Surgical Airway : Cricothyroidotomy

Originally posted by NousDefionsDoc


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.

i think the point was don't try to control the bleeding until after the airway is obtained. You would be amazed at how people stop cutting and start clamping not recognizing in the flurry that seconds and minutes are passing while the patient has no airway. As surgeons we tend to control bleeding as we go so it goes against the natural instinct if that makes sense.

doc t.

[NousDefionsDoc]

As surgeons we tend to control bleeding as we go so it goes against the natural instinct if that makes sense.

Roger. Thank you.

[NousDefionsDoc]

Check this out

[swatsurgeon]

that is a re-newed version of the old puncture cric kit. Doc-T hit it...the bleeding issue makes someone question the procedure....OMG! Am I in the wrong place, did I cut something REALLY bad.....just keep going and finish the airway. The pressure from the tube or tape or securing device will ususally tamponade the bleeding. It's very low pressure bleeding1-3 mmHg and will stop by raising their head. As faras abandoning the procedure, thattypically wouldn't happen in the field for SF (or similiar) care but happens with EMS and even Emergency Medicine docs. I have been called STAT 4-6 times a year for a "failed" cric which turned out to be due to significant bleeding with the procedure.
I have spoken to many a combat medic that when the face is burned, frag'ed, the tongue is lacerated, etc, the cric is the 1st step, not the last for an airway. I'm going to attach 2 pictures, 1 is an explosion in the mouth (M-80) but could be something seen in the field and the second is a massive blunt trauma to the face...how would you approach the airway??

[swatsurgeon]

here are the 2 pics...first blunt trauma, second explosion

[swatsurgeon]

oops...the previous one was the explosion....now for blunt

[swatsurgeon]

the impotant message for the field is 1) never lean them back, they'll drown and 2) CRIC!!!!!!!. Never needed lidocaine for either of them and they were both wide awake.

[Sacamuelas]

Good pics... and great advice, Thanks Doc. Another oral/maxillofacial trauma case, here is a case done by one of my good buddies/old classmate of mine last year. Standard ETT would be "difficult".

[rakkasan187]

Here is a decent vid of a cricothyroidotomy as well as some other procedures.....

CLICK HERE

The procedure shown uses the horizontal incision. I was taught the vertical as mentioned earlier. Another interesting thing is the cutter uses the tracheal hook inferior to the incision versus superiorly. I really like using the hook and Trousseau Dialator. It makes the procedure much easier but obviously we should train to do it with field expedient tools. BTW I have never done one for real...only on the pig trachs and mannekin...

rak

[18C/GS 0602]

This article came out in Academic Emergency Medicine this June. In the discussion section they talk about a study by Katz et al 2001 done in Orlando (the same one that ccrn cited) that showed a miss rate of 25%. A follow up to the Katz study by the same authors showed a decrease in miss rates from 25% to 9% after the implementation of protocols that required ET CO2 detection devices. They also showed that in a subset of paramedics that had 100% compliance with the ET CO2 monitoring they had a 0% miss rate.


Emergency Physician–Verified Out-of-hospital Intubation: Miss Rates by Paramedics
James H. Jones, MD, Michael P. Murphy, MD, Robert L. Dickson, MD, Geoff G. Somerville, BS, EMT-P and Edward J. Brizendine, MS

-ABSTRACT

Objectives: To prospectively quantify the number of unrecognized missed out-of-hospital intubations by ground paramedics using emergency physician verification as the criterion standard for verification of endotracheal tube placement. Methods:The authors performed an observational, prospective study of consecutive intubated patients arriving by ground emergency medical services to two urban teaching hospitals. Endotracheal tube placement was verified by emergency physicians and evaluated by using a combination of direct visualization, esophageal detector device (EDD), colorimetric end-tidal carbon dioxide (ETCO2), and physical examination. Results: During the six-month study period, 208 out-of-hospital intubations by ground paramedics were enrolled, which included 160 (76.9%) medical patients and 48 (23.1%) trauma patients. A total of 12 (5.8%) endotracheal tubes were incorrectly placed outside the trachea. This comprised ten (6.3%) medical patients and two (4.2%) trauma patients. Of the 12 misplaced endotracheal tubes, a verification device (ETCO2 or EDD) was used in three cases (25%) and not used in nine cases (75%). Conclusions: The rate of unrecognized, misplaced out-of-hospital intubations in this urban, midwestern setting was 5.8%. This is more consistent with results of prior out-of-hospital studies that used field verification and is discordant with the only other study to exclusively use emergency physician verification performed on arrival to the emergency department.

[crash]

Surgical airway (cricothyroidotomy). -Trained use only. An emergency cric set can be fashioned by cutting an IV drip chamber in half. Find the anatomical landmark of cricothyroid membrane below "adam's apple." Make a longitudinal incision through the skin and visualize the membrane. Take top half of cut IV drip chamber, remove cap on spike that usually goes into IV bag. Insert spike through cricothyroid membrane. If patient needed a surgical airway, there will be a rush of air. The drip chamber needs to be secured in place with 100 mph tape or tac sutures. An ambu-bag can be attached to the drip chamber and the patient ventilated.

Found this on the net, I've never heard of this method, seems ok in theory, not sure if you could move enough air through the spike on a IV drip chamber.


Anyone heard of this method before?

update: tested this a little at work today, the drip chamber does not fit a bvm, its a litle bigger, but cutting a slit in the side and over lapping it will fit, with minimal leakage.
Now breathing normally you cannot move enough air through the spike of the drip chamber, but with a BVM you can put enough air in, exhalation however, not so much. So if the pt's upper airway was not completely occluded and the pt could exhale; it could work.
I was breathing through it for about 5 mins inhaling through the spike and BVM exhaling out my nose.(not cric'ed of course)

[Roguish Lawyer]

Originally Posted by crash

Surgical airway (cricothyroidotomy). -Trained use only. An emergency cric set can be fashioned by cutting an IV drip chamber in half. Find the anatomical landmark of cricothyroid membrane below "adam's apple." Make a longitudinal incision through the skin and visualize the membrane. Take top half of cut IV drip chamber, remove cap on spike that usually goes into IV bag. Insert spike through cricothyroid membrane. If patient needed a surgical airway, there will be a rush of air. The drip chamber needs to be secured in place with 100 mph tape or tac sutures. An ambu-bag can be attached to the drip chamber and the patient ventilated.

Found this on the net, I've never heard of this method, seems ok in theory, not sure if you could move enough air through the spike on a IV drip chamber.


Anyone heard of this method before?

Try the search button.

[clapdoc]

As a FOG 91bs I can tell you that the crico saved a lot of guys lives during Viet Nam, especially when there was lag time between the injury and medevac.
I have seen hollow bamboo used as an airway and it kept the patient alive until dustoff got there or we could get the hell out.



clapdoc sends.