Surgical Airway : Cricothyroidotomy

[Sacamuelas]

"The essential indication for a surgical airway is the need for an airway.

However, the usual first preference is for orotrachael intubation. (Nasotrachael intubation is slower and should be attempted only if the patient is haemodynamically stable and can be hand ventilated for long enough to obtain optimum pre-oxygenation). The hard collar may be temporarily removed if the neck is protected by in-line immobilisation. A Surgical Airway should be performed if orotrachael intubation is unsuccessful.

Situations in which a Surgical Airway should be considered as the primary method include Major Maxillo-Facialary Injury (eg compound mandibular fractures, Le Forte III Midface Fracture), Oral Burns, Fractured Larynx.

The simplest technique is needle cricothyroidotomy. This involves placing a 12 Gauge Cannula into the trachea via the cricothyroid membrane. This will allow adequate ventilation for up to 45 minutes, hypercapnea being the main limiting factor. This may buy enough time to obtain expert airway assistance and attend to other emergency procedures. (NB This is the prefered technique for children under the age of 12.)

Formal Crycothyroidotomy is the classic surgical airway. It is safer and quicker then attempting Formal Tracheostomy in the Emergency Room. The patients cervical spine is immobilised in the neutral position. A Right Handed Surgeon stands on the patient's right. The area is preped and draped. Local anaesthetic with adrenaline is used only in the conscious patient who has a patent airway. In an asphyxiated / dying patient there is insufficient time.

The thyroid cartilage is stabilised with the left hand as the right hand makes the incision. The first incision is 3cm long transverse incision through the skin overlying the crycothyroid membrane (closer to the crycoid cartilage then then the thyroid cartilage). The second pass of the scalpel is again transverse, through the crycothyroid membrane into the airway. With the scalpel blade protruding into the airway, it is rotated 90 degrees so that it is now longitudinal, holding the two edges of the incised membrane apart.

The left hand now releases the thyroid cartilage and picks up an artery forcep. The artery forcep is placed into the airway, through the exposed gap, and opened so as to take over from the scalpel as the means of holding the incised edges apart. The scalpel can now be removed and placed in the sharps tray. The right hand then picks up the endotracheal tube or tracheostomy tube and inserts it into the airway, directed towards the chest. The best size ET tube for an adult cricothyroidotomy is a size 6.0.

After confirming adequate position, the tube should be secured and suctioned. A definitive airway will be required as soon as the patient is stable, fully assessed and appropriate interventions have been performed.

Fortunately, with skilled airway doctors in most trauma centres, surgical airways are rarely required."

[Sacamuelas]

basic anatomy for landmarks

[Roguish Lawyer]

Oh fine, do this one while Crip is totally occupied. I see how you are. LOL

[Sacamuelas]

It's a tribute!! LOL

[ccrn]

I dont have anything to add to this other than it shouldnt be used as a substitute for good airway management skills.

Many EMS systems have banned cric prehospital at all.

It is good for true upper airway obstruction when ETT or double lumen tube (ie Combitube) cannot be used.

I think all EMT-P and airway qualified providers should have more time in the OR intubating, say a certain amount of hours per year rather than a refresher every two years-

ccrn

[steel71]

Hum, let's try some of my calls ( this is the training everybody should go through) lol
call #1, 500 lb ,male pt found supine on the bathroom floor with coffee ground emesis coming out if the pt's mouth and rectum, unk down time, weak radial pulse, it's only you and your emt partner( with 1 week of experience)
call # 2, 10 yr old female was playing soccer , syncope while playing, pulseless, apneic,crowd of 300 people on the feild, yelling at you to do something, oh yeah it's only you and your partner.
call # 3, 1 yr old male, parents found the pt at the bottom of their pool, pt was out of their site for 45/60 sec, you find the pt on the pool deck, with a pulse but apneic, oh, mom has been yelling at you since the 1st sec you got on scene, her husband tries to restrain her, but she slaps him and starts screaming in you ear while you try to intubate her child.
I think it' s the environment your in that test your skills, not the procedure. The OR was the place I learned how to intubate during paramedic school, cool temp and great lighting, perfect environment, stable pt, hey it doesn't get any better then this! But, those days are long gone, and I don't think I'm going to learn anything by doing EET in an OR,ER setting.

[rogerabn]

Having worked prehospital I can certainly relate to the stress of the crisis situation that you work in. Intrubating patients under duress can be challenging to say the least.
But one can never get enough experince intubating patients. The nice thing about refreshing your skills in the OR, is that you can take your time. Really identify the anatomical landmarks. and increase confidence levels. More often than not most of the paramedics that rotate though my OR miss intially, possivbly due to the stress of being observed, and working in an "alien" setting. I have yet to have any paramedic student or experinced provicer "bag" every intubation we allow them to attempt. Even we who practice intubation on a daily basis, tube the goose once in awhile. Over confidence is killer in airway management, the more experince the better.

[ccrn]

**RESULTS: Of 108 patients intubated in the prehospital setting, the ETT was found to be misplaced on assessment in the ED in 25% of cases (esophageal placement, 17%; hypopharyngeal placement, 8%). Fifty-six percent of the patients with esophageal ETTs and 33% of those with hypopharyngeal ETTs died in the ED. The rate of ETT misplacement was 37% in trauma patients compared with 14% in medical patients (p<0.01). Failure to detect ETCO2 on patient arrival at the ED was noted in all but one of the patients with esophageal ETTs (the one exception was a patient who was breathing spontaneously upon arrival), and in four of nine with hypopharyngeal ETTs, as well as 17% of the patients with correctly placed ETTS (all of whom were asystolic with no return of spontaneous circulation).

CONCLUSIONS: The alarmingly high rate of unrecognized ETT misplacement in the prehospital setting within this EMS system suggests a need for an evaluation of the scope of this problem in other communities. **


This is just one of many studies I found on a search. I wont even go into details of my own experiences working in ER recieving intubated pts from EMS.

This is not to say I do not respect them because I do, in fact I admire them.

But to say one would NOT benefit from continuing education under controlled environments from higher providers is remiss in my opinion.

My apologies for going off topic-

ccrn

few comments...

Nasotracheal intubations are quick and do not require hemodynamic stability...the only requirement in a breathing patient. That said, it is not the first choice of airway due to the risk of sinusitis and risk of necrosis if left for a prolonged period.

As for surgical crics...well, any EMS system that allows RSI needs to teach their prehospital people to perform crics... We have had a few performed in our system that went well, but it is not always that way. It is not a procedure that is performed often in any ER and takes practice to be fast like anything else.

I typically make a longitudinal incision, not transverse as there are anterior jugular veins that tend to get cut in a transverse incision and bleeding just makes the airway more difficult. It usually takes more than two passes of the scapel as the people winding up with surgical airways rarely have long skinny necks. Four or five passes is more typical. And I have never seen anyone use a needle cric except in a child...it is a terrible airway.

doc t.

Originally posted by ccrn
**RESULTS: Of 108 patients intubated in the prehospital setting, the ETT was found to be misplaced on assessment in the ED in 25% of cases (esophageal placement, 17%; hypopharyngeal placement, 8%). Fifty-six percent of the patients with esophageal ETTs and 33% of those with hypopharyngeal ETTs died in the ED. The rate of ETT misplacement was 37% in trauma patients compared with 14% in medical patients (p<0.01). Failure to detect ETCO2 on patient arrival at the ED was noted in all but one of the patients with esophageal ETTs (the one exception was a patient who was breathing spontaneously upon arrival), and in four of nine with hypopharyngeal ETTs, as well as 17% of the patients with correctly placed ETTS (all of whom were asystolic with no return of spontaneous circulation).

CONCLUSIONS: The alarmingly high rate of unrecognized ETT misplacement in the prehospital setting within this EMS system suggests a need for an evaluation of the scope of this problem in other communities. **


This is just one of many studies I found on a search. I wont even go into details of my own experiences working in ER recieving intubated pts from EMS.

This is not to say I do not respect them because I do, in fact I admire them.

But to say one would NOT benefit from continuing education under controlled environments from higher providers is remiss in my opinion.

My apologies for going off topic-

ccrn

\

can you give the citation for this abstract. I am guessing its old...from prior to CO2 detectors placed on most EMS trucks. -+

[swatsurgeon]

Just to echo doc-T (a fellow trauma surgeon) the cric is usually a last ditch effort...most patients can be managed with BVM and a nasal airway.....that said, if the cric is going to happen don't fall into the trap of abandoning the procedure due to bleeding. I do and teach the vertical incision also....the anterior jugular veins are 1) always present, 2) always distended unless the patient lost a lot of blood and 3) have a 30-40% incidence of being in the wrong place. All that you'll cut with the vertical incision is the bridging anterior jugular and that typically is small and the cric apparatus usually compresses it. That being said the #1 reason people abandon the cric once initiated is BLEEDING. Remember that A comes before B or C.....I know, I'm preaching to the choir on this one but if you start it, finish it...isn't that one of your motto's anyway? (I hope that wasn't in bad taste!!!)
I have a saying....no one dies without an airway...believe it, live it.
T-2

[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

[Sacamuelas]

Originally posted by Doc T
I typically make a longitudinal incision, not transverse as there are anterior jugular veins that tend to get cut in a transverse incision and bleeding just makes the airway more difficult. It usually takes more than two passes of the scapel as the people winding up with surgical airways rarely have long skinny necks. Four or five passes is more typical. And I have never seen anyone use a needle cric except in a child...it is a terrible airway.
doc t.

Thank you very much Ma'am- Also thanks to SwatSurgeon for both of your comments.

Let me refocus this a little since it seems it has taken a civilan EMS slant. This is for a review for SF medics and early basci education for the potentials. The likelyhood of them facing oral maxillo-facial trauma and/or severe burns is a distinct possibility. That is why this thread was started. I think everyone will stipulate that ALL medical personnel should get as much personal experience in standard ETT placement as they can. The more the better- I agree completely with Rogerabn. It isn't only EMT's that place bad placed airways, I have seen MD's, RNA's, and RN's do it too- oh yeah, DMD's too . LOL

Back on point, based on the incision technique recommendations of our resident trauma surgeons, I will post a pic of the anterior triangle of the neck for all viewing this thread that don't have familiarity of the anatomy. Thanks again Doc t and SS.

[Sacamuelas]

Follow-up question for Doc T or SS-

WHen making your vertical(longitudinal) initial incision, what length of an incision do you make? I realize that you would make it larger for access/visibility if needed, but what is your initial cut length?

[swatsurgeon]

I make it 2 cm...... never be reluctant to make it as long as necessary. It usually gets extended when we convert to a tracheostomy. Incision size never hurt anyone...better a big scar and breathing patient than a cosmetic scar and no airway....besides you guys wear your scars proudly!!