a blog series on emergency medicine procedures

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A SURGICAL AIRWAY IS IMMINENT…

YOU CANNOT INTUBATE – CANNOT VENTILATE!

INDICATIONS

• Cannot intubate:
  • Multiple attempts with most experienced operator
  • Both conventional and rescue techniques attempted (1)
• Cannot ventilate:
  • Cannot get chest rise with BVM, LMA, or other rescue devices between attempts
• Cannot maintain O2 sat > 90%

OR

• Extreme facial or oropharynx deformity

CONTRAINDICATIONS

• Other airway options have not been considered
• Pediatric patient (for open surgical method) (<10-12 years old, varies depending on expert opinion)
• Tracheal transection, larynx or cricoid cartilage fracture, obstruction at or below the membrane

DIFFICULT AIRWAY ALGORITHMS

• Thorough summation of EM airway algorithms

• Difficult airway prediction literature (Dr. Prucha)

Watch this video to learn a simplified approach from Dr. Reuben Strayer.

From Dr. Reuben Strayer’s Advanced Airway Management for the Emergency Physician 

HUNTING & GATHERING

• Ask for the DIFFICULT AIRWAY CART (located in CC 6 currently)

  • Be familiar with contents of drawers (from top to bottom):

    • ONE (melker kits, cric tray)

    • TWO (LMAs)

    • THREE (tracheostomy tubes, misc)

    • FOUR (more tracheostomy tubes, 6.0 ETT, jet insufflation device and 14g angiocaths, intubating lighted stylet, misc)

• Obtain the following ASAP:

  • Universal precautions: Facemask/eye protection (!), gown, gloves, hat

  • If time allows: STERILE

  • Mayo stand

  • 4×4 sterile gauze

  • Chlorhexidine

  • 10 ml syringe
  • Lidocaine with epi (if patient awake)

  • #10 Scalpel (or #11)

  • Bougie (recommended)

  • Cricothyrotomy Tray

    • Items to ignore: most

    • Items to keep: Tracheal hook (optional: 2 skin hooks), Trousseau dilator, sterile drapes

  • Tracheostomy tube or modified cuffed 6.0 ETT. Ignore the Melker Kit from drawer ONE (see below for discussion on percutaneous cric methods) 

    • Pick a tracheostomy tube with at least a 6.0 inner diameter (ID) from drawer THREE or FOUR

    •  Tracheostomy tube components:

      • Obturator for entry

      • Some have a removable inner cannula (helps with secretions, mucus plugs). Leave this in.

      • Cuffed (preferred) or uncuffed outer cannula

PROCEDURE

• Mark the neck
  • Vertical line to signify first incision (do this early if any airway concern)
    

    * Already established: inability to intubate, ventilate, or place a sufficient rescue airway with the highest skilled operator, and anesthesia has been notified *

• Designate a single, dedicated provider to gown up and prepare
• Announce to the room that a cricothyrotomy will be performed

• Position self on patient’s right side (if right hand dominant)

• Prep skin of anterior neck (chlorhexidine)

• Mayo stand: open cric kit and sterilely drop only necessary equipment

• Sterilize yourself

• Drape patient

• Test reliability of balloon (ETT or tracheostomy tube) with 10 ml of air

• Laryngeal Handshake (Levitan, R) – feel structures in this order: hyoid -> thyroid cartilage -> cricoid cartilage -> cricothyroid membrane (index finger)

• Keep both cartilages (thyroid and cricoid) stabilized with your non-dominant hand throughout the procedure.

• Cut vertical (3-5 cm), horizontal (1 cm) across membrane, rush of air/blood, (finger vs. hooks/dilator), (bougie vs. nothing), TUBE

• Advance tube about 3-5 cm max from its tip (or hub if tracheostomy tube)
• Inflate balloon and remove obturator, check ETCO2, secure tube, ventilator, suture small bleeders, CXR
• Sedate. Pain control.
• Quickly debrief with your team, and move on to the next step in the patient’s care. Do not idle. Take care of why the patient needed to be placed on a ventilator.

TECHNIQUE

There are several techniques for performing the cricothyrotomy. Here we focus on two:

1) The Traditional Open Cricothyrotomy

From Roberts & Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013

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From Hebert R, et al. Cricothyrotomy. In: Procedures Consult, 2008.

2) The Bougie-Aided Open Cricothyrotomy

Very similar to traditional method except finger/bougie instead of hooks. Why this method is often preferred:

• Time is brain.
  • Small RCT with animal lab: bougie-aided faster than standard technique (67 vs. 149 seconds) with less failures (1/10 vs. 3/11) (2)
• The finger then bougie method gives you a continuous connection to the inside of the trachea
• NOTE: You MUST use a tracheostomy tube or ETT that is AT LEAST 5.5mm inner diameter or it will not pass over the bougie

Sim lab demonstrating bougie method

From Bill Hinckley’s Bougie-Aided Cricothyrotomy Video 

Actual bougie-aided cric (EMCrit)

From EMCrit.org, Scott Weingart, Surgical Airway Performed by Ram Parekh 

What about the percutaneous Seldinger (Melker kit) technique?

Thoughts on why open method is preferred:

• This is not a visual procedure, and relies on palpation of landmarks. With significant anatomic distortion, finding the membrane with a needle alone may be difficult
• This can be a chaotic, infrequently performed procedure. The fewer the steps, the better

Evidence why open method is preferred:

• Systematic review presented a handful of studies comparing Seldinger to open cric in sim labs: both with equal success rates although surgical was faster (3)
• 24 real-life cases over 40 years by 2 Australian physicians: traditional open cric is fast on average at 83 seconds (4)

To learn more about technique (and pretty much everything about the surgical airway), click here…EMCRIT SURGICAL AIRWAY

KEEP IN MIND…

• Cricothyrotomy is a fairly infrequent procedure (only 0.9% of emergency resident intubations led to cricothyrotomy in a large study) (5)
• Sim labs increase speed, comfort levels, and success rates (6)

UP NEXT…ANATOMY and PEARLS, PITFALLS, TROUBLESHOOTING ON CRICOTHYROTOMY

CLICK HERE FOR PART II

PLEASE SHARE ANY OF YOUR OWN THOUGHTS ON CRICOTHYROTOMY PROCEDURE AND TECHNIQUE IN THE COMMENTS SECTION!

Textbook References

Hebert R, Bose S, Mace. Cricothyrotomy and Percutaneous Translaryngeal Ventilation. Chapter 6, 120-133.e2. In: Roberts J, et al. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th Saunders; 2013.

Article References

1. Butler KH, Clyne B. Management of the difficult airway: alternative airway techniques and adjuncts. Emerg Med Clin North Am. 2003 May;21(2):259-89. PubMed PMID: 12793614
2. Hill C, Reardon R, Joing S, Falvey D, Miner J. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med. 2010 Jun;17(6):666-9. PubMed PMID: 20491685
3. Langvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy–a systematic review. Scand J Trauma Resusc Emerg Med. 2013 May 31;21:43. PubMed PMID: 23725520
4. Paix BR, Griggs WM. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel-finger-tube’ method. Emerg Med Australas. 2012 Feb;24(1):23-30. PubMed PMID: 22313556
5. Sagarin MJ, Barton ED, Chng YM, Walls RM. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med. 2005 Oct;46(4):328-36. PubMed PMID: 16187466
6. Wong DT, Prabhu AJ, Coloma M, Imasogie N, Chung FF. What is the minimum training required for successful cricothyroidotomy?: a study in mannequins. Anesthesiology. 2003 Feb;98(2):349-53. PubMed PMID: 12552192

Image References

Hebert R, et al. Cricothyrotomy. In: Procedures Consult. Elsevier; 2008.

Authorship

Author: Jonathan Ameli MD

Faculty Reviewer: Gita Pensa MD and David Lindquist MD