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#8Essential Emergency Airway Care-Surgical

Airways

Andrew Brainard, MD, MPH, FACEM, FACEMhttp://www.thesharpend.org/

abrainard01@gmail.com

#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

– SHORT• Short Neck

– 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

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Locate Cric Kit

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Cricothyrotomy Assessment• Laryngeal Handshake

• Ultrasound

• SHORT•S: surgery (previous)

•H: haematoma (swelling)

•O: obesity•R: radiation•T: tumor

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Identification of Anatomical Landmarks

A

F

E

DCB

G

A- Thumb and index finger, palpate the hyoidB- Palpate the lateral sides of the thyroid lamina and the midline thyroid prominenceC- Find the inferior cornu of the thyroidD- The cricothyroid membrane is between the thyroid cartilage and the cricoid cartilage and above the softer tracheal ringsE- Locate the cricothyroid membrane with the laryngeal handshake F- Stabilize the larynx with your non-dominant handG- Rest your dominate hand on the patient’s sternum H- Cut

H

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• 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

When to Cric Cricothyroidotomy

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Preparation

• The “double prep”– Don’t wait until too late– Assess, clean, and mark neck early

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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

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Cric Technique

• Scalpel-Bougie-Tube • Optimize patient • Oxygenate with BVM/LMA• Locate cricothyroid membrane• Decide to CUT• 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)

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Airway briefing and checklist• 60y/o with head and face trauma. Who is not protecting his

airway and not oxygenating.

• This is a predicted very difficult airway.

• We will Prepare “double setup” for cric and be ready for an emergent cricothyrotomy

• Declare an 888 airway emergency

• We will use 200mg of ketamine and 100 mg of Rocuronium if needed

•I’ll be team leader •Linda as primary airway operator •I’ll be the backup airway operator •Joyce as airway assistant•James also push the drugs

• The plan is:•A- Direct/bougie/7-0 tube•B- Video/7-0 tube w/ stylet•C- I-LMA #3.5”•D- Scaple-Bougie-6-0 Tube cric

• You can look for 1 minute as we assess and prepare the neck.

• If we can’t intubate and can’t oxygenate will will place an I-LMA, if that doesn’t work, we will perform a scalpel-bougie-tube cricothyrotomy

• Understand your roles

• Questions?

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Brief Cric references• Richard Levitan, ACEP now

http://www.acepnow.com/article/tips-tricks-performing-cricothyrotomy/ (accessed on 1/05/14)

• Richard Levitan, ACEP Now http://www.acepnow.com/article/make-incision-insert-tube-cricothyrotomy/ (accessed on 1/05/14)

• Darren Braude, EMrap TV, Bougie guided cric: https://vimeo.com/67187062 (accessed on 03/06/2014)

• PHARM- PreHospital And Retrieval Medicine- Video of actual cric: http://prehospitalmed.com/2013/02/27/actual-emergency-cricothyrotomy-video/(accessed on 05/06/2014)

• PHARM- PreHospital And Retrieval Medicine- http://prehospitalmed.com/2013/11/17/levitan-the-laryngeal-handshake-and-the-cartilaginous-cage/ (accessed on 05/06/2013)

• The Melker Emergency Cricothyrotomy Catheter Tray: http://www.cookmedical.com/cc/dataSheet.do?id=4815 (accessed on 22/03/2013)