a blog series on emergency medicine procedures
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
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 *
- Vertical line to signify first incision (do this early if any airway concern)
- 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
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
- 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
- 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
- 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
- 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
- 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
- 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
Jon, what would you think about an intubating laryngeal mask in this situation? We are supposed to have the Air-Q (chosen, rather than the Fastrach, because it uses standard ET Tubes) in the airway cart and I see it has gone missing again; I wrote to Dave Portelli and we’ll try to get it re-stocked. In the CT you show, I wonder what the anterior neck might look like, for landmarks…..
I purposefully avoided a hefty discussion on decision making and other devices just due to length of post, but yes, that would be great to have in the cart. We may have it (I didn’t specifically look for it), but if you didn’t see it…
Regarding landmarks, in a few days, I will post a detailed discussion on landmarks/anatomy with pictures galore 🙂
Pingback: The Cricothyrotomy Part 2: Pearls, Pitfalls, and Troubleshooting | Brown Emergency Medicine
Pingback: The Cricothyrotomy Part 3: Pediatric Points | Brown Emergency Medicine