the patient recovers from their illness. Does the membrane grow back? Do they do fine without it? Does it require surgical repair by ENT later on.

    • they do just fine without repair–as it is not done, same for trachs. Not sure how much of the membrane heals if any–can just tell you the skin is closed and it heals well.

  8. Nice podcast.
    Andy Neill’s video link here is dead. It has moved to a new link.


  9. Dante Lima says:

    Hi Scott. Fantastic as always! For how long do you think is safe to leave the cric before converting it to a tracheostomy?

    • the idea that it has to come out right away has been debunked by the recent ENT literature. Prob. a few days is fine. Depends on whether you have a long unstable ETT sitcking out of the hole.


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