cricothyroidotomy simulation

[farcefiasco]

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[swatsurgeon]

Find a slaughter house or butcher and get a hog trachea. If u are affiliated with ems, they have training maniquins equipped with neck anatomy that can be cric'ed.
OK, that was the perfect question for Google.......try there first then search here but no more questions like that........

Ss

[Pete E]

Has any one developed a field expedient trainers for simulating a cric, outside of an airway dummy?

A couple of examples of what I'm looking for would be along the lines of using pig's feet for suturing, or wrapping some IV tubing with coban on a piece of balsa wood as a vein/arm simulator--things that would give someone an approximation of the tactile sensation involved.

I was thinking something along the lines of flexible tubing (depending on the width between rings, it may approximate tracheal rings and, with the addition of something to simulate the thyroid cartilage ((the rubber triangle of a reflex hammer?)) would allow for finding the appropriate land marks) with an incisible (don't think that's a word....) "shell" that would be easy to replace.

Thanks in advance for any ideas.


Looking at your location in the US, you could probably get some deer tracheaif you know any hunters.

I know a lot of US bases allow hunting on their associated training area, so it I'll bet you have local servicemen who are hunters who would be able to sort you out..

Regards,

Peter

[farcefiasco]

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[swatsurgeon]

farcefiasco,
I have been giving your question more thought and based on my personal experience of digging others out of failed cric's, I will offer the following.
Simulation , once or a hundred times gives you the moves. If you take the cric procedure and divide it up into it's individual components, you are facing challanges that simulation will not provide......
There are a few things to work out in advance that you can work on though....just follow me for a minute.
- exactly what equipment will you be using, nearly every time
- is this a needle cric or a formal with a tube of some kind
- how many times have you reviewed an anatomy book of the neck
- 'if' you access to an ultrasound (u/s) machine: have someone show you what a cricothyroid membrane looks like under u/s guidance, then feel the persons neck...do this on several different people. Now feel their necks and mark the location of the cricothyroid membrane and VERIFY with the u/s.
- how well do you deal with active bleeding from a neck wound? The number 1 reason cric's fail is wrong location, people are fooled by the lower indent of the throid cartilage, second reason they fail is vigorous bleeding and the thought of "oh sh*t" what did I hit!. The neck has anterior jugular veins and in ~15% of people, a bridging jugular that if you make the vertical incision, you will transect and it will bleed magnificently........don't stop, this is where I get called by E.D. docs, residents, PA's, etc.
The manual skills required are few and you can walk through them on a piece of ventilator tubing covered in duoderm or chicken skin.
My point is simulation prepares you ONLY for the steps, nothing else. Will you be doing this in the field, under fire, exhasted, out of breath, with your heart rate faster than the patients...you get my drift. Practice on anything you want so the steps of performing it are hardwired into your brain. Then do the human anatomy lesson. Until you do this on enough humans, you can't get "comfortable" with any procedure.
Best of luck. Thought I'd give you one of my surgical/trauma quotes: "No one dies without an airway"

ss

[98G]

This note was sent to me recently regarding this issue and I can PM the details if you are interested. This is strictly dealing with 68W/18D's deployed so no experience in the EMT environment or their equipment.

Classification: UNCLASSIFIED
Caveats: NONE

We have been looking at how to make airway treatment for combat casualties
better, and have found two items that prevent successful surgical airway
applications. The first is the medic does not know the anatomical landmarks to
make the initial surgical incision. They are either too high on the neck or
too low. Most manikins we practice on have exaggerated landmarks and when a
medic has to actually find the landmarks on a real person it is much harder.
The second problem is most surgical cric sets use an endotracheal tube which
is cut down or intact. These tubes are six inches or more in length and when
the excited medic tries to insert it they have a tendency to put it in way to
far.
So to help prevent these problems we have started having the student practice
finding the landmarks on their classmates and drawing a line on their neck
where they would make the incision. We can eliminate the problem with a tube
that is too long by not giving them a long one. Your tube is the perfect
length to get the air in but not long enough to create problems.

Thanks again for your help

[Red Flag 1]

This note was sent to me recently regarding this issue and I can PM the details if you are interested. This is strictly dealing with 68W/18D's deployed so no experience in the EMT environment or their equipment.

An ET tube pearl FWIW. Trimming Endotracheal Tubes is common; it helps shorten the distance to the mouth/nares where the tube is better supported. I have been called to evaluate ET tube "leaks" after trimming. On a few occasions I found cuff pilot tubes cut or the inflation valve failing. I have been able to avoid replacing an otherwise usable ET Tube by sliding a 22ga needle inside the leumen of the pilot tube and inflating the ET cuff. Once inflated to a sealed airway, simply clamp the pilot tube with clamp on the pilot tube to keep the ET cuff inflated, and remove the needle. A 22ga was a perfect size to inflate the cuff.

Be well.

RF 1

[swatsurgeon]

In the hands of a skilled operator, any tube will do. In the hands of the less skilled or experienced, the common problems related to the longer ETT may not be recognized , ie trouble shooting skills are not as 'mature' and complications are more prone under those circumstances. I have used tracheostomy tubes, endotracheal tubes, tubes made just for crics as well as a fat tubed pen. It matters little what you have available if you have the training and knowledge base to correctly place and maintain the conduit that is available to you. Remember, most things are presented for the least trained person to be able to complete the task.
ss

[swatsurgeon]

B.O.
It's venous bleeding...about 5-10 minutes of direct digital pressure should stop it. it's knowing where to put pressure depending of which vein got lacerated...anterior jugular (vertical orientation) or bridging jugular (horizontal orientation).

ss

[Pacer]

SS (syd)

without hijack...

what are your current recs here or at ISTM...

ACS's horizontal skin and membrane in one thrust? vertical skin/horizontal membrane in two stage? or "it depends" which confounds that "decision" process?

I remember you backed me up on a facial GSW (unfortunately brain dead after resusc) where surface anatomy was not cool. incision was 'generous" to assure adequate reflection of gas filled tissue, but the 'technician' never let go of the ring and verified the anatomical chain (hyoid, thyroid, cricoid, trachea, ciroid, membrane) twice before incision and once after the skin was relieved. (four step technique as written in Roberts and Hedges Clinical Procedures in Emergency Medicine)

Secondly, do you concur or dispute that if the 'tech' pays close attention to the cuff "+1" cm is in the lumen of a 6-0, then mainstem is pretty unlikely?

Thanks for sharing with an old 'retired' compadre.

Pacer/Barry

Would you go one step further, as the "mission" shifts to post blast civilian trauma (terrorism medicine...within the possible purvue of the operators here) where "infants/kids" may be the victims rather than fellow team mates.

Classical wisdom is to await anatomical maturity (about 8 years) before surgical cric, and without 'special equip" needle cric is 'somewhat" limited in efficacy to between 20 and 40 minutes of oxygenation.

I recall another Philly case (before your arrival at 'stein...by likely ten years) where a child at an institution aspirated a cellophane wrapper that defied identification until post.

I think Ricky W also did a ped trach in resusc while you were there or just before.

Recollection is that the issue of surgical TRACH is that the likelihood of big red is much higher, getting off the midline much easier, and thyroid needs reflection or bisection.

Do you have a field expedient to faciliate the retraction of the thyroid to gain access to mid trach rings with less vascular risk?