Emergency Medicine Hub / Procedures & Anesthesia • 3 min read • 3 sections

Critical Airway & Vascular Procedures: Cricothyrotomy, IO & Umbilical Lines

Step-by-step emergency mastery of high-stakes resuscitation procedures: surgical cricothyrotomy (scalpel-finger-bougie technique), needle jet ventilation, bougie-assisted rapid sequence intubation, extraglottic devices (LMA, King LT), ultrasound-guided peripheral IV, intraosseous (IO) access sites and flow rates, and neonatal umbilical vein catheterization (UVC).

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

Cannot Intubate, Cannot Oxygenate (CICO)

Immediately declare emergency. Prepare surgical airway. Do not attempt endless repeat laryngoscopy.

Scalpel-Finger-Bougie Cricothyrotomy

1. Palpate cricothyroid membrane between thyroid cartilage and cricoid cartilage. 2. Vertical 3-4 cm midline skin incision. 3. Transverse stab incision through cricothyroid membrane. 4. Insert index finger into tracheal lumen to maintain tract. 5. Advance coudé tip of bougie into trachea (feel tracheal clicks). 6. Railroad lubricated 6.0 mm cuffed ETT over bougie into trachea. Inflate cuff, ventilate, verify end-tidal CO2.

Extraglottic Airway Rescue

Insert King LT or LMA as supraglottic bridge while preparing surgical airway or when glottic visualization is impossible.

Bougie-Assisted RSI

First-line tool for Cormack-Lehane Grade 2b/3 views. Advance bougie under direct/video vision; tactile tracheal ring clicks (present in 90%) and carina hold-up (resistance at 30-40 cm) confirm intratracheal location. Railroad ETT with 90° counterclockwise rotation.

Intraosseous (IO) Sites & Flow Rates

Proximal Humerus (fastest flow, closest to right atrium, 5-8 L/hr under pressure; use 45 mm yellow needle), Proximal Tibia (2 cm distal and 1-2 cm medial to tibial tuberosity, use 25 mm blue needle), Distal Tibia (3 cm proximal to medial malleolus). Flush with 20-40 mg 2% lidocaine over 2 minutes in conscious patients to relieve severe pain of marrow expansion.

Umbilical Vein Catheterization (UVC)

Identify single, wide, thin-walled vein at 12 o'clock (paired umbilical arteries are thick-walled, contracted at 4 and 8 o'clock). Cannulate 3.5-5.0 Fr catheter only 3-5 cm until free blood return (low-lying emergency position, avoids portal vein infusion of hypertonic dextrose/epinephrine).

Bottom-Line Clinical Pearl

In a 'Cannot Intubate, Cannot Oxygenate' (CICO) crisis, execute the Scalpel-Finger-Bougie surgical cricothyrotomy: vertical skin incision, horizontal stab through cricothyroid membrane, finger dilation, advance bougie into trachea, and railroad a 6.0 mm cuffed ETT. In neonatal arrest, the umbilical vein is a single, thin-walled, large-caliber vessel located at 12 o'clock, canalized cleanly with a 3.5-5 Fr catheter.

CANNOT INTUBATE, CANNOT OXYGENATE (CICO) CRITICAL ACTION

When direct/video laryngoscopy fails, BVM ventilation fails, and a supraglottic airway cannot maintain SpO2 > 90%, you are in a CICO crisis. Hypoxemic cardiac arrest occurs within minutes. Transition immediately to the surgical neck. Abandon attempts at oral intubation and perform the Scalpel-Finger-Bougie cricothyrotomy without hesitation!

Emergency Vascular Access: Speed, Flow & Anatomy

Access Modality	Anatomical Landmarks	Equipment & Needle Gauge	Average Flow Rates & Pearls
Proximal Humerus IO	Greater tubercle of humeral head (internally rotate arm, place hand on abdomen)	45 mm (yellow) IO needle; angle 45° to horizontal plane pointing towards opposite axilla	Up to 5,000 mL/hr under pressure; superior drug delivery time to central circulation compared to tibial IO
Proximal Tibia IO	Flat anteromedial surface of tibia, 2 cm medial and 2 cm distal to tibial tuberosity	25 mm (blue) IO needle in adults; 15 mm (pink) in infants; insert perpendicular (90°) to bone cortex	Approx 1,000-1,500 mL/hr under pressure; easy landmarks in cardiopulmonary arrest and pediatric code
Ultrasound-Guided PIV	Basilic, cephalic, or deep brachial vein of mid-arm	Long 1.88-inch to 2.5-inch 18G/20G catheter to ensure >= 2/3 of catheter resides in vein lumen	Infuse fluids/pressors reliably; avoids central venous catheterization in coagulopathic or combative patients
Neonatal Umbilical Vein (UVC)	Cut cord 1-2 cm from abdominal wall; single large thin-walled vein at 12 o'clock	3.5 Fr (preterm) or 5.0 Fr (term) catheter connected to 3-way stopcock	Insert 3 to 5 cm only until free blood return (emergency low position); enables immediate epinephrine/blood/fluid infusion in neonatal code

Scalpel-Finger-Bougie Cricothyrotomy Technique

The scalpel-finger-bougie technique is the fastest, highest-success emergency surgical airway (performed in < 40 seconds):

1. Stabilize Larynx: Grasp thyroid cartilage with non-dominant thumb and middle finger. Identify cricothyroid membrane with index finger. 2. Incision: Make a generous 3 to 4 cm vertical midline skin incision with a #10 blade (vertical incision avoids anterior jugular veins and accommodates anatomic distortion). 3. Cricothyroid Puncture: Re-palpate the membrane through the incision. Turn scalpel blade horizontal and make a bold transverse stab through the lower half of the cricothyroid membrane. 4. Finger Dilatation: Insert index finger into tracheal lumen. Feel the inside of the cricoid ring and cartilages (confirms airway entry). 5. Bougie Placement: Slide the coudé tip of an Eschmann tracheal tube introducer (bougie) alongside your finger into the trachea. Feel for tactile clicks of the tracheal rings; advance until hold-up at the carina (~10-15 cm). 6. Tube Railroad: Advance a 6.0 mm cuffed endotracheal tube (or #6 Shiley tracheostomy tube) over the bougie with a 90° counterclockwise twist. Inflate cuff with 5-10 mL air, verify end-tidal CO2, and secure with umbilical tape or commercial holder.

Procedural Pitfalls

Reluctance to commit to surgical airway: The leading cause of death in CICO is physician hesitation and repeated failed oral laryngoscopy attempts; declare CICO early!
Railroading ETT bevel caught on cricoid: If the tube catches on the cricothyroid membrane or cricoid cartilage while railroading over the bougie, rotate the tube 90° counterclockwise so the bevel faces posteriorly to slide smoothly into the trachea.

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