# Needle cricothyrotomy



## rennex (Dec 18, 2012)

We are learning about advanced airways but a question popped up in my mind after class (should've occurred during), so I am asking here: 

if advancing the ET to its deepest depth and returning it to the previous depth still does not remove the obstruction and allow ventilations of the patient, why would making a hole into the trachea work? Wouldn't the obstruction still be there?


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## mycrofft (Dec 18, 2012)

How would advancing the ET to it's fullest depth remove an obstruction? Maybe shove a solid obstruction into one or another main bronchus (usually right) which wold presumptively make the other lung available, or bust through a big clotted guck-ball?

In either event, once you put both a needle and a cuffed catheter into the same space, it's sort of like a pit fight, and one guy has the knife. Be prepared to go all-needle or promptly withdraw the tube and get another.


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## Medic Tim (Dec 18, 2012)

rennex said:


> We are learning about advanced airways but a question popped up in my mind after class (should've occurred during), so I am asking here:
> 
> if advancing the ET to its deepest depth and returning it to the previous depth still does not remove the obstruction and allow ventilations of the patient, why would making a hole into the trachea work? Wouldn't the obstruction still be there?



The hole will hopefully be below the opstruction. There are also times(face/head trauma) where a rescue airway or traditional tube won't work. (Though the pt is probably effed at that point)


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## Merck (Dec 18, 2012)

I'm not exactly sure why you would ram the ETT as deep as it can go....


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## mycrofft (Dec 18, 2012)

Merck said:


> I'm not exactly sure why you would ram the ETT as deep as it can go....



"Maybe shove a solid obstruction into one or another main bronchus (usually right) which wold presumptively make the other lung available, or bust through a big clotted guck-ball?"







As you can see, on the average bear, the tube of a traditional ET is going below the level a cric will take place at. I have seen an ET's cuff deflated by a combination of too-small tube and attempt to give trans-tracheal epi during a botched field code once .


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## Merck (Dec 18, 2012)

Yes I'm aware of the anatomy.  I can say that is is much more likely that an obstruction is superior to the cords and should be cleared prior to the intubation attempt.  If for some reason there was something solid enough to obstruct below the level of the cricothyroid membrane then you likely wouldn't know about it until after the intubation.  At this point it's not very likely that the patient would be completely occluded.

In terms of a teaching point to a new medic I'd say that a cric should be performed as part of an escalating difficult airway algorithm and will come after failed attempts or inability to visualize/pass a tube, etc.  I don't know that the 'hey there's an obstruction so ram it down a bronchus' is a great teaching point.  Not saying it hasn't happened but I've done my share and never had to resort to that.


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## WTEngel (Dec 18, 2012)

Advancing the tube to the carina (or deeper) and then pulling back is something I have never heard of. 

In fact, this method sounds like it would inhibit ventilation of at least one lung, and possibly both if your luck didn't improve.

You push the obstruction into the right mainstem with the tube, and get a gunky plug stuck in the tip of the ETT in the process, then withdraw, ventilate, and blow the plug into the other mainstem...following the path of least resistance? Does this sound plausible to anyone else, or am I thinking too much into it?

In my experience the proper escalation for obstructed airway is:

If FBO is visible on laryngoscopy, remove object with forceps.

If unable to remove with forceps, move to surgical airway (assuming you see obstruction, but are unable to manipulate and remove it.)

In the event that provider saw the ETT pass through the vocal cords, and the "can't ventilate, can't oxygenate" situation persists despite ruling out other causes (DOPE, costal rigidity due to fentanyl administration, etc.) then proceed to surgical airway.

I am not advocating the "slice first, ask questions later" mentality, however I have seen providers with excellent airway management skills get bogged down in an intubation attempt that went nowhere but downhill after the first miss. They just could not seem to get their feet underneath them.

There are very few airways out in the field that refuse to "play by the rules" but when you encounter one, you better be ready to think on your feet, or else you are going to find yourself in an un-recoverable flat spin pretty quick.

All that is to say, I have never heard of advancing the tube then withdrawing as a correction method for FBO or can't ventilate can't oxygenate, and I think your time would be better spent dealing directly with the obstruction of possible, or bypassing it entirely.


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## WTEngel (Dec 18, 2012)

Merck said:


> Yes I'm aware of the anatomy.  I can say that is is much more likely that an obstruction is superior to the cords and should be cleared prior to the intubation attempt.  If for some reason there was something solid enough to obstruct below the level of the cricothyroid membrane then you likely wouldn't know about it until after the intubation.  At this point it's not very likely that the patient would be completely occluded.
> 
> In terms of a teaching point to a new medic I'd say that a cric should be performed as part of an escalating difficult airway algorithm and will come after failed attempts or inability to visualize/pass a tube, etc.  I don't know that the 'hey there's an obstruction so ram it down a bronchus' is a great teaching point.  Not saying it hasn't happened but I've done my share and never had to resort to that.



Great minds think alike...and apparently simultaneously.


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## rennex (Dec 18, 2012)

Medic Tim said:


> The hole will hopefully be below the opstruction. There are also times(face/head trauma) where a rescue airway or traditional tube won't work. (Though the pt is probably effed at that point)



Would putting the ET down far enough to go past the carina and into one lung provide better ventilation than trying to ventilate through a 14 gauge catheter? 

@Merck it's protocol here.


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## VFlutter (Dec 18, 2012)

mycrofft said:


> How would advancing the ET to it's fullest depth remove an obstruction? Maybe shove a solid obstruction into one or another main bronchus (usually right) which wold presumptively make the other lung available, or bust through a big clotted guck-ball?
> 
> In either event, once you put both a needle and a cuffed catheter into the same space, it's sort of like a pit fight, and one guy has the knife. Be prepared to go all-needle or promptly withdraw the tube and get another.



One lung ventilation is common in thoracic surgery but I have never heard of trying to ram an obstruction into the Right Main Stem in a unable to ventilate situation. One lung ventilation presents a lot of complex issues but I suppose its better than dead. However like Merck said I can not really think of any common situation where a large obstruction would be present below the cords.

The only situation I can think of is a pediatric mediastinal tumor (I can't think of the specific name) that can collapse the bronchus after giving paralytics. That's not really an obstruction in the trachea but rather a occluding force from outside.


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## mycrofft (Dec 18, 2012)

"I don't know that the 'hey there's an obstruction so ram it down a bronchus' is a great teaching point. Not saying it hasn't happened but I've done my share and never had to resort to that."

Your reply is very politic. Thank you, point taken. OP you getting this?


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## Merck (Dec 18, 2012)

I'm not going to argue against someones protocol; it just seems odd to me.

My experience in teaching is that students can tend to take stuff a little more literally than you expect.  Teaching for the common things (i.e. obstruction on or superior to the cords) will allow for the most benefit.  I would think that the technique of advancing the tube with a known obstruction is necessary rarely and teaching that technique, especially prior to a cric attempt is a little odd.

Go with what you're taught for your area but that's not what we teach here.

A side note - single-lung ventilation (assuming your ramming technique is successful...) can be tricky.  Few practioners seem to adequately account for the differences in lung volumes and pressures, especially with bag/mask ventilation.  There is a large possibility of nasty volu-/barotrauma.  As well the now blocked lung will likely become atelectactic and even more susceptible to a pneumonia.  What we do on the street is great but if they're going to develop ARDS in 3 days, partly as a result of what we've done, have we really accomplished anything?

Yeah, that's a little more general warning as well but though it bears mentioning.


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## mycrofft (Dec 18, 2012)

Chase said:


> One lung ventilation is common in thoracic surgery but I have never heard of trying to ram an obstruction into the Right Main Stem in a unable to ventilate situation. One lung ventilation presents a lot of complex issues but I suppose its better than dead. However like Merck said I can not really think of any common situation where a large obstruction would be present below the cords.
> 
> The only situation I can think of is a pediatric mediastinal tumor (I can't think of the specific name) that can collapse the bronchus after giving paralytics. That's not really an obstruction in the trachea but rather a occluding force from outside.



Sums it up, thanks you. Have to be a freakish or iatrogenic event to get down there, or it bypassed the upper airway entirely (say, shrapnel or other trauma acting through the wall of the trachea or bronchus? Bronchial bleed after overpressure or chemical insult? Just fishing here and not going to be common anyway). Used to be a subject during CPR classes, in the days when we would try to force inflations past airway obstructions. Now, we don't even try that.
I'll sit back and read now...:blush:


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## rennex (Dec 18, 2012)

The "ramming" of the tube is only after visualizing the ET going through the cords but unable to ventilate. Unfortunately I am only able to repeat what my CIC says and that would be it is more beneficial to ventilate one lung than unable to ventilate at all.

Needle cricothyrotomy is not allowed within the five boroughs but it is a state skill so while we practice the skill, I feel like we're glossing over a lot of information about it.


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## Veneficus (Dec 18, 2012)

*rant on...*

Using a neede cric without a jet insuflator is just outright stupid.

Try this at home:

1. Pull the adapter off of an ET tube.

2. Attach a BVM to the universal adapter potion.

3. Remove the catheter from a 14g.

4. Attach catheter to the remaining part of the adapter you have the bvm on. 

5. Go ahead and give the bag a squeeze.

(you may notice almost nothing happens)

6. Now be realistic and give that catheter a 90 degree bend and try again.

How did that work out for you?


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## mycrofft (Dec 18, 2012)

Veneficus said:


> Using a neede cric without a jet insuflator is just outright stupid.
> 
> Try this at home:
> 
> ...



Put the end in your mouth and try to breathe through it along with the insufflations. (Oh, I was going to shut up!).
I read somewhere that needle cric were *verboten* without proper gear for jet insufflation.


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## Merck (Dec 18, 2012)

My bad - I wasn't considering a needle cric specifically (thought the statements I put up stand).  Here all Advanced Care Paramedics (roughly EMT-P) are trained and expected to cric if necessary.  We utilize the Melker set and this allows placement of a 6 tube.  Works well from the two I've had to do.

Needle cric only, as with the above mentioned 14g, would be a last ditch effort to provide some oxygenation at the expense of ventilation.  Likely not going to do much but might manage to help maintain a sat to the hospital (also our only option in peds as we don't have a set for kids).

If that is a method we would likely shove a 6 ETT into a 10cc syringe with the plunger out and inflate the cuff.  Attach to the catheter in place and squeeze like a mofo.

KCCO


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## NYMedic828 (Dec 18, 2012)

Our "protocol" here in NYC has us do the whole "insert tube to deepest depth" thing in an attempt to force the obstruction into the right mainstem...

Personally I have never done it, nor have I had a chance to do it for that matter. I don't really see it as a plausible treatment either considering the airway goes from big to small you only run the risk of causing more damage if it doesn't happen to work.

As far as the needle cric goes, we are trained to do it but it was removed from protocol/scope at the local level. NYS still allows it. It was basically deemed to be a useless procedure for the reasons vene stated.

I've been shown how to make an improvised jet insuflator in the past out of soft suction tubing and an oxygen line but it seemed less than optimal. I imagine the only hope would be to crank the tank up to 25LpM and cross your fingers.


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## rennex (Dec 18, 2012)

I believe part of the reason the city doesn't allow needle crics is because of the ineffectiveness of using a BVM through a 14 gauge catheter.

It might be coming back into our protocols but through utilizing the "Quick Trach" kit.


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## WTEngel (Dec 18, 2012)

I didn't even consider you would be using a 14g catheter. 

My opinion is if you are going to do a procedure, you better have the right equipment. A 14g catheter, ETT adapter, BVM, et al is improv at best, not the right equipment...


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## Merck (Dec 18, 2012)

Yeah, the needle thing is not going to be too effective, I was just passing on what I've been told in the past about the needle cric.

The Melker set is great (and no, I have no disclosures).  Used it twice both with success though of course there are still risks.  Last was just a few weeks ago on a full obstruction at an eating contest.


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## TheLocalMedic (Dec 19, 2012)

They used to include a scalpel in our cric kits to incise the skin over the cricothyroid membrane but recently took them out due to a few instances of "oops, looks like I cut right through that membrane, I guess the hole is big enough for me to slip an ETT in there now".


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## VFlutter (Dec 19, 2012)

TheLocalMedic said:


> They used to include a scalpel in our cric kits to incise the skin over the cricothyroid membrane but recently took them out due to a few instances of "oops, looks like I cut right through that membrane, I guess the hole is big enough for me to slip an ETT in there now".



In a surgical cric aren't you supposed to use the scalpel to cut through the circothyroid membrane?


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## TheLocalMedic (Dec 19, 2012)

Chase said:


> In a surgical cric aren't you supposed to use the scalpel to cut through the circothyroid membrane?



Right, but we've only ever had needle cric kits.  So yeah...


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## VFlutter (Dec 19, 2012)

TheLocalMedic said:


> Right, but we've only ever had needle cric kits.  So yeah...



Gotcha


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## JDub (Dec 19, 2012)

This reminds of a call I had recently. We were dispatched on a difficulty breathing call. Upon arrival we found a patient who had a trach but she could still breathe on her own. Her hospice nurse was there and said they just walked in to find her stoma hanging about halfway out and she was having difficulty breathing. You could tell that she was having very a difficult time breathing and her 02 sats were around 90-92%. My medic tried to reposition the stoma but was unable to do so. He ended up just pulling out the stoma and replacing it with one of our ET tubes and the patient was able to breath much easier and her 02 sats came up.

However, I began to start thinking... What would have been the appropriate action to take if after attempting to use one of our ET tubes, we were still unable to effectively ventilate the patient? Medics can do needle crics here, but I don't think that would have done anything. I asked my Medic after the call and he said he didn't know what he would have done.


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## Merck (Dec 19, 2012)

Just for interest sake the kit we use includes a scalpel.  After performing a perc needle cric you fee a guidewire then make some small incisions to help the introducer pass through the tissue.  It's not actually for cutting the membrane down itself.


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## NYMedic828 (Dec 19, 2012)

I feel like needle cric only exists as another means of allowing EMS to perform a skill they aren't properly trained/educated to perform fully (surgical trach).


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## Veneficus (Dec 19, 2012)

mycrofft said:


> Put the end in your mouth and try to breathe through it along with the insufflations. (Oh, I was going to shut up!).
> I read somewhere that needle cric were *verboten* without proper gear for jet insufflation.



I would think so...

But a lot of medical directors seem to think that the needle cric is a safer and more desirable procedure to give to their medics instead of the surgical cric. Because it sounds scary and they are likely not comfortable with doing it themselves.

Most places that I have seen or heard of that teach it do not even know automated equipment is required.

What is more shocking is it is often in a protocol and providers have no training on it at all.

In short, medical director fail.


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## Veneficus (Dec 19, 2012)

WTEngel said:


> I didn't even consider you would be using a 14g catheter.
> 
> My opinion is if you are going to do a procedure, you better have the right equipment. A 14g catheter, ETT adapter, BVM, et al is improv at best, not the right equipment...



Scary, but that is how people are being taught to do it all over the US.

(Which is technically good for me because I get paid to teach people how to properly do it.)


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## Veneficus (Dec 19, 2012)

*So much to reply to...*



Chase said:


> In a surgical cric aren't you supposed to use the scalpel to cut through the circothyroid membrane?



There are multiple techniques, it is often thought that there is better healing when you bluntly dissect the membrane (how I was taught) compared to incising the membrane (another acceptable technique.) From the emergent standpoint, just get the tube in, because if the person dies they will not heal at all and the question of what heals better is moot. 




NYMedic828 said:


> I feel like needle cric only exists as another means of allowing EMS to perform a skill they aren't properly trained/educated to perform fully (surgical trach).



A cric is an emergent procedure, a trach is not considered "emergent." 

When you need an emergent surgical airway, the cric is usually the airway of choice. It is often later converted to a trach. (the fact that it can be is one of the reasons surgeons actually get to practice doing it.)

In the words of the surgeon who taught me: "People are tough and the point of this is to cut them, that is not a saw in your hands, it is a knife, use it properly."


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## Achilles (Dec 19, 2012)

So how many times have you guys done a cric in the field?


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## NYMedic828 (Dec 19, 2012)

Achilles said:


> So how many times have you guys done a cric in the field?



0. Probably will always be 0.

 We did surgical and needle in class that was it. Along with being shown how to make a Macgyver'ed jet insufflator. 

Haven't needle decompressed anyone either. I've had the opportunity if I went by other people's guidelines but id rather let more educated folks jam needles into vital areas if I don't absolutely need to do it...


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## DrankTheKoolaid (Dec 19, 2012)

I just performed a needle cric less the 2 weeks ago for a GSW to the neck with a failed airway and ill give you some quick tips so if you have to do it yourself in the field you won't fumble through it. 

First, you don't ventilate through a cric, you oxygenate so don't expect chest rise the way you would think but when performed correctly you should and will hear lung sounds and it will not be all that difficult to bag. 

Jet insufflator would have been great but we don't carry them and a BVM works just fine attached to a 15mm adapter off of a 3.0 ett. This brings up a very important point. Practice with your equipment, in training I always used a 15mm off of a 3.5ett but when :censored::censored::censored::censored: hit the fan I realized that they no longer worked because we switched vendors on our tubes and wasted a few seconds having to open another tube to grab the adaptor. 

While not spelled out in protocols you as the thinking medic who understands physiology need to understand we need to be concerned with more then just oxygenation but also ridding the body and lungs of waste gasses IE CO2. So plan on inserting a second needle for off gassing as it will not occur though your initial cric with constant pressure of O2 already present. And there is plenty of space for the 12ga for the oxygenation and a 14ga for off gassing. 

I can not stress enough that this should be practiced regularly in both a skills station setting, and but also in your head so the steps come naturally and without conscious thought should you ever have to actually perform one in an emergent situation


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## Veneficus (Dec 19, 2012)

Achilles said:


> So how many times have you guys done a cric in the field?



Never, just in the OR and ER.


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## Doczilla (Dec 19, 2012)

I've done about a baker's dozen in Afghanistan. Not sure if you count that though.


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## Veneficus (Dec 19, 2012)

Doczilla said:


> I've done about a baker's dozen in Afghanistan. Not sure if you count that though.



Why wouldn't you count that?

Given the conditions in Afghanistan, you should probably count each twice.


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## Christopher (Dec 19, 2012)

Veneficus said:


> I would think so...
> 
> But a lot of medical directors seem to think that the needle cric is a safer and more desirable procedure to give to their medics instead of the surgical cric. Because it sounds scary and they are likely not comfortable with doing it themselves.
> 
> ...



Our protocols are surgical w/ bougie assistance. We had the quicktrach's, but nobody likes them and they're far more complicated in practice.

Something we've practiced, to ensure we have options, is using the bigger PTX needles for rescue oxygenation while you prep for the full cric. Dr. Minh le Cong, of RFDS/prehospitalmed.com, advocates for simple cannula thru cricothyroid membrane then intermittent application of 4-6 L/min O2 via simple tubing. Case reports are favorable as a rescue means. Effectively though, you're only using this as a bridge to a definitive solution.


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## Veneficus (Dec 19, 2012)

Christopher said:


> Our protocols are surgical w/ bougie assistance. We had the quicktrach's, but nobody likes them and they're far more complicated in practice.
> 
> Something we've practiced, to ensure we have options, is using the bigger PTX needles for rescue oxygenation while you prep for the full cric. Dr. Minh le Cong, of RFDS/prehospitalmed.com, advocates for simple cannula thru cricothyroid membrane then intermittent application of 4-6 L/min O2 via simple tubing. Case reports are favorable as a rescue means. Effectively though, you're only using this as a bridge to a definitive solution.



Just my thoughts...

Because a highly skilled doctor or a few highly skilled practicioners can get something to work doesn't make it ready for everyone.

I have recently relearned never to underestimate the "art" of it.


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## Christopher (Dec 19, 2012)

Veneficus said:


> Just my thoughts...
> 
> Because a highly skilled doctor or a few highly skilled practicioners can get something to work doesn't make it ready for everyone.
> 
> I have recently relearned never to underestimate the "art" of it.



I don't disagree in its readiness, however, selection of the simpler O2-tubing to cannula hub technique is preferred (in my mind) to the syringe + ETT adapter + BVM "trick".

The more human factors deficiencies you remove from the technique the better (for high stress, low practice, low frequency events).


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## NYMedic828 (Dec 19, 2012)

Christopher said:


> I don't disagree in its readiness, however, selection of the simpler O2-tubing to cannula hub technique is preferred (in my mind) to the syringe + ETT adapter + BVM "trick".
> 
> The more human factors deficiencies you remove from the technique the better (for high stress, low practice, low frequency events).




That is basically the idea of the improved means of jet insufflation I was shown. I think we used suction tubing so you can cover the hole when you wanted to let in oxygen or let Co2 out.

 How much CO2 really exits the lungs passively though through such a small opening?


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## NYMedic828 (Dec 19, 2012)

NYMedic828 said:


> That is basically the idea of the *improved *means of jet insufflation I was shown. I think we used suction tubing so you can cover the hole when you wanted to let in oxygen or let Co2 out.
> 
> How much CO2 really exits the lungs passively though through such a small opening?



improvised*


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## Veneficus (Dec 19, 2012)

Christopher said:


> I don't disagree in its readiness, however, selection of the simpler O2-tubing to cannula hub technique is preferred (in my mind) to the syringe + ETT adapter + BVM "trick".
> 
> The more human factors deficiencies you remove from the technique the better (for high stress, low practice, low frequency events).



I certainly agree.


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## Merck (Dec 19, 2012)

To answer the question I've done two with the cric set.  Percentage-wise however that's running around 0.01% of intubation scenarios so not an often done thing.

I think there is much more to be gained from spending more time teaching adequate BLS techniques such as 2 person BVM, adequate positioning, watching for gastric insufflation +/- Sellick manouever, and proper suctioning.  Also improvement to DL technique and training with more live-practice (i.e. with anesthetists), better attention to axes and positioning, high-flow nasal oxygen and pre-oxygenation.

Good training in the common can overcome the need for many emergent airways which may or may not just be iatrogenic.


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## Veneficus (Dec 19, 2012)

NYMedic828 said:


> That is basically the idea of the improved means of jet insufflation I was shown. I think we used suction tubing so you can cover the hole when you wanted to let in oxygen or let Co2 out.
> 
> How much CO2 really exits the lungs passively though through such a small opening?



A better question would be:

"Is relative hypercarbia more beneficial than trying to get the Co2 out?"


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## NYMedic828 (Dec 19, 2012)

Veneficus said:


> A better question would be:
> 
> "Is relative hypercarbia more beneficial than trying to get the Co2 out?"



Is it?


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## Veneficus (Dec 19, 2012)

NYMedic828 said:


> Is it?



No idea, that is why it is a question


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## Merck (Dec 19, 2012)

There's no way you're going to ventilate at all with a 14g or something in the neck.  A little bit of oxygenation is the best you could hope for.  Applying suction will likely just drop the oxygen content of the air in the lungs and perhaps cause proximal airway collapse.  Emergency oxygenation is the best you can hope for.  If the person is relatively healthy otherwise they can tolerate the hypercapnia for a bit.


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## mycrofft (Dec 19, 2012)

Corky said:


> I just performed a needle cric less the 2 weeks ago for a GSW to the neck with a failed airway and ill give you some quick tips so if you have to do it yourself in the field you won't fumble through it.
> ...
> This brings up a very important point. Practice with your equipment, in training I always used a 15mm off of a 3.5ett but when :censored::censored::censored::censored: hit the fan I realized that they no longer worked because _we switched vendors on our tubes and wasted a few seconds having to open another tube to grab the *adaptor*_. *
> 
> ...



* emphasis mine.
That's one offshoot of the end of the Cold War. NATO milspec greatly influenced uniformity of adapters etc., because if your device needed an adapter, it would not as likely be purchased (versus a device which did NOT need an adapter) in the hundreds of thousands. 

Corky, you'r singing my song. Practice like you're going into a gunfight with a new sidearm, don't simulate when you can help it, and USE the materials, don't just LOOK.


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## mycrofft (Dec 19, 2012)

Merck said:


> To answer the question I've done two with the cric set.  Percentage-wise however that's running around 0.01% of intubation scenarios so not an often done thing.
> 
> I think there is much more to be gained from spending more time teaching adequate BLS techniques such as 2 person BVM, adequate positioning, watching for gastric insufflation +/- Sellick manouever, and proper suctioning.  Also improvement to DL technique and training with more live-practice (i.e. with anesthetists), better attention to axes and positioning, high-flow nasal oxygen and pre-oxygenation.
> 
> Good training in the common can overcome the need for many emergent airways which may or may not just be iatrogenic.



Hear hear. Historically, how many crics have been attempted (and versus how many succeeded) when what was needed was a simple airway, or even a better head-tilt?

And as for needle supplanting incision, I was told that many layperson and other field crics were botched with bad results after the person either went clean out the ventral side of the trachea, and/or slit the thyroid. Sort of like tourniquets in many ways except even less frequently useful.


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## rennex (Dec 19, 2012)

Thanks guys, I appreciate the input.


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