Surgical Airway : Cricothyroidotomy

Originally posted by Sacamuelas
The likelyhood of them facing oral maxillo-facial trauma and/or severe burns is a distinct possibility. That is why this thread was started.

in both cases an orotracheal intubation would STILL be your first line...if unable then a surgical airway would be a possibility. You don't mean to imply that this is the first choice?

Originally posted by ccrn
http://www.paracademy.com/events/abst_june01.htm

This study was conducted in '97 and submitted in '01. There are many more but I chose this one as it more closely resembles my own experience and challenges the results of most other studies claiming only 1-5% undetected esophageal intubation. Further searching did reveal that most studies including recent ones achieved results this study challenged.

My search results show end tidal co2 detectors including colorimetric as far back as '92 aboard EMS with one OR study as far back as '88-

ccrn

but they were not mainstain until much more recently. A few EMS units may have had them in '97 but certainly not the majority.

[Sacamuelas]

Originally posted by Doc T
in both cases an orotracheal intubation would STILL be your first line...if unable then a surgical airway would be a possibility.

Correct. That was definitely not my intention. Thanks for clarifying a possible misunderstanding. As stated earlier ma'am.

Originally posted by Sacamuelas
However, the usual first preference is for orotrachael intubation.... A Surgical Airway should be performed if orotrachael intubation is unsuccessful.

Otherwise, my AprofSoldier username would be 'surgicalcric' right? Oops, sorry James- and he is not even here to defend himself. HAHA

[Gypsy]

Originally posted by Sacamuelas

Otherwise, my AprofSoldier username would be 'surgicalcric' right? Oops, sorry James- and he is not even here to defend himself. HAHA

No but I shared it with him, he told me to tell you he got a kick out of your tribute.

[ccrn]

Originally posted by Doc T
but they were not mainstain until much more recently. A few EMS units may have had them in '97 but certainly not the majority.

I am told by the EMT-P personel here in my very rural Midwestern region that they have been using colorimetric detectors for about ten years.

Originally posted by ccrn
I am told by the EMT-P personel here in my very rural Midwestern region that they have been using colorimetric detectors for about ten years.

if that is the case what is their excuse for such a high rate of esophageal intubations? It should have been recognized and treated prior to arrival to an ER.

In my experience in all places I have been I would guess about a 1-2% rate of esophageal intubations and mostly in patients arriving in arrest.

doc t.

[ccrn]

The study I presented was conducted in Orlando Florida not the Midwest nor by the EMS system that serves the area I live in.

As this is Sacamuelas' thread regarding cricothyrotomy this is the last I will mention it unless you wish to start another thread regarding oral intubation or in PM-

ccrn

Originally posted by ccrn
[url]

This study was conducted in '97 and submitted in '01. There are many more but I chose this one as it more closely resembles my own experience and challenges the results of most other studies claiming only 1-5% undetected esophageal intubation. ccrn

the above quote by you seems to indicate that the EMS system in your area has similar results to the study (regardless of the fact that it was from Orlando)...namely a high yield of esophageal intubations as found in the study. I do not believe Saca will mind if we continue on...

I am curious how your EMS system is rectifying the problem. Are the EMS providers having to go through additional training?

[ccrn]

Originally posted by Doc T
I do not believe Saca will mind if we continue on...

The EMT-P I spoke with on the phone yesterday stated their successful intubatiuon rate closer mirrored other study results of 95-99%. He states that they are required to do four intubations per year to remain qualified. If they do not get them in the field they go to the OR.

My own experience is subjective (I worked localy for one year in ED/ICU) as I have not participated in any studies of local EMS RSI, however I would disagree with his claim.

The fact that the Orlando study and the EMS system in my area are seperated by both time and geography might support that other EMS sytems could be experiencing similar results as the study claims. Idependent research would be the only way to confirm this. Apparently most providers are not motivated to find out.

It is not my EMS system other than the fact that I live here. They are doing nothing to add to intubation training at this time according to them. I got the feeling from speaking to them that they would appreciate it if they did. If I was director in charge of that program I would probably want to rotate my people through a program in a large city just as many of the small rural hospitals here do with their nursing staff.

A call to an air-ground service in the large metropolitan area where I work reveals 120 hours adult and pediatric OR time initialy, then 4 hours a year with an MD doing ETT, LMA, and cric on sheep. They feel this is adequate as long as a candidate gets the entire initial training-

ccrn out

[Sacamuelas]

Originally posted by Doc T
I do not believe Saca will mind if we continue on...

LOL.... I think I just got the civilian trauma surgeon equivalent of the "Team Sergeant Stare"!! hahaha

I have been overruled, play ball. LOL But I reserve the right to still ask questions about technique and managing complications of the procedure even after Doc T proves that ccrn is the ONLY person in his area or this country it seems to believe that the EMT's are incompetant at ETT. LOL

Originally posted by Sacamuelas
But I reserve the right to still ask questions about technique and managing complications of the procedure

you can ask away...

as for complications...they are few.

Bleeding as I mentioned above which is a horrendous thing because it makes the procedure much more difficult

incision too deep in the excitement and you can go through the back wall of the trachea and give an esophageal injury.

complications are very rare though....

doc t.

[NousDefionsDoc]

By allah Saca, I'm impressed. Excellent thread, posts and training aids. Outstanding. Here's your Senior Medic's Smiley Face for your class -

The way I was taught to do it is lift the skin, cut and blunt dissect with forceps. Make entrance with the forceps, not a blade and open the forceps to make way for the hose. I think there is less chance of cutting the aforementioned veins this way.

Aspiring medics - anatomy is important.

swatsurgeon - the "abandon because of bleeding" - I don't get this. I find it incredible that anyone trained would make an incision, then not go on to establish an airway for any reason.

[NousDefionsDoc]

incision too deep in the excitement and you can go through the back wall of the trachea and give an esophageal injury.

I almost invariably see new guys be too hesitant about cutting. How is it with surgeon wannabes?

[ccrn]

Originally posted by Sacamuelas
...after Doc T proves that ccrn is the ONLY person in his area or this country it seems to believe that the EMT's are incompetant at ETT. LOL

I never meant to give this impression. I believe EMT-P's are second only to anesthesiologists and CRNA's with the acception of one pulmonologist in California I know who can intubate faster and smoother than anyone Ive ever seen.

My intent was that even they as well as any other provider can only benifit from continuing education. Perhaps I stressed that too strongly for some.

As far as "abondoned because of bleeding" Ive seen new residents do this and have to have the fellow or attending take over-

Originally posted by NousDefionsDoc
I almost invariably see new guys be too hesitant about cutting. How is it with surgeon wannabes?

most of our residents have gotten to do a few crics... and they get alot of experiences with tracheostomies so are usually comfortable by the time it happens. It is not a junior level procedure (crics...trachs are) because typically airway is a big problem by the time we move onto a cric...

so the surgeon wannabe is typically a 3-5 year resident...

I personally have never seen an esophageal injury from a cric... have seen bleeding from all sorts of things including the anterior jugulars...

doc t.