#8 Crash Cricothyrotomy• Learning Objectives

– Review• Prep

team/plan/room/equipment• Discuss Difficult Airway

Algorithm• Describe a “Crash Airway”• Declare: Can’t Intubate, Can’t

Oxygenate!– Surgical Cric• Locate equipment• Double Setup• Proper technique

– Scalpel– Bougie– Tube

• Indications

• R40: 40 y/o M swollen tongue, difficulty breathing– Hx angioedema – Obtunded, GCS 6, SaO2 80%

• On Arrival– Sitting Up, Nasal O2, rebreather 02

>15lpm– SaO2 75% and GCS 5– LEMON

• Protruding tongue, Swollen face, 0-3-2, stridor

– Consultant suggests Crash Cric• Declare: Can’t Intubate, Can’t

Oxygenate– Skip Checklist

• +/- sedation/paralysis • Difficult Airway Call (888)• Crash Cricothyrotomy

– End scenario after tube confirmation

Locate Cric Kit

Cric Assessment• Laryngeal Handshake

• Ultrasound

• SHORT•S: surgery (previous)•H: haematoma (swelling)•O: obesity•R: radiation•T: tumor

Indications• Cant intubate, can’t oxygenate

(CICO).• When an experienced clinician

thinks it will be safer than intubation from the top.– Continue to attempt to ventilate

from the top with an LMA/BVM• Age cut-offs?

– APLS suggests <12y/o– Some say <6y/o– Others say <3y/o – AKA: it depends

Preparation• Can use the “double prep”– Assess, clean, and mark neck

Equipment• Simple Cric Kit– Scalpel– (Bougie on Airway Cart)– 6-0 endotracheal tube (cuffed)

– Dressing Pack• Skin Marker• Antiseptic• KY• 10ml syringe • Blue pad

• Cook surgical-and percutaneous airway kit

Cric Technique

• Scalpel-Bougie-Tube • Optimize patient • Oxygenate with BVM/LMA• Locate cricothyroid membrane• Vertical cut skin• Horizontal cut membrane • Bougie• 6-0 ETT over bougie until cuff enters• Confirm and ventilate

Bougie Crichttp://www.youtube.com/watch?v=wVQFJR7qmrQ (7min)

•We have prepared a “double setup”

•We are are ready for an emergent cricothyrotomy

•We can not intubate and we can not oxygenate.

•Declare an 888 airway emergency

• Our plan is:•A- Attempt direct/bougie/tube•B- Oxygenate with #5 I-LMA•C- Perform scalpel/bougie/cric if sats <80%•D- Perform open cric

• Questions?

• Oxygenate the patient!

Airway Briefing and checklist