Cricoid Pressure & Gastric Distention
Objective: Stop default cricoid pressure, bag slowly enough that the chest (not the belly) rises, and treat gastric distention as a ventilation failure you can fix.
Why This Is Hard
Someone was taught “cricoid on every tube.” DAS and modern ALS teaching: routine cricoid can worsen the view and is not a proven aspiration shield. Meanwhile the real street killer is gastric insufflation from fast, hard bagging — especially with a leaky mask. The belly rises, the diaphragm goes up, and now you cannot ventilate.
- Two-person BVM, slow squeeze, watch the chest. If the epigastrium balloons, you are in the stomach.
- Do not apply cricoid as a reflex. If your protocol still uses it for a specific RSI step, that is protocol — it is not BLS bagging.
- OG/NG decompression if you have it and the belly is the problem. BURP (external larynx manipulation) is not the same as Sellick.
Street Sequence
- Open, suction, two-person seal, adjunct. Squeeze over one second. Watch chest, not fingers on the cricoid.
- If the belly rises: slower rate, smaller volume, better seal, consider an SGA that you can still bag through.
- If distention is already there and they are crashing: decompress per protocol while you fix the airway.
- Intubation looks still follow attempt limits. Cricoid is not the reason the tube missed.
Field Rules (Education)
- Routine cricoid is out: it can displace the airway and has weak evidence as an aspiration preventer. Do not make it default BVM.
- Gastric insufflation is in: high rate and high volume with a poor seal fill the stomach. That is a you problem, not a “need cricoid” problem.
- BURP vs Sellick: backward-upward-rightward pressure on the thyroid cartilage to improve a view is not cricoid pressure on the cricoid ring. Name which one you are doing.
- Decompress: a tight, tympanitic belly after bagging needs a tube in the stomach if you are trained and equipped — and a better ventilation plan.
- No default cricoid
- Slow bag — watching chest not belly
- Belly rising: decompress and fix the seal
- BURP is not Sellick
Field Pitfalls
- Cricoid on every BVM because “that is how I was taught.”
- Squeezing the bag as fast as compressions in a patient with a pulse.
- Ignoring a ballooning epigastrium while collecting laryngoscopy looks.
Practice
60-second drill
Partner bags at 20/min, belly rising, sat falling. Two corrections. Then: a helper puts two-handed cricoid on a BVM patient with a pulse. What do you say?
Related: Effective BVM Ventilation, Airway Attempt Limits.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- Difficult Airway Society guidelines — cricoid is not routine; external larynx manipulation is a separate, named maneuver
- AHA 2025 Part 7: Adult BLS — effective ventilation is chest rise at a controlled rate — not gastric inflation
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.