Chapter 54

• Any difficult intubation in patients whose cricothyroid membrane can be located
• Especially suited for facial trauma (nasal intubation contraindicated)

• If possible, discuss all aspects of procedure with patient to enhance cooperation and to minimize anxiety
• However, often performed as an emergency procedure
• Use of an antisialagogue (glycopyrrolate) is strongly recommended
• Use of anxiolytics (midazolam, dexmedetomidine) is urged but not required
• Adequate topicalization of mucous membranes is also strongly recommended

• 5 mL of 2% lidocaine in 10 mL syringe with 25 G needle
• Retrograde intubation access kit (if not available, this technique has been performed using a Tuohy needle and an epidural catheter):
• NB: Some kits have a tube exchanger that allows insufflating oxygen; these exchangers have only one tapered end
• Magill forceps
• Appropriately sized endotracheal tube
• Viscous lidocaine for topicalization of mucous membranes and for lubrication

###### Figure 54-1. Contents of Retrograde Intubation Kit

(A) Hollow tube exchanger (note tapered end on the left); (B) syringe with Angiocath; (C) clamp; (D) needle; (E) standard 15-mm adapter connector for oxygen administration through tube exchanger using an Ambu-type bag or an anesthesia machine circuit; (F) Luer Lock adapter and connector for oxygen administration through tube exchanger using a jet ventilation device; (G) guidewire with J-tip visible.

• IV access secured
• Oxygen by nasal cannula
• If possible, topicalization performed by gargling and swishing of viscous lidocaine
• Patient supine with head extended to expose neck, cricothyroid membrane identified by palpation and marked
• Skin wheal using lidocaine 2% is made over the cricothyroid membrane. Stabilize larynx between thumb and index. The needle is advanced through the cricothyroid membrane until air is aspirated into the syringe. 3 to 4 mL of lidocaine 2% is injected into the trachea for topicalization of subglottic structures. The patient will cough. Have assistants maintain patient to avoid movement that could cause the needle to injure the back wall of the trachea
• Once topicalization of the airway is complete, connect the introducer needle of the retrograde intubation kit to a 10 mL syringe with 5 mL of saline. Stabilize larynx as above. Insert needle through the cricothyroid membrane with the bevel facing upward and the needle directed cephalad at a 45° angle to the skin. A distinct pop is felt as the cricothyroid membrane is pierced, and air can be aspirated into the syringe (see Figure 54-2)
• The needle in the airway is maintained in place with one hand while the syringe is removed from the hub. The guidewire supplied in the retrograde intubation kit is slowly advanced through the needle (see Figure 54-3), directed cephalad, while an assistant observes the oropharynx for the tip of the guidewire (this may require several passes)
• The guidewire has a J-tip and a straight tip. It also has two marks, which correspond to the length of wire that ...

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