What position is a patient in for a cricothyrotomy?

October 1, 2025 •

4 min read

During a life-threatening "cannot intubate, cannot oxygenate" (CICO) scenario, a cricothyrotomy is performed to secure an emergency airway. Understanding what position is a patient in for a cricothyrotomy is paramount, as proper positioning maximizes landmark visibility and increases the chances of a successful outcome. This procedure's success depends heavily on a clear and accessible surgical field.

Quick Summary

Patients are typically placed supine with neck extension for a cricothyrotomy to expose the neck and access the cricothyroid membrane. Modifications are crucial for patients with a suspected cervical spine injury, who must be kept in a neutral, in-line position with manual immobilization.

Key Points

Standard Position: For cricothyrotomy, the patient is typically placed supine with their neck extended to expose the surgical site.
C-Spine Precautions: In cases of suspected cervical spine injury, the neck must be kept in a neutral, in-line position with manual stabilization to prevent further injury.
Neutral Position Challenge: Performing a cricothyrotomy in the neutral neck position is more difficult due to less prominent landmarks and a smaller target area.
The 'Laryngeal Handshake': This technique uses the non-dominant hand to stabilize the larynx, pull the skin taut, and identify landmarks during the procedure.
Airway is Priority: Although C-spine protection is vital, securing the airway takes precedence in a CICO emergency, necessitating the procedure to proceed under the safest possible conditions.
Modified Techniques: The practitioner's technique must adapt depending on whether neck extension is possible or if a neutral position must be maintained.
Post-Procedure: Once the airway is secured, the practitioner can confirm placement and proceed with ventilation.

Standard Positioning: Supine with Neck Extended

The standard and most common patient position for a cricothyrotomy is supine with the neck extended, often with the head in a neutral position. This positioning serves several key purposes for the performing clinician, primarily making the anatomical landmarks of the neck more prominent and easier to palpate. Extending the neck places the cricothyroid membrane in a more accessible position for the scalpel and tube insertion. In cases where a cervical spine injury is not suspected, hyperextension of the neck may be used to further improve access. This can be achieved by placing a rolled towel or blanket under the patient's shoulders.

Benefits of Neck Extension

Clearer Anatomical Landmarks: The cricothyroid cartilage, cricoid cartilage, and the membrane between them are brought into sharper relief, making them easier to identify by palpation.
Maximized Membrane Height: Extension increases the vertical height of the cricothyroid membrane by a significant percentage, providing a larger target area for the incision.
Taut Skin: Stretching the neck makes the skin taut, which helps prevent it from rolling or shifting during the incision, ensuring a more precise cut.

The 'Laryngeal Handshake'

To maximize stability and ensure proper landmark identification in the standard position, many practitioners utilize the "laryngeal handshake" technique. This involves using the non-dominant hand to grasp the patient's larynx and stabilize it. The thumb and middle finger hold the sides of the thyroid cartilage, with the index finger palpating the cricothyroid membrane in the midline. This technique also helps to pull the skin taut over the membrane.

Modified Positioning for Cervical Spine Injury

One of the most critical modifications in emergency airway management involves patients with suspected or confirmed cervical spine (C-spine) trauma. In this scenario, maintaining a neutral, in-line position is paramount. Any movement of the neck could exacerbate a spinal injury and lead to permanent neurological damage.

How to Position with a C-Spine Injury

Avoid Extension: The neck must not be extended or hyperextended. The patient remains flat in the neutral position.
Manual Immobilization: An assistant is responsible for maintaining continuous manual in-line stabilization (MILS) of the patient's head and neck throughout the procedure.
Airway Priority: While cervical spine protection is crucial, securing the airway takes priority in a CICO emergency. The procedure is performed with the head and neck in the neutral position to minimize movement.

Challenges with Neutral Position

Difficult Palpation: With the neck in a neutral position, anatomical landmarks are less prominent, making palpation more difficult, especially in obese patients.
Smaller Target: The cricothyroid membrane is shorter in height when the neck is not extended, presenting a smaller target for the incision.

Comparing Positioning for Cricothyrotomy


Feature	Standard Positioning (No C-Spine Injury)	Modified Positioning (Suspected C-Spine Injury)
Patient Position	Supine with neck extended or hyperextended	Supine with neck in neutral, in-line position
Neck Support	Rolled towel under shoulders is optional for optimal extension	Manual in-line stabilization (MILS) is mandatory
Surgical Exposure	Excellent, landmarks are prominent and visible	Challenging, landmarks are less distinct
Cricothyroid Membrane	Larger, more easily accessible target area	Smaller, more difficult to access target area
Primary Goal	Maximize surgical access and speed	Secure airway while minimizing spinal cord movement
Technique	Standard surgical or needle technique applied	Techniques adapted to account for reduced visibility and stability

Conclusion: The Importance of a Tailored Approach

The positioning of a patient for a cricothyrotomy is a critical element of this high-stakes emergency procedure. For patients without cervical spine concerns, the standard supine position with neck extension is preferred to maximize landmark identification and ease of access. However, in the presence of known or suspected C-spine trauma, this approach is abandoned in favor of a neutral, in-line position with strict immobilization to prevent catastrophic spinal cord injury. A competent practitioner must be able to adapt their approach based on the clinical scenario, prioritizing both airway patency and patient safety. Medscape eMedicine offers a comprehensive overview of the procedure.

Procedural Steps and Positioning Checklist

Assess and Decide: Confirm the need for an emergency cricothyrotomy in a CICO situation.
Manage C-Spine: Evaluate for signs of cervical spine injury. If suspected, ensure manual in-line stabilization (MILS) is in place before any movement.
Position the Patient: Place the patient supine. Extend the neck only if C-spine injury is not a concern. Keep the neck neutral with MILS if C-spine injury is suspected.
Identify Landmarks: Perform the "laryngeal handshake" to palpate the thyroid cartilage, cricoid cartilage, and cricothyroid membrane.
Prepare the Neck: Apply antiseptic solution to the anterior neck, if time permits.
Perform Incision: Execute the procedure according to the chosen technique, ensuring continuous stabilization of the anatomy with the non-dominant hand.

Frequently Asked Questions

The primary reason for extending the neck is to make the anatomical landmarks, specifically the cricothyroid membrane, more prominent and accessible for the incision.

For a patient with a suspected or confirmed cervical spine injury, the neck is kept in a neutral, in-line position, and an assistant must maintain manual in-line stabilization (MILS) throughout the procedure.

With the neck in a neutral position, the cricothyroid membrane is shorter and the surrounding cartilages are less prominent, making them harder to palpate and visualize accurately.

The 'laryngeal handshake' is a stabilization technique where the practitioner grasps the thyroid cartilage with their non-dominant hand to keep the anatomy stable, pull the skin taut, and guide their finger to the cricothyroid membrane.

No, if a cervical spine injury is even suspected, the neck must be kept in a neutral, in-line position. Airway management takes priority, but measures to prevent further spinal cord injury must be taken seriously.

Yes, proper positioning is critical for maximizing the chances of a successful and quick procedure. Optimizing landmark identification and stability reduces the risk of complications, especially in emergency situations.

Unlike a cricothyrotomy, which uses neck extension (if no C-spine injury), endotracheal intubation often uses a 'sniffing position' (neck flexed, head extended) to align the oral axis with the laryngeal and tracheal axes. Cricothyrotomy does not require this specific axis alignment.