# Emergency Cricothyrotomy or Tracheostomy



## MMiz (Jun 27, 2006)

Around here you won't find many units mergency that mess around with this stuff.  With our short transport time I can't even imagine what an ER doc would say if a unit brought one in.

A few months ago there was a traumatic injury and one of our senior medics attempted an emergency trach.  He had to open two OB kits and pull a macgyver.  He was ultimately successful, though I don't know the outcome of the patient.

100% of our emergency calls go before a CQI board of two medics and the education coordinator.  A doctor reviews the "tough cases."  The CQI board saw the narration on the run report, and now has purchased PERTRACH kits for the ALS units.

Has anyone done an emergency cricothyrotomy or tracheostomy in the field?  Any feedback on the PERTRACH kits?


----------



## akflightmedic (Jun 27, 2006)

Since 1996, I have only done 3 surgical crics. It is rare when they are needed but when you do, you need to have the ability and the tools.

The pertrach is a waste of time to me. Time is essential. All you need is a scalpel, ET tube, betadine, gauze and tape. I just found the pertrach to be more laborious and time consuming than just utilizing a scalpel and tube.

You can fashion a cric kit yourself instead of buying namebrand pre-packaged kits.


----------



## Guardian (Jun 27, 2006)

totally agree with akflight


----------



## Guardian (Jun 27, 2006)

Where I work, we do needle cricothyrotomy (on peds) and open (surgical) cricothyrotomy (on adults).  Transport times should not matter unless you have a time traveling machine.  Brain damage secondary to apnea does not take very long.  Remember, we are not a taxi service.  We are a service that provides MEDICAL CARE and transport.  Our transport times are rarely over 15 mins and yet our surgical airways have made the difference between life and death many times.


----------



## Flight-LP (Jun 27, 2006)

Per-trach's aren't worth the time or money. Just like AK said, do it the simple and effective way or better yet, drop a Shiley.


----------



## Ridryder911 (Jun 28, 2006)

Any DOc that would get upset because a crich or trach is done in lieu of not having an airway, needs to repeat medical school. 

Yes, I have done many crichs and even a few trachs.. nothing to brag about.. they needed them short and simple. 

The Golden Rule of Airway is : 
Position
Oral/Nasal
Intubation
Alternate airway 
Surgical.... PERIOD

Here is a link to ENW  AIRWAY FORM HELL!  Please read ...great info! http://www.enw.org/AirwayHell.htm

Fear and Fumbling {Valuable Maxims}:
"There is nothing to fear but fear itself." 

Most airway problems, even extreme, can be worked as an algorithmic sequence of steps. 

The best that can be done, under the circumstances, is the best that can be done. 

If help can be called, do so early before the situation has utterly deteriorated. 

Even a small partial airway may be sufficient to starve off cerebral death until help arrives. 

Fall back to a simple method if it will at least temporize. 

Even a modest plan may be successful if continued firmly. 

Use any method in which one has confidence and experience, yet, if need be, pursue a method that seems applicable despite only textbook knowledge without experience


----------



## Jon (Jul 7, 2006)

In PA, ALS can't preform "sugical" airways - but the cook kits and melker kits, where you use dilators, are OK.

Otherwise it is an angiocath and a jet ventilator.


----------



## Rangat (Jul 10, 2006)

Our ILS can do Needle Crics when they want, but our EMS doesn't carry Jet Insufflation devices. So you have to bag with a S3 ET tube coupling, or use a modified High Cap 10d/ml admin line with an O2 cilinder. It is nothing compared to normal breathing, but it keeps the hypoxaemia at bay... It happins quite often. Many ppl are going out of their way to carry 12g Jelcos. Helps a lot.


----------



## Rangat (Jul 10, 2006)

if ur far from the hospital, the best is to call ALS to quickly come do a trach...


----------



## Jon (Jul 10, 2006)

Rangat said:
			
		

> Our ILS can do Needle Crics when they want, but our EMS doesn't carry Jet Insufflation devices. So you have to bag with a S3 ET tube coupling, or use a modified High Cap 10d/ml admin line with an O2 cilinder. It is nothing compared to normal breathing, but it keeps the hypoxaemia at bay... It happins quite often. Many ppl are going out of their way to carry 12g Jelcos. Helps a lot.


Yeah... I've seen several services carry 10's or 12's for needle trachs....


----------



## natrab (Jul 21, 2006)

We're not allowed to do surgical crichs here.  All we can do is a cath which is pretty worthless.  Either way, we can put a 12 in there and try to bag through a 3mm ET tube adapter.


----------



## doc5242 (Aug 8, 2006)

in the military we were allowed to do surgical ones, in the civiliian sector up here we are not, we have TTJ kits in our trucks which is nothing more than a 14 gauge and a tube.


----------



## rhan101277 (Jul 8, 2008)

Wanted to see if this has changed any.  Also I would assume the person would need to be in some very bad shape.  Maybe crushed jaw or something where you can't open their mouth.

Guess only medics can do this procedure, since EMT's can't use a glucometer.


----------



## mikeylikesit (Jul 8, 2008)

rhan101277 said:


> Wanted to see if this has changed any. Also I would assume the person would need to be in some very bad shape. Maybe crushed jaw or something where you can't open their mouth.
> 
> Guess only medics can do this procedure, since EMT's can't use a glucometer.


 yes only medics can preform these. it is very valuable if the patients airway is completely blocked off from intubation.


----------



## rhan101277 (Jul 8, 2008)

mikeylikesit said:


> yes only medics can preform these. it is very valuable if the patients airway is completely blocked off from intubation.



Is it a standing order, or do you have to call medical control to do it?


----------



## mikeylikesit (Jul 8, 2008)

rhan101277 said:


> Is it a standing order, or do you have to call medical control to do it?


 Yes sir, for both Cricothyrotomy or Tracheostomy you need Med. Control to advise you to preform these procedures.


----------



## Ridryder911 (Jul 8, 2008)

rhan101277 said:


> Is it a standing order, or do you have to call medical control to do it?



Don't worry about such procedures until you reach that level... You still have a l-o-n-g way to go yet...




mikeylikesit said:


> Yes sir, for both Cricothyrotomy or Tracheostomy you need Med. Control to advise you to preform these procedures.



Actually no. I have not worked for a service in a while that required medical control for airway placement, crich's, trach's have been standing orders due to delay = death. 

R/r 911


----------



## CFRBryan347768 (Jul 8, 2008)

rhan101277 said:


> Wanted to see if this has changed any.  Also I would assume the person would need to be in some very bad shape.  Maybe crushed jaw or something where you can't open their mouth.
> 
> Guess only medics can do this procedure, since EMT's can't use a glucometer.



Yeah, not often you see some one placing an ET tube with a glucometer or even a basic airway I say basic because Im pretty sure you could do it, OPA or NPA.


----------



## Outbac1 (Jul 8, 2008)

We have Melker kits here for ACP and CCP use. No call to med control needed. I think there were two done province wide last year.  Not something that gets done a lot.


----------



## MSDeltaFlt (Jul 8, 2008)

Rangat said:


> Our ILS can do Needle Crics when they want, but our EMS doesn't carry Jet Insufflation devices. So you have to bag with a S3 ET tube coupling, or use a modified High Cap 10d/ml admin line with an O2 cilinder. It is nothing compared to normal breathing, but it keeps the hypoxaemia at bay... It happins quite often. Many ppl are going out of their way to carry 12g Jelcos. Helps a lot.



On my ground service in my state, medics can only needle.  However, we do still have demand valves on 50 psi ports for some sort of ventilation.  In order to get oxygen to the lungs through a cath, you need 50 psi.  An AMBU bag through a cath is about as useless as t*ts on a boar hog.

In the air, the nurse can go surgical in my primary state.  We both can across the river.  What I've found is that low tech is the best tech.  Keep it simple, and you can't go wrong.  Just don't lose your hole once you make the cut.


----------



## akflightmedic (Jul 8, 2008)

mikeylikesit said:


> Yes sir, for both Cricothyrotomy or Tracheostomy you need Med. Control to advise you to preform these procedures.



Guess that would vary by department, state or whatever.

As Rid said, I have never had to call for orders on that kind of thing due to the time factor. It has always been a standing order in all the states and jobs I have worked in.


----------



## mikeylikesit (Jul 8, 2008)

akflightmedic said:


> Guess that would vary by department, state or whatever.
> 
> As Rid said, I have never had to call for orders on that kind of thing due to the time factor. It has always been a standing order in all the states and jobs I have worked in.


 Ours i knd of a department thing since they are rarely used in the area.


----------



## akflightmedic (Jul 8, 2008)

mikeylikesit said:


> Ours i knd of a department thing since they are rarely used in the area.



They are rarely used anywhere, which is exactly why it should be allowed and be a standing order for that rare occassion when you do need it.

Low need for something so important is not a great excuse for not providing something. IO's, OB kits, Mag Sulfate...so on and so on are rarely needed or used yet we have them for that rare occurrence.

Not bashing you, just commenting on the illogical justification.


----------



## firemedic7982 (Jul 8, 2008)

akflightmedic said:


> Low need for something so important is not a great excuse for not providing something. IO's, OB kits, Mag Sulfate...



IO's not common? 

We do IO very regularly. EVERY cardiac arrest gets one, muti systems trauma, uncon unk-etiology, etc.


----------



## mikeylikesit (Jul 8, 2008)

akflightmedic said:


> They are rarely used anywhere, which is exactly why it should be allowed and be a standing order for that rare occassion when you do need it.
> 
> Low need for something so important is not a great excuse for not providing something. IO's, OB kits, Mag Sulfate...so on and so on are rarely needed or used yet we have them for that rare occurrence.
> 
> Not bashing you, just commenting on the illogical justification.


 that's OK its not my policy.


----------



## boingo (Jul 9, 2008)

firemedic7982 said:


> IO's not common?
> 
> We do IO very regularly. EVERY cardiac arrest gets one, muti systems trauma, uncon unk-etiology, etc.



Really?  Why is that, practice?  At 90$ a pop, seems like a lot of expense if you already have IV access.  What is the IO giving you that your IV isn't?  If you don't have IV access, sure, but for EVERY arrest, multi system trauma and uncons, seems a bit excessive.


----------



## akflightmedic (Jul 9, 2008)

firemedic7982 said:


> IO's not common?
> 
> We do IO very regularly. EVERY cardiac arrest gets one, muti systems trauma, uncon unk-etiology, etc.



Seems a bit extreme and very cookbook. I will not rehash the education argument in this thread but it is what I am hinting at.

I men seriously, go back and reread what you wrote. EVERY arrest??  EVERY Unconcious UNKN etiology...WTF???


----------

