EMCrit Podcast 131 – Cricothyrotomy – 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

Cricothyrotomy on an Actual Patient

Watch this video before going forward

Review Article

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

You probably would benefit from this Systematic Review of Cricothyrotomy as well

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 (Page 112, bottom left)


We Suck at Finding the Membrane

(Acad Emerg Med 2915;22:908)

Use a Checklist so you are Ready!


Click for Full-Size
Click for Full-Size

Here was the original CricCON Wee

ANZCA report on transition from supraglottic to infraglottic airway (they ref CricCON2)

Which Trach Should you use?

  • This one
  • Or, less preferably, a 6 or 6.5 ETT (confirm your bougie fits well before you ever do an actual cric)

Needle Cric

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

Some Evidence I Like

  • Best review demonstrating the lack of goodness inherent in needle techniques (BJA 2015;114(3):357)

My Current Cric Method


See it on a Real Patient

see this post for full attribution and explanation

Other Cricothyrotomy Lecture Videos

Build a Cric Trainer

Here are My Slides

Now on to the Video…


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  1. says

    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. says


    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…)


    • says

      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.

  3. says

    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

    • says

      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.

      • SAMGHALI says

        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..?

  4. 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.

    • says

      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.

  5. 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?

    • says

      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.


  1. […] This was a Pre-hospital case, an elderly patient who had been smoking with his home oxygen nearby. He had sustained severe facial burns. Although he was fully conscious on the HEMS team arriving, it was pretty evident that his airway would deteriorate rapidly and we were in the middle of rural England, with the nearest Major Trauma Centre 1hr away. It ended up being a difficult intubation eventually leading to a can not intubate, can not ventilate (CICV) situation. I had reflected a lot on this case and for the case debrief, had written some personal learning points. A few months previously, i had given a talk to paramedics and doctors on surgical airway. This was essentially an amalgamation of Scott Weingart’s SMACC talk (http://emcrit.org/podcasts/surgical-airway/) […]

  2. […] Cricothyroidotomy is the final common pathway for the cant intubabte cant oxygenate scenario. As I mentioned in an earlier post I am an advocate for open cricothyroidotomy because the evidence from the NAP4 report on over 3 million complications in airway management suggests that needle cricothyroidotomy fails 60% of the time. Scott Weingart gave a nice talk on the subject at SMACC Gold […]

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