The Cricothyrotomy Part 2: Pearls, Pitfalls, and Troubleshooting

a blog series on emergency medicine procedures

In the last post (the cricothyrotomy part 1) we focused on the basics of preparation and technique for the cricothyrotomy procedure. Here we focus on the pearls, pitfalls, and troubleshooting with a strong emphasis on anatomy.

As an aside…

Always consider alternatives to the cricothyrotomy, and especially, the “crash” cricothyrotomy

  • Try other non-invasive rescue maneuvers including the intubating LMA as Dr. Nestor mentioned last week

  • Review the difficult airway algorithms that were briefly acknowledged last week, and strive for expertise in airway decision-making

  • Do not hesitate to overhead anesthesia for assistance in any difficult airway

  • Avoid paralyzing patients with tenuous airways in appropriate situations, and consider awake (fiberoptic or other) intubation, or even awake cricothyrotomy with ketamine (and local anesthetic)

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PEARL #1: KNOW YOUR ANATOMY…

Why is this so important? First let’s explore some potential pitfalls….

pitfall-sign

PITFALL: You make your vertical incision OFF midline

  • You may not find the membrane
  • Complications: you may injure the following structures:
    • Cricothyroid muscles
    • Recurrent laryngeal nerves (uncommon)
    • Carotid artery / Internal Jugular vein (very rare)

pitfall-sign

PITFALL: You make a horizontal cut too SUPERIOR

  • Superior to cricothyroid membrane:
    • This is above the cords, and likely the location of your issue (i.e.: obstruction or other)
    • Complications: increased risk of vascular and nerve damage: superior laryngeal vessels and the internal branch of the superior laryngeal nerve

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The Cricothyrotomy Part 1: The Procedure

a blog series on emergency medicine procedures

A SURGICAL AIRWAY IS IMMINENT…

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YOU CANNOT INTUBATE – CANNOT VENTILATE!

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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

PROCEDURE

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CITW 9: The Racing Heart

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: A 60 year old female presents with palpitations after walking on the beach with friends. She states she was sitting at her favorite clam shack, and felt the onset of a “rapid heart rate”. Thinking she was dehydrated, she drank some water, and her palpitations resolved after five minutes. After returning home, the palpitations recurred, and after 40 minutes she felt “really tired, really washed out”, but at no point had any chest pain, dyspnea, or lightheadedness. She looked “gray” to her husband, so he called 911.

Vitals: BP 160/110, HR 210, T 98.7 °F, RR 22, SpO2 99% on RA

Notable PE: Pale and anxious appearing. On auscultation, tachycardic without murmur, rub, or gallop. Regular rhythm. Intact and equal pulses throughout. Mild increased work of breathing. Lungs are clear bilaterally. No lower extremity edema.

The following EKG was obtained:

BeforeWhat’s the diagnosis?

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The Neonate in Shock: When to think CARDIAC

Clinical Case:

2-week-old male with history of “funny breathing” since birth presents to ED with 1 day of decreased feeding, now with 30 second apneic and cyanotic episode at home tonight.

Sternal_retractions-3** Neonates in shock MAY show obvious signs/sx of end-organ dysfunction (similar to adults), but their presentation may be subtle and progress rapidly!**

 Signs/Symptoms of Shock in Neonate:

  • History
    • Poor feeding
    • Respiratory distress (tachypnea, cyanotic/apneic episode)
    • Altered mental status (irritability, difficulty awakening)
  • Physical Exam
    • Tachycardia
    • Tachypnea
    • Hypotension
    • Poor Perfusion: Decreased capillary refill, mottled skin

Differential Diagnosis:

Think of “THE MISFITS” to recall critical diagnoses in the neonate in shock:

T –       Trauma (accidental and non-accidental)
H –       Heart disease and Hypovolemia
E –       Endocrine (congenital adrenal hyperplasia, hypothyroid, etc)
M –      Metabolic
I –        Inborn errors of metabolism
S –       Sepsis
F –      Feeding problems, Formula mishaps (under- or over-dilution)
I –        Intestinal catastrophes (NEC, volvulus, etc)
T –       Toxins
S –       Seizures

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You Put a Catheter Where? The Groin May Not be as Dirty as Previously Reported

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing:  Marik, P. Flemmer, M. Harrison, W. “The Risk of Cathether-Related Bloodstream Infections with Femoral Venous Catheters As Compared to Subclavian and Internal Jugular Venous Cathethers: A Systematic Review of the Literature and Meta-Analysis.” Critical Care Medicine, 2012, Vol 40(8). 2479-2485

Main Points:

  1. This 2012 meta-analysis demonstrated that catheter-related blood stream infection (CRBI) risk is no different between internal jugular, subclavian, and femoral catheter insertion. The authors demonstrated that previous level 1A guidelines regarding femoral catheter infectious risk were in error.
  2. The overall risk of CRBI is declining over the recent years and likely due to the combination of more precautions at the time of insertion as well as vigilant management of the catheter once placed.

Background:

There is significant morbidity and mortality associated with CRBI. In the United States alone, an estimated 30-60 thousand patient deaths occur annually secondary to this infectious process. In 2011 a clinical recommendation from respected organizations including the CDC’s Healthcare Infection Control Practices Advisory Committee as well as the Infectious Disease Society of America issued a class 1A recommendation to “avoid using the femoral vein for central access in adult patients.” This recommendation would suggest that there is strong supporting data including at least one well performed RCT. The purpose of this meta-analysis by Marik and his colleagues was to call into question the validity of such an absolute statement. Marik and his partner Flemmer performed an exhaustive literature search and were able to find 2 RCTs and 8 cohort trials to include in their meta-analysis. This literature review was more comprehensive then the citations provided by the societies issuing the level 1A recommendations. There study, however, focused solely on the question of CRBI and did not address concerns other concerns associated with central venous access such as injury to nearby structures, DVT, or bleeding.

Details:

This study reviewed more data than the 1A recommendation from the CDC and IDSA and could not find compelling evidence that the femoral vein should be avoided for concerns of CRBI. Furthermore, it appears that the universal precautions that are being used currently have likely led to an overall decrease in CRBI compared to the years past. For example, the rate of CRBI in the United States in 1998 was 5.32/1,000 catheter days and has subsequently dropped to 2.05/1,000 in recent data. The Welsh Healthcare Associated Infection Program which is the largest collection of data and noted that in over 55 thousand catheter days in 2009 and 2010 there were only 0.61/1,000 catheter day infectious risk with no difference between insertion sites. Marik and his colleagues therefore note that the site of preference should “depend on the expertise and skill of the operator and the risks associated with placement.” The authors recommend against using femoral vein catheters in renal transplant patients, patients who would benefit from early mobilization as well as the massively obese due to a subgroup analysis in the Parienti study that noted worse outcomes in these individuals.

The average CRBI density in the compilation of trials was noted to be 2.5 +/- 1.9 per 1,000 catheter days (range 0.6-7.2). In compiling the data it was noted that two of the cohort trials, Lorente and Nagashima, appeared as statistical outliers increasing the heterogeneity of the meta-analysis significantly. It is unclear why these two trials demonstrated a more than two-fold increased risk of CRBI with femoral catheter insertion. If these trials were removed from the data the authors noted that there appeared to be no heterogeneity within the study (RR 1.02, 95% CI 0.64-1.65, p = 0.92, I² = 0%). This study also performed a meta-regression that appeared to demonstrate a significant interaction between the risk of infection and the year of publication (p = 0.01).

Level of Evidence:

Based on the design of this study, including RCTs and cohort trials, with a few limitations this study was graded a level III based on the ACEP Clinical Policy Grading Scheme for meta-analyses.

Surprises:

In many aspects of medicine it is curious to see how wide practice variation can be, especially when considering geographic and healthcare system influences. This notion is highlighted by reviewing the different guidelines within this meta analysis by various public health/safety committees across the United States and United Kingdom.

Relevant articles:

Lorente, L. Henry, C. Martin, MM. et al. “Central Venous Catheter-Related Infection in a Prospective and Observational Study of 2, 595 Catheters.” Crit Care, 2005 9. R631-5

Nagashima, G. Kikuchi, T. Tsuyuzaki, H. et al. “To Reduce Catheter-Related Bloodstream Infections: Is the Subclavian Route Better than the Jugular Route for Central Venous Catheterization?” J Infec Chemother, 2006 12. 363-65

Parienti, JJ. Thirion, M. Megarbane, B. et al. “Members of the Cathedia Study Group: Femoral v. Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy: A Randomized Controlled Trial.” JAMA, 2008 299. 2413-22

Source Articles:

Marik, P. Flemmer, M. Harrison, W. “The Risk of Cathether-Related Bloodstream Infections with Femoral Venous Catheters As Compared to Subclavian and Internal Jugular Venous Cathethers: A Systematic Review of the Literature and Meta-Analysis.” Critical Care Medicine, 2012 Vol 40(8). 2479-2485

By

Anatoly Kazakin MD

Tricks of the Trade: A-Line Kits for Vascular Access

Ever struggle with vascular access?

Ever tried a 20G A-Line kit?

Even if you have,  once a flash is obtained it is common to not be able to thread the wire. If you pull the needle out of the catheter, it is rigid and difficult to replace in the catheter and rarely results in salvaging the attempt. In this video, I show you that by cutting the white cap off the back of the a-line kit, it will liberate the guide wire allowing the proceduralist to use it as a backup if the first attempt at placing the catheter fails. I have found,  many times when a flash is obtained but the wire doesn’t pass, the attempt can be salvaged with this technique. Enjoy…

 

US articles: PTX in trauma, FAST for Thoracotomy, Pedi Hip Effusions

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Brown Ultrasound Tape Review:  10/15/15

Article 1: FAST Exam to Predict Survivors of ED Thoracotomy

Inabi, et al. FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy. Annals of Surgery 262(3):512-518, 2015.

Fresh off the trauma surgical press last month, this study examined the utility of FAST exam (specifically parasternal and subxiphoid cardiac views) to predict positive outcomes (survival to discharge or organ donation) of ED resuscitative thoracotomy (RT).

This was a prospective cohort study at LA County/USC Medical Center. In 3.5 years, 187 patients arrived in traumatic arrest and underwent FAST and RT (that’s 4-5 thoracotomies a month – WOW!). They documented +/- pericardial fluid and +/-  cardiac motion. PGY2-4 EM residents performed the FAST exams after some formal training, and they were supervised by “faculty” – not clear if those were surgeons or EM attendings.

About ½ patients lost vitals at the scene and another ¼ both en route and in the ED. Overall survival – 6 patients (3.2%). Overall organ donation – 3 patients (1.6%). Cardiac motion on FAST was 100% sensitive for the identification of survivors and organ donors (and 73.7% specific).  While the tables and discussion include a lot on the presence or absence of pericardial fluid, this did not impact the sensitivity or specificity of FAST. If cardiac motion was absent, the likelihood of survival was 0.

Bottom line: Given that RT is such a high risk, low survival procedure, cardiac FAST can be used (with excellent sensitivity) to identify traumatic arrest patients with better odds of survival or organ donation from ED thoracotomy. No cardiac motion means pretty much no chance of survival or organ donation.


 

Article 2: Handheld E-FAST for Pneumothorax

Kirkpatrick, et al. Hand-Held Thoracic Sonography for Detecting Post-Traumatic Pneumothoraces: The Extended Focused Assessment With Sonography for Trauma (EFAST). Journal of Trauma 57:288-295, 2004.

This was another trauma surgery study out of Vancouver Hospital and Health Sciences Centre interested in the test characteristics of hand-held US to look for PTX in trauma patients. They compared EFAST examinations for PTX to:

(1) CXR results

(2) a “composite standard” of clinical information, which included some combination of CXR, CT if it happened, clinical course, and need for chest tubes/needle decompression

(3) CT alone (the gold standard for patients who had a CT).

This was a retrospective chart review on trauma patients (note – those who were in “physiologic extremis” with suspected PTX were excluded). All EFASTs were done by the attending trauma surgeon using a linear transducer. They looked for lung sliding or comet tail artifacts or color power Doppler evidence of pleural sliding in at least 3 rib spaces. PTX was diagnosed if neither sliding nor comet tail artifacts were seen.

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When life gives you LEMONs- Predicting difficult intubations in the ED

Article:

Reed MJ, Dunn MJ, & McKeown DW. Can an Airway Assessment Score Predict Difficulty at Intubation in the Emergency Department? Emerg Med J 2005; 22(2): 99 – 102.

Main Points:

  1. Rapid assessment tools can be helpful in predicting difficult intubations in the emergency department
  1. Use of SOME elements of the LEMON (look, evaluate, mallampati, obstruction, neck mobility) approach to airway assessment MAY be helpful in predicting likely laryngoscopic view (Cormack- Lehane grade) as a proxy for difficulty of intubation. The following are more likely found in patients with high grade views (2-4).
  • large incisors
  • reduced inter-incisor distance
  • reduced thyroid to floor of mouth distance

Background:

Predicting difficult intubations is not always straightforward. At the time of publication (2005), little validation of rapid assessment of possible difficult intubations in the ED. The authors test the use of the LEMON approach as a predictor of difficult intubations, and suggest key parts of the assessment that are most helpful.

 

Details:

The study was a prospective, observational trial conducted in the UK at a teaching Emergency Department between June 2002 and September 2003.   156/177 patients intubated over that time were included in the study. Those excluded were done so because no LEMON assessment was completed. Of the remaining included, a modified LEMON assessment was completed including: LOOK- facial trauma, large incisors, large tongue, facial hair; EVALUATE- inter-incisor distance (<3 fingers), hyoid-mental distance (<3 fingers), thyroid to floor of mouth distance (<2 fingers); MALLAMPATI 1/2 versus 3/4 ; OBSTRUCTION; and NECK MOBILITY- cervical collar versus no collar. One point was assigned for each criterion that was found. If a criterion was though unassessable, a score of zero was given. Outcome was determined by laryngoscopic view as outlined by the Cormack-Lehane grading scale; grade 1 was considered an easy intubation, grades 2-4 were considered difficult. ALL intubations were successful, and if multiple attempts were used, the grade of view on the successful attempt was used. Authors used Fischer’s exact test to compare the categorical variables, Student’s t test to compare continuous data. Spearman rank sum test was used to assess correlation between categorical variables.

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ROCKstars – Case 1: US-Guided Central Venous Access (CIV)

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An elderly patient is in the RIH Critical Care bay with severe sepsis and needs central access.  Luckily, Drs. Adam “Hyperechoic” Haag and Eddie “Rule ‘Em Out” Ruhland are on shift.  They settle on the right Internal Jugular vein, but traditional sternocleidomastoid muscle (SCM) and clavicular bone landmarks are not apparent.  So a linear-array probe is correctly placed transversely over the triangle formed by the bifurcation of the SCM, to where the IJ and Carotid are seen in parallel…but there is some sort of hyperechoic, noncompressible mass…

They identify the thrombus, and instead find the Femoral vein, where CIV access is successfully achieved on the first attempt with no immediate complications.  The use of US to guide this procedure changed this patient’s course and potentially saved a complication.  

But exactly how much safer, faster, and more reliable is US-guided CIV placement?

THE ISSUE

  • Vascular access is critical in emergent situations
  • Body habitus, dehydration, poor perfusion, anatomical abnormalities, or history of IVDU can cause difficulties and delays when using landmark-based techniques
  • Complications of CIV placement include arterial puncture, excessive bleeding, vessel laceration, pneumothorax, hemothorax, and necessitation of multiple attempts
  • US guidance was identified in 2001 by United States Agency for Healthcare Research and Quality as one of the top 11 means of increasing patient safety, but this was based on one study of subclavian lines at one large urban center (1)

The “SOAP-3” Trial (2005)

  • A concealed, randomized, controlled study of 201 patients
  • Studies dating back to the 1990s in EM and Anesthesia (4) had demonstrated the efficacy of ultrasound-guidance, but this was the first study in the ED setting comparing the anatomical landmark method, the static “quick look” US-guided method, and dynamic “real time” US-guided method
  • In the “quick look” group, US was used to identify landmarks, the skin was marked, and the catheter was placed without real-time US guidance
  • EM residents and Attendings passed a 1h training course, then placed 10 CIVs with dynamic US guidance to qualify to participate

RESULTS

Dynamic

US Guidance

Static

US Guidance

Anatomical Landmarks Method
Overall Success 98% 82% 64%
First-Attempt Success

(OR vs LM)

5.8 3.4
Avg # of Attempts 1.7 1.6 3.2
Avg Total Sec 30 20 150
Complications 2 2 8

DISCUSSION

  • Dynamic guidance is superior but requires the most training
  • Static guidance is vastly superior to Landmark, and while slightly inferior to Dynamic, it requires less training
  • 10% of the study patients had “extremely narrow” (<5mm) IJs bilaterally, which could explain the inferior performance of the LM technique, even with experienced practitioners
  • All the complications were arterial punctures, and these were not statistically significant

References

  1. Agency for Health Care Research and Quality (AHRQ). Evidence Report/Technology Assessment: Number 43. Making Health Care Safer. A Critical Analysis of Patient Safety Practices: Summary 2001. 2007.
  1. Milling, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial.  Critical Care Medicine, 2005, Aug;33(8); 1764-9.
  1. Sulek et al.  A Randomized Study of Left versus Right Internal Jugular Vein Cannulation in Adults.  J Clin Anesth, 2000, Mar; 12(2): 142-5
  1. www.sonoguide.com/line_placement.html

Slow, big breaths ain’t what the doctor’s ordering

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing:  The Acute Respiratory Distress Syndrome Network. “Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome” N Eng J Med, May 2000; 342(18): 1301-08

Main Points

This landmark study was stopped early! It determined that in patients with acute respiratory distress syndrome (ARDS) who are treated with lower tidal volumes than those treated with traditional volumes:

  1. Mortality is decreased by 31.0% vs 39.8% (P = 0.007)
  2. Breathing without assistance increases by the 28th day by 65.7% vs 55.0%
  3. The number of ventilator free days increases by 12 ± 11 vs 10 ± 11. days (P = 0.007)

ARDS is a life-threatening condition for which the mortality was quoted in this study to be approximately 40 to 50 percent.  (To be blunt, any study that uses death as its primary outcome is looking at a very ill cohort.) 

Much has been learned about the pathophysiology of ARDS, but very little headway has been made in the treatment of it. The authors of this study looked at adjusting ventilatory tidal volume and plateau pressures for treatment for ARDS.  The authors also measured plasma interleukin-6 in the first 204 of 234 patients as a measure of lung inflammation. The results were significantly in favor of the lower tidal volume group.  

Details

This was a prospective, randomized controlled study that assorted 861 patients into two groups.  Patients were randomly selected to be treated with tradition ventilation treatments, initial tidal volumes of 12 ml per kilogram of predicted body weight and a plateau pressure of 50 cm of water or less, versus lower tidal volumes of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less.

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