Morgenstern, J. Pediatric front of neck access (the surgical tracheotomy), First10EM, April 7, 2025. Available at:
https://doi.org/10.51684/FIRS.141354
Case
It is the scenario of nightmares: a young child with an airway obstruction. They came in with stridor, and although you were initially thinking severe croup, the story doesn’t quite fit, there is no response to medical therapy, and this patient is incredibly sick. There is significant hypoxemia despite a nonrebreather. You can’t wait for backup, so you proceed rapidly to RSI. Advancing the video layngoscope, you see a large mass in the larynx but no other recognizable anatomical structures. BVM doesn’t work, and the mass prevents an LMA. You declare a “can’t intubate can’t oxygenate” scenario, and proceed to…
Note: This is a difficult topic with differing opinions. This post focuses on the simplified clinical approach to a can’t intubate can’t oxygenate scenario in a child. If you are interested in the literature that informs this approach, check out this accompanying article. The main point is that needle based approaches fail far too often, and so despite being widely recommended, are not a good choice for rescuing a pediatric patient in the can’t intubate can’t oxygenate scenario. A surgical approach has higher success rates, fewer complications, and therefore should be preferred.
A word of caution
Although I think the evidence makes it very clear that the surgical approach is preferable to needle based approaches for front of neck access in the can’t intubate can’t oxygenate scenario in pediatrics, I have never performed a pediatric tracheostomy. This approach is distilled from many sources, but advice varies widely among sources. When sorting through the advice, my focus has been on the simplicity and speed required in the emergent scenario, as too often the procedure is described as it should be performed in the elective or semi-urgent scenarios, and it isn’t clear that the steps translate perfectly the the emergent scenario. In an effort to avoid confusion, I have tried to describe a single approach. However, some variations, debate, and alternatives are discussed at the end in the “Notes” section.
Be cautious learning a procedure from a novice. Take this is a starting point, but like I will, try to find a simulator where you can get real training on this rare but essential emergency medicine procedure.
My approach
Announce to the room that you are in a can’t intubate can’t oxygenate scenario.
Throughout the procedure, a second provider (if available) should continue attempts at rescue oxygenation from above (BVM, LMA, or intubation).
Expect a bloody procedure. Wear PPE including eye protection.
Position the patient. Expose the neck fully, with the head in full extension. (At this point, even if there are continued attempts at intubation, the surgical airway is the priority, and positioning should prioritize the success of this life saving procedure.)
Identify the trachea and cricothyroid membrane using “the laryngeal handshake” with your non-dominant hand. Stabilize the larynx between your thumb and third finger while palpating the cricothyroid membrane with your index finger.
Key decision point: is the child older or younger than 8 years old? Children 8 and older have anatomy close enough to an adult, with a cricothyroid membrane large enough to accommodate a small endotracheal tube, and therefore you should proceed with your standard surgical (scalpel, finger, bougie) cricothyroidotomy, exactly as you would in the adult CICO scenario. That procedure is outlined in this prior article. If the child is younger than 8, or quite small, you will have to proceed with a surgical tracheotomy. (Some experts recommend a needle based approach, but with a success rate of around 50%, if you start with a needle, you must expect it to fail and be ready to move on within 45 seconds.)
The surgical tracheotomy
Necessary equipment: scalpel, pediatric endotracheal tube, ideally a pediatric sized endotracheal introducer (bougie), capnography
Equipment that might help if available immediately: lidocaine (with epinephrine), a shoulder roll, suction, good lighting, Kelly clamps or a trousseau dilator, a large 0-silk suture. (I would train for the procedure with the minimum equipment always available in the emergency department. However, creating a kit for your department and training specifically on your own equipment is reasonable, as long as you always work in the same place, and your department is good at ensuring equipment is always stocked and available.)
Take 5 deep breaths. Slow is fast, fast is smooth. Rushing with shaky hands is a recipe for cutting the carotid artery.
Make a vertical midline incision in the skin, starting just below the cricoid cartilage. This is not the time to worry about aesthetics, or even hemorrhage. Give yourself plenty of space to work with a reasonable sized incision. The key exception to this is that the innominate vein and artery can run higher in children, often rising above the sternal notch, and so you want to avoid the bottom 25% of the neck.
Find the trachea. Be careful to remain in midline. Dissect down to the trachea, careful to identify and avoid the major vascular structures. Unlike the adult procedure, which because of blood is guided entirely by touch, vision might be more important in young children. They have very small airways which are very floppy, and so can feel a lot like vascular structures. Good lighting, suction, and having an assistant to provide some horizontal traction on the skin will be invaluable (but be prepared to proceed blindly if blood obscures your view).
Stabilize the trachea using your nondominant hand. If this proves difficult (especially when attempting to introduce the endotracheal tube), use the largest suture you can find, and introduce “stay sutures” around the tracheal rings to allow for upwards traction and stabilization.
Make a vertical incision down the front of the trachea, aiming to cut 2 (or 3 at most) tracheal rings. This may be a blind cut, obscured by blood. Focus on what you can feel, not what you can see. This is usually done with a scalpel, but sharp scissors can also be used if available, and might give you more control. (Simpson 2022)
Insert a pediatric size bougie.
Railroad a small pediatric endotracheal tube over the bougie. This may require horizontal spreading of the tracheal rings, which can be accomplished by opening a kelly clamp in the incision, or by applying lateral traction to stay sutures. (The Trousseau dilator is the tool specifically designed for this job, if you are creating an emergency kit.)
Check tube position with waveform capnography.
Secure the airway.
Once the airway is secured, you can manage any bleeding with sutures or direct pressure.
Notes
“It is important to remember to access the trachea using a vertical incision and to avoid incision of more than 2 tracheal rings, since this drastically reduces the risk of severe and irreparable complications. The risk of complete transection of the trachea can be reduced by avoiding a horizontal cut.” (Berger-Estilita 2021)
The best method of stabilizing the trachea is unclear to me. Some people use “stay sutures”, running the 0-silk through the trachea, and pulling directly up to hold the trachea in place. (Simpson 2022) Others suggest grasping it with towel forceps.(Johansen 2010) Although reasonable, finding a 0-silk when I need it can be difficult, and I have never seen towel forceps in the ED. I worry that the added need for equipment complicates this step, and will slow or delay a needed life saving procedure. On the other hand, watching many videos (mostly veterinary) of tracheostomies being performed, it is often difficult to insert the tube into the trachea, and so I may be underestimating the value of stay sutures. A cricoid hook is another option, if such a thing is available.
I have practiced this procedure in simulation, but never in a live patient. In adults this is entirely a tactile procedure, but the small rubbery airway in children apparently makes this very hard. However, without OR lighting, trained assistants, cautery, and other specifically designed tools, I am wary of advice that makes this a purely visual procedure as well. As compared to adults, I am prepared to take a little more time with exposure and suction, but seconds matter in a CICO scenario, and I am therefore also prepared to proceed blindly. I think the most important point is to be vigilant about staying in the midline of the neck. Making sure the head is firmly secured will help. Similar to performing a lumbar puncture, it will also be important to maintain a sense of the overall anatomy, rather than getting too focused on the exact location of the procedure.
Cliff Red teaches this as a 2 person procedure (wich allows an assistant to perform excellent traction and suction). His team has simulated and refined this procedure many times, and so that expertise is important. However, Cliff works as part of a team that works at a higher level than most emergency departments. They have time dedicated to training together. For most community emergency doctors, who are likely never to encounter the pediatric CICO scenario, I don’t think we can count on having trained assistants available.
The images used above are not mine. They are photoshop composites of images from many sources, but I unfortunately lost track of where the files originated. If you recognize an image that should be credited, I am happy to add credit, and obviously if there is a copyright issue I will remove it.
Other FOAMed Resources
First10EM
The pediatric can’t intubate can’t oxygenate scenario (Use a knife)
Emergency Airway Management Part 4: Cricothyroidotomy (surgical front of neck access)
Other
Dr Cliff Reed talks through Paediatric Tracheostomy:
Even a pediatric ENT surgeon doesn’t consider himself an expert in surgical front of neck access in children, because it is thankfully so rare. Hear some excellent thoughts in this YouTube video:
References
Berger-Estilita J, Wenzel V, Luedi MM, Riva T. A Primer for Pediatric Emergency Front-of-the-Neck Access. A A Pract. 2021 Apr 6;15(4):e01444. doi: 10.1213/XAA.0000000000001444. PMID: 33821828
Campisi P, Forte V. Pediatric tracheostomy. Semin Pediatr Surg. 2016 Jun;25(3):191-5. doi: 10.1053/j.sempedsurg.2016.02.014. Epub 2016 May 11. PMID: 27301607
Desiato VM and Wertz AP. Pediatric Tracheostomy. In: Coppola CP, Kennedy AP, Lessin MS, Scorpio RJ. Pediatric Surgery: Diagnosis and Treatment. Springer International Publishing; 2022.
Haag AK, Tredese A, Bordini M, Fuchs A, Greif R, Matava C, Riva T, Scquizzato T, Disma N. Emergency front-of-neck access in pediatric anesthesia: A narrative review. Paediatr Anaesth. 2024 Mar 11. doi: 10.1111/pan.14875. Epub ahead of print. PMID: 38462998
Johansen K, Holm-Knudsen RJ, Charabi B, Kristensen MS, Rasmussen LS. Cannot ventilate-cannot intubate an infant: surgical tracheotomy or transtracheal cannula? Paediatr Anaesth. 2010 Nov;20(11):987-93. doi: 10.1111/j.1460-9592.2010.03417.x. Epub 2010 Sep 29. PMID: 20880155
Klemm E, Nowak A. Tracheotomy and Airway: A Practical Guide. Springer International Publishing; 2020.
Marcotte A, Mascarella MA, Nguyen LH, Nemeth J. Just the facts: indications and technique for emergency tracheotomy. CJEM. 2023 Aug;25(8):653-655. doi: 10.1007/s43678-023-00538-7. Epub 2023 Jun 10. PMID: 37300653
Simpson NS, Spaur KM, Strobel AM, Kirschner EJ, Driver BE, Reardon RF. Novel Technique for Open Surgical Tracheostomy in Small Children. West J Emerg Med. 2022 Feb 23;23(2):235-237. doi: 10.5811/westjem.2021.11.53296. PMID: 35302458