Ditch the Needle? Not in Pediatrics

Thank you everyone for the best birthday wishes today! I am very grateful to have friends around. It wouldn’t be the best birthday without a new post. Here we go! Someone commented on my post entitled Ditch the Needle, Teach the Knife Part II regarding the applicability with cricothyrotomy in pediatrics. The previous post was intended for adult population only, but I didn’t really specify the age limit of using surgical cricothyrotomy. I am grateful for you guys’ comments as I don’t do pediatric cases on a regular basis. So it was good that someone brought this to my attention. I figured it would be a good topic to discuss so we can learn from it all together.

I read a few references on the age limit of performing surgical cricothyroidotomy, but there are various age limits from 5-12 years old based on different references. According to Pediatric Advanced Life Support, pediatric airway is considered age between 1-8 years old. As we know, pediatric patients may have immature cartilage and smaller cricothyroid membrane, and hence surgical cricothyroidotomy may be contraindicated. If a needle cricothyroidotomy is performed, it is a temporary fix and can be used up to 40 minutes before CO2 goes up too much. The hypercarbic state may be harmful particularly in head trauma situations. Set your ventilation with I: E ration =1:4 or even longer for completely occluded airway. Tracheostomy should be placed as soon as possible preferably within 24 hours to prevent glottic and subglottic stenosis.


Needle cricothyroidotomy is not a secure airway; it provides oxygen while you can figure out how to place a definitive airway. Here below are steps by steps:

  • Locate the trachea! Identify cricothyroid membrane between the thyroid and cricoid cartilage
  • Attach a fluid-filled syringe to a 14 gauge intravenous catheter. L
  • Aspirate as you enter the skin at a 30-45 degree caudally (towards the feet).
  • Aspirate while advancing the catheter and retract the needle until you aspirate air and hear a pop.
  • advance the catheter over the needle. The hub of the catheter may be attached to a 3.0 or 3.5 mm pediatric ET tube adapter.
  • Oxygenate by using a BVM and high flow oxygen.


Cote CJ, Hartnick CJ. Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children? Pediatr Anesth 2009; 19

Johansen K, Holm-Knudsen RJ, Charabi B et al. Cannot ventilate-cannot intubate an infant: surgical tracheotomy or transtracheal cannula? Pediatr Anesth 2010; 20: 987993.

Caplan R, Benumof L, Berry F. Practice guidelines for management of the difficult airway: an updated report from the american society of anesthesiologists task force on management of the difficult airway. Anesthesiology 2003; 98: 12691277.

Patel C, Diba A. Measuring tracheal airway pressures during transtracheal jet ventilation: an observational study. Anaesthesia 2004; 59: 24851.

Goldstein B, Shannon DC, Todres ID. Supercarbia in children: clinical course and outcome. Crit Care Med1990; 18: 166168.


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