Sellick maneuver for BASIC resuscitation...what's up?

mycrofft

mycrofft

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My boss/friend says a local EMS instructor is asking about it because his students are asking about it, allegedly it is "becoming the standard".
I get the basics (use the hard cartilige around the cricoid to compress the esophagus without shutting off the airway), but it ties up another rescuer, one more set of feet and shoulders etc to work around and coordinate, and has some important contraindications, plus it hurts mui grandioso and has people squishing the neck by the thyroids.

What say? Is it YOUR standard? How does it work?
 
mycrofft said:
My boss/friend says a local EMS instructor is asking about it because his students are asking about it, allegedly it is "becoming the standard".
I get the basics (use the hard cartilige around the cricoid to compress the esophagus without shutting off the airway), but it ties up another rescuer, one more set of feet and shoulders etc to work around and coordinate, and has some important contraindications, plus it hurts mui grandioso and has people squishing the neck by the thyroids.

What say? Is it YOUR standard? How does it work?
Click to expand...

Only if there is an extra pair of hands.

A lot of people teach it improperly though. It should not hurt. The pressure should also not be straight back, it should be like pushing skin away from the center. The more diffuse the pressure the more of the esophagus is occluded. If you are performing the procedure correctly, you can do it even to yourself without discomfort, you will sound like a duck when you talk and your secretions will build really fast because you cannot swallow but aside from that there is no pain.

It is also important that it is the cricoid ring that is depressed not the thyroid. For the same reason the emergent cric exists, it should keep away from the coomon location of the thyroid, and the pressure is not really enough to cause a rupture unless you have a hot nodule,neoplasm, or destruction from hasmimotos or the like.

If we have an extra set of hands we employ it. We do not call for additional aid to do it. Rather then crowd them in we have them reach through people already there.
 
Sort of like I used to do with a too-tight helmet chin strap.

..only lower.

Hurts if I do it, and things crackle.

And the extra hands...all I keep seeing is "One...two...THREE!" (shuffle ouch shuffle yikes shuffle ow shuffle).
Seriously, when I googled it,the first article said it's practicality was being calle dinto question, but the NIH cited article from Aussieland said it was taught as the standard by AHA since 2007 for resuscitation (news to me).

Thanks!
 
it's even in the video from AHA and the instructor is supposed to pause and discuss it.
 
Geez, am I behind. And I'm certified to teach CPR.

I guess it will be in the profesional CPR stuff I'm about to learn.
Pssst, cheese it, I gave my boss the URL and maybe he'll join in.
 
http://www.scielo.br/scielo.php?scr...0034-70942008000600010&lng=en&nrm=iso&tlng=en

http://www3.interscience.wiley.com/cgi-bin/fulltext/118802143/HTMLSTART

Interesting stuff in these reviews. Apparently, 20 N of force on the cricoid hurts in a conscious patient, 30 is recommended, and 40 starts interfering with intubation. And on top of that, positioning matters. The second review talks about a study that tested periop RNs, and about others that tested residents and anesthesiologists. All three concluded that it needs specific training, particularly in the amount of force applied, and both reviews have suggestions for training devices.

In short, it's not something that most basics can be trusted with, and even if it were, it's not clear how useful it is.
 
Everytime somone mentions the Sellick Manever i cant help but think of this guy:

tom-selleck-magnum-pi-c10102602.jpg
 
Unless I am trying to intubate somebody after giving them really awesome drugs that the helicopter registrar and/or paramedic carries in the Thomas pack I don't see the point of using Sellick as part of standard CPR.

If you are worried about distending the stomatch while bagging somebody for example, then your technique sucks.
 
I've only been on one cardiac arrest and we used it. Witnessed arrest aed in place in 30 seconds and still it was difficult to keep his head in a neutral position because he started stiffening up within ten minutes. There were 4 of us. One did compressions, one held the mask in place as we were having a heck of a time sealing it because he was so stiff already and his head would not go neutral completely. one bagged him and the medic. Medic had me apply pressure with my free hand since I was bagging him. He did get meds and tubed and ventelations went easier then but he never puked. We were not clamoring over each other either. With good communication we switched rolls as one became fatigued and the medic just stepped back for a second and returned. No tripping or elbows in the face or other unpleasant things. Sadly for how well we all worked together he didn't survive but all that to say yes we were trained to do it and yes we use it when indicated.
 
MrConspiracy said:
http://www.scielo.br/scielo.php?scr...0034-70942008000600010&lng=en&nrm=iso&tlng=en

http://www3.interscience.wiley.com/cgi-bin/fulltext/118802143/HTMLSTART

Interesting stuff in these reviews. Apparently, 20 N of force on the cricoid hurts in a conscious patient, 30 is recommended, and 40 starts interfering with intubation. And on top of that, positioning matters. The second review talks about a study that tested periop RNs, and about others that tested residents and anesthesiologists. All three concluded that it needs specific training, particularly in the amount of force applied, and both reviews have suggestions for training devices.

In short, it's not something that most basics can be trusted with, and even if it were, it's not clear how useful it is.
Click to expand...

"Vanner e Pryle 19 observed that 30 N (equivalent to 3 kg) was the necessary force that should be applied on the cricoid cartilage to prevent regurgitation of NS in 10 cadavers with esophageal pressure of up to 55 cmH2O."

If these cadavers were preserved, there would be a reduction in the elasticity of the esophagus, requiring more force to close it completely. You see the same thing with the pyloric sphincter in the stomach on preserved bodies. A few other sphyncters and vaults have similar characteristics in the preserved. It makes these numbers a bit suspect in my mind.

There is also the relative viscocity of stomoach contents compared to NS. again, I would take these numbers with a grain of salt.


"In awake individuals, applying more than 20 N on the cricoid cartilage can cause pain, cough and nausea. Thus, during anesthetic induction, while the patient is awake, 10 to 20 N should be applied, and 30 to 40 N when the patient is unconscious20."

I only got to read the study out of Brazil, the other wants me to buy it. (which isn't in the plan) "can cause pain" I find a bit suspect as well. Pain being not only subjective, but I encourage anyone to experiment with the difference in reported pain in hispanic cultures compared to any other culture.

From my observations they have a broad definition of "pain" which seems to refer to anything that is abnormal. They are also extremely vocal about pain, which itself can be a way to cope with it.

I don't agree with the AHA on everything, actually, rather a few things, but they decided to put the instruction in the BLS video for healthcare providers, so at least their consensus seems to think even non emergency HCPs (like LPNs, and nursing aides) can perform it effectively and safely enough.

Anyone performing any procedure improperly creates risk. All procedures have some level of risk, as always it is a decision that has to be weighed.

Going soley on education I could make a very strong argument that only a physician should be able to care for patients, but as always. Medics talk about how little basics know, nurses, the same with medics...

Taking a leaf from Mycroftt,

"Five is four"
 
I don't understand why everyone is stressing about whether this procedure hurts on awake volunteers. To be doing this procedure means that someone isn't breathing (at least not enough to support them) and are likely unconscious. You don't do cricoid on awake patients.

CPR, defibrillation, intubation etc hurt a lot too, there is a reason that we do them on people who are not awake.
 
backwards upward reverse pressure. I learned about it in basic school only because i read ahead and asked about it. They didn't teach it other than that.

I've assisted with many intubations in the ICU and often been the one holding sellicks. Not too difficult and the intubator can always tell you more or less pressure.

Education is definitely in order
 
Sellick maneuver - sayonara

Something (someone) tells me that the 2010 AHA guidelines will be moving away from the application of cricoid pressure during intubation... for whatever that's worth.

Not that what the AHA says actually means anything <_<
 
The big thing is that they are going to be moving away from intubation during arrests all together.
 
zmedic said:
The big thing is that they are going to be moving away from intubation during arrests all together.
Click to expand...

Ahh, so we are now coming to the conclusion that the body magically refreshes the air in the lungs to maintain perfusion, or are they proposing that intubation be replaced with BIADs, a res-q-pod, and good compressions?

I would agree it seems difficult to argue that this is evidence-based medicine when somehow the evidence changes every few years. At least at the moment it does seem to make sense.
 
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jjesusfreak01 said:
Ahh, so we are now coming to the conclusion that the body magically refreshes the air in the lungs to maintain perfusion, or are they proposing that intubation be replaced with BIADs, a res-q-pod, and good compressions?
Click to expand...


Well... when compressions are done a vacuum IS created in the chest, which is why some places are doing an NRB and nothing more.


However, I believe they will just (again) downplay the importance of intubation, but not completely un-recommend it. They just don't want compressions to stop for an intubation to take place.
 
Linuss said:
Well... when compressions are done a vacuum IS created in the chest, which is why some places are doing an NRB and nothing more.


However, I believe they will just (again) downplay the importance of intubation, but not completely un-recommend it. They just don't want compressions to stop for an intubation to take place.
Click to expand...

Is a paramedic really going to be alone during an arrest to have to make that decision? Wouldn't they at least have a partner that could continue compressions while they intubated? And that my friends, is my newb question of the day. :blush:
 
You have to stop compressions in order to intubate.
 
jjesusfreak01 said:
Ahh, so we are now coming to the conclusion that the body magically refreshes the air in the lungs to maintain perfusion, or are they proposing that intubation be replaced with BIADs, a res-q-pod, and good compressions?
Click to expand...

There is no substitution for good quality compressions (when/if they can make a difference).

Plain and simple, the cardiac arrest survival rate is abysmal at best... let's define "survival" as Mr. Jones achieving ROSC, enjoying a moderate hospital stay, and returning to life/work/whatever after being discharged. Pacing a patient, dropping them off at the ER, and Hi Fiving back at the station that "you brought him back" doesn't count for squat. These patients, for the most part, are dead when we arrive and all we are doing is going through the motions.

The witnessed arrest is where the real difference can be made. Read up on the 3 Phases of Cardiac Arrest - Time Sensitive Model ( Lance Becker, MD). I found it quite fascinating, and relatively enlightening.
 
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