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NousDefionsDoc
03-29-2005, 19:31
you Docs want to tell us about it?

Surgicalcric
03-29-2005, 21:44
Sarnt:

Are you looking for an explaination of, indications for, contraindications against, equipment needed, etc?

edited this part for clarity
My understanding of it (in paramedic terms) is that RI refers to introducing a wire into the trachea through the cricoid membrane and passing it up and out of the mouth. Once the wire is passed up out of the mouth the tube is guided over the wire and then the vocal cords by using the wire as a guide.

It is a procedure that takes a lot of practice/training IMHO. (I hope I explained that right. We only touched on it slightly during in-service once as we did not use the procedure at that time and still dont.)

It looked more time consuming to me (Paramedic) than whipping out the trusty laryngoscope or other airway adjunct of choice, in the field anyway.

An alternative to RI would be a Bougie(sp) Inducer. Its similar to a stylette but longer and with a larger more rounded distal end. It is introducer thru the cords then the tube is advanced over it. Once the ET is in place the BI is retracted. They were looked at once by my service to aid in tubing patients whose very anterior. Better IMNSHO for EMS/FD use as there is not the worry of perforating the trachea, or other anatomy, while bouncing down the road... errr...enroute to the ER. They seemed to be used in the OR quite frequently where DocT and I once were employed.

HTH,

Crip

ccrn
03-30-2005, 08:14
I think Crip has it right based on my experience.

Ive only seen it a couple of times myself-

SwedeGlocker
03-30-2005, 09:37
Whille i belive that this is another tool in the box i cant really see the use for a military medic. If you cant intubate then i belive thats it better used time to do a cric.

18C/GS 0602
03-30-2005, 12:44
NDD is this what you were referring to?

http://www.acutedoc.com/alternativeairways/Retrograde%20Intubation.htm#Indications

I have been taught the procedure during an airway course, but I havenít used it or seen it done. It is another tool in the box, but I think in hospital environment there are better options. It might be a viable option in prehospital/wilderness/tactical environments.

52bravo
03-30-2005, 13:37
what are you looking for?

i have to go on what SG says, a tool in the box. This is probably the route of choice in the setting of maxillofacial trauma.
you can use a seldinge crit. set for it

Surgicalcric
03-30-2005, 14:52
... This is probably the route of choice in the setting of maxillofacial trauma...

The AOC for me is a Cric.

I fully understand its another tool in the box and believe me when I say the more the better. I guess for me it comes down to another perishable skill set. If not performed often enough it may take more time to reaquaint yourself with than need be to secure the airway.

Just my .02.

Crip

rogerabn
03-30-2005, 15:28
Retrograde intubation as I was taught is a technique using a guide wire inserted into the trachea though the cricoid cartridge. and advanced up towards the cords. Once the wire is visualized it is advanced out of the oral pharynx to the point that a oral ETT can be advanced over the wire. One the holds the wire with some hemostats and advances the tube past the cords. This is so rarely used I have only seen it in videos during school. Used with local anesthetics and LIGHT sedation. This is used in the most difficult of airways, and rarely used..
I myself use an intubating stylet for almost all my intubations except for peds. And I always have a Bougie on the table next to me. If you donít secure an airway the first time, then you better have a back up ready to go NOW. No matter how good of a tube jockey you might think you are, there is an airway that is out there that will humble you real quick. Confidence is good, over confidence is a killer.

Having been humbled more times than I can count. Roger Coleman CRNA :D :D

Endorphin Rush
03-30-2005, 20:11
I'm with Rogerabn on this one...

I was shown this technique in an ATLS class years ago. I believe the wire is introduced into the trachea via the Cricothyroid membrane and then up through the cords until visualized in the oropharynx. The ETT is then guided past the cords by way of the stylette. This is not a guaranteed intubation, even so. And once you've cut the cricothyroid membrane (which is not particularly vascular all by itself) you've got a bloody mess to intubate around. I've actually seen this technique attempted unsuccessfully, in a fall victim with gross maxillofacial trauma, after which our flight nurse simply passed as large a tube as would fit through the Cricothyroid membrane, inflated the cuff, and ventilated away.

jasonglh
03-30-2005, 21:06
Great thread with lots of info!

I have only seen it attempted once. Our local hospital is a teaching hospital with a level 1 trauma center right here in the heart of BFE. If I remember right the ER Doc had a student with him that night and used it on a guy with multi GSW and a bullet wound to the jaw. Looked like round shattered his jaw and his airway was a mess. I think his buddies brought him to the ER in the back of a truck.

It seemed at the time to me it would have been just as easy and faster to use that Nu-trake (SP?) kit.

What kits do you guys have for a Cric ?

NousDefionsDoc
03-30-2005, 22:11
Retrograde intubation as I was taught is a technique using a guide wire inserted into the trachea though the cricoid cartridge. and advanced up towards the cords. Once the wire is visualized it is advanced out of the oral pharynx to the point that a oral ETT can be advanced over the wire. One the holds the wire with some hemostats and advances the tube past the cords. This is so rarely used I have only seen it in videos during school. Used with local anesthetics and LIGHT sedation. This is used in the most difficult of airways, and rarely used..
I myself use an intubating stylet for almost all my intubations except for peds. And I always have a Bougie on the table next to me. If you donít secure an airway the first time, then you better have a back up ready to go NOW. No matter how good of a tube jockey you might think you are, there is an airway that is out there that will humble you real quick. Confidence is good, over confidence is a killer.

Having been humbled more times than I can count. Roger Coleman CRNA :D :D
That is my understanding of it as well. Bassackwards

52bravo
03-31-2005, 07:26
What kits do you guys have for a Cric ?


a knife, a tube+cuff (6.0 fit all!!!!!!) and pean. it what i use i my medic bag. i have useed the selding set(min trach II i think it is call) and it can also be use for Retrograd.
but the army use the set call minitrach(only knife and tube) dont like it.
for a trauma PT a cuff can do the driffrens.
the quicktrach is god as well but has menny wrong palcement in some test(some says).

Frank

Surgicalcric
03-31-2005, 07:46
I have used two different types of Cric sets:

1.) Nu-Trake commercially available

2.) #11 blade, 6.0 ET, and tape (ofcourse)

HTH,

Crip

jasonglh
03-31-2005, 16:10
We only carried a needle kit and then a few years before I left EMS we had the Nu-Trakes. I remember there was some controversy as to whether or not a Paramedic in KY could use the Nu-Trake since it came with a scapel. Out medical director said we could use it so thats all I needed to hear on that.

I remember only being on 2 calls where we called for orders to use it but was denied both times only to have the ER Doc use it once we got there.

Hell it cant be that hard Radar did it on MASH after all! ;)

24601
03-31-2005, 19:18
That's where Michigan is a bit messed up. When I left, you could do cric's in Ottawa county, but not Kent, unless you were a flight nurse or up. The trauma center, plus 4 hospitals are in Kent county, Ottawa is lots of farm land. I've heard of medcom trying to make Paramedic's take them out once they crossed county lines. Noone even tries to do them, the kits were taken off.

JAGeorgia
04-03-2005, 11:30
If I had a magic toolbox it would also contain a fiberoptic laryngoscope (like a shorter, D cell powered version of a bronchoscope). Darn nice tool if you can get your hands on one.

IMHO

Red Flag 1
02-08-2008, 15:32
Best done with an epidural needle and an epidural cath. Needle introduced through cricothyroid membrane with bevel directed upward...epidural cath passed through the needle and advanced until retrieved by a clamp in the posterior oral pharynx...needle is removed...epidural cath is threaded into ET tube and used as a guide through vocal cords blind....cath is removed once the ET tube is beyond the vocal cords...ET tube cuff inflated and bilateral breath sounds checked.

This is not an easy task! The best answer is fiberoptic intubation via oral or nasal route. In a pinch a needle thyrotomy with a 14ga IV cath directed down the airway...remove the needle and leave the cath...a peds ET tube adapter( I think 4.0mm) will fit into the cath hub...ambu bag or demand O2 source can be used for a short period of time. I used this once for a patient with a shotgun wound to the face while my fiberoptic equipment was enroute to the ER....I was able to oxygenate the patient pretty well but CO2 retention became an issue after a short period of time.

RF 1