a blog series on emergency medicine procedures

PEDIATRIC POINTS

In our last 2 posts (the cricothyrotomy part 1 and the cricothyrotomy part 2), we focused on adults. That is because the open surgical airway is often contraindicated in children as we discuss below, and there is an alternative method depending on age.

PEARL: the cricothyroid membrane in children is significantly different…

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

• Smaller
• More anterior
• Funnel shape
• Structures like the larynx are more difficult to stabilize

PEARL: in the majority of cases, open surgical cric on children is contraindicated

• Children younger than 10-12 years old should not have an open surgical cricothyrotomy according to most emergency medicine textbooks
• Why: risk of injuring important structures due to the anatomical differences listed above
• Instead, if a non-invasive airway is impossible, perform a percutaneous needle cricothyrotomy

PEARL: what type of ventilation to use

• Bag ventilate if the patient is < 5 years old (risk of barotrauma with jet)
• Jet ventilate if the patient is greater than 5 years old

SUMMARY

Child < 10-12 years old, cannot intubate, cannot ventilate, and rescue airway devices not working? Perform percutaneous needle cricothyrotomy (see below).

< 5 years old? Bag ventilate.

> 5 years old? Jet ventilate.

TECHNIQUE

• Percutaneous needle puncture of the cricothyroid membrane
• Translaryngeal ventilation (PTLV) by jet insufflation OR bag insufflation (age dependent)

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

From Beck et al, Academic Emergency Medicine, Percutaneous Transtracheal Jet Ventilation, 2011 

Please also view these resources from our own Brown faculty!

Dr. Valente Sim Video 

Procedurettes Junior Jet Job

PLEASE SHARE ANY PEDIATRIC POINTS ON THE CRICOTHYROTOMY 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.

Image References

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

Authorship

Faculty Reviewers: Gita Pensa MD and David Lindquist MD 

Author: Jonathan Ameli MD

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)

PEARL #1: KNOW YOUR ANATOMY…

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

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: 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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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

• 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

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