Cricothyrotomy revisited

[ExpatMedic0]

I read a recent article in EMS world which can be found here http://www.emsworld.com/news/11233937/ind-medic-credited-for-save-with-surgical-cricothyrotomy

What I found interesting was that, "...Of the 3 million AMR runs over the last two years in America, there have been only 38 successful cricothyrotomies"(emsworld.com).

What has your experience been with this procedure?

Do you feel we get enough continuing education and Psychomotor practice to stay current on it?

Do you think its underutilized due to provider comfort level/lack of training, or that the correct number being done should probably be around 38/3 million?

 

[chaz90]

Well, they are supposed to be low frequency high yield procedures. Having said that, I would wager a guess they are under utilized in the US as a whole. I think there is a reluctance to go to something seen as that extreme, but there is a time and place for it. In this case, I find it interesting that the medic who performed the procedure had already done one earlier this year. Based off of the 38/3 million statistic you mentioned (and frankly, I don't know any others), the vast majority of medics could reasonably expect to get through a career of full time 911 without ever pulling out the cric kit. I don't have any information of course, but these statistics would lead me to believe that this particular medic has a much lower threshold to cut than most. The individual provider's comfort and personal attitude make a huge difference in willingness to take that step. We all need to know when the line is crossed and the scalpel (or QuikTrach kit) needs to be used, but I can confidently say that I have met paramedics who would never be comfortable pulling the trigger.

Continuing training to keep up with this skill does need to be emphasized. Every expiring kit should be opened and used for education, and anatomy labs/skill practice should be held at least once a year to keep up some level of familiarity. Even a veteran medic is going to feel somewhat amped up when he realizes a cric is going to be necessary, and that isn't the time to pull out unfamiliar equipment or look for unfamiliar landmarks. I know that's why many services have gone to the QuikTrach. I've seen and played with the PerTrach, and that's painfully complicated to use as infrequently as we do. There's some argument to use a simple scalpel, spreader, and cut down ETT as well.

 

[jwk]

I read a recent article in EMS world which can be found here http://www.emsworld.com/news/11233937/ind-medic-credited-for-save-with-surgical-cricothyrotomy

What I found interesting was that, "...Of the 3 million AMR runs over the last two years in America, there have been only 38 successful cricothyrotomies"(emsworld.com).

What has your experience been with this procedure?

Do you feel we get enough continuing education and Psychomotor practice to stay current on it?

Do you think its underutilized due to provider comfort level/lack of training, or that the correct number being done should probably be around 38/3 million?

For the proper indications, clearly it should be done. There are a number of cric sets on the market, some simple, some more complicated, but all allow a surgical airway to be placed fairly easily. The hardest thing to do would be to pull the trigger because, no way around it, it's a really big deal. It is easily the most invasive thing done by paramedics (or anyone dealing with airway management for that matter) and you can train on it all the time, but until you actually have to do it..... I was in EMS for five years, and I do the airway management workshops for my anesthesia department - and have done more than 30,000 general anesthetics where every patient requires airway management and I've done exactly ZERO crics in my career spanning almost 40 years. I've seen exactly one cric in all that time, done on the nursing floor at the hospital on a patient who lost their airway due to post-op bleeding from their neck surgery.

Interesting that AMR gives their stats as "38 successful cricothyrotomies". I wonder how many were attempted and what the problems were with those that were unsuccessful? Bleeding? Inability to place? Improper placement?

I won't second guess the paramedic in question, because I wasn't there. The article doesn't indicate if other airway management techniques were tried and were unsuccessful. Crics are rare, as they should be and a cric as a PRIMARY method of airway management should be an exceedingly rare event, and of course one of those indications would be airway trauma. My main concern is that they are used inappropriately as a backup to failed intubation. Failed intubation should not mean failed airway management. The progression should not be BVM - attempt ETT - cric. If you use the ASA Difficult Airway Algorithm, a surgical airway is at the absolute bottom of the list.

 

[Carlos Danger]

If you use the ASA Difficult Airway Algorithm, a surgical airway is at the absolute bottom of the list.

It is at the bottom of the list for the ASA, but the ACOS used to (it may have changed; I haven't taken ATLS in years) say "3 failed attempts at ETI --> cut the neck. No foolin' around with sissy LMAs and such for us." I think that is still the approach at Shock Trauma.

And unfortunately, some interpret it being at the bottom of the algorithm as meaning you should wait a long time, trying other things over and over, before you finally make the leap.

I can see how one person might have to do 2 crics. Obviously it's statistically unlikely, but maybe he works in an area where he sees a disproportionate amount of severe trauma and is also for some reason less squeamish about it. Maybe he had some prior training (military) where they really drilled into his head not to hesitate doing it.

I had a scene call once where I needed to do a cric but due to a combination of pre-existing abnormalities and severe neck and facial trauma, I could not locate the landmarks, and ended up doing a "blind / modified retrograde" instead (long story). Anyway I remember it was a fairly easy decision to make once I realized I would not be able to secure an airway otherwise. I think the hard part is reaching that point where you can see clearly that it needs to be done.

 

[Christopher]

My main concern is that they are used inappropriately as a backup to failed intubation. Failed intubation should not mean failed airway management. The progression should not be BVM - attempt ETT - cric. If you use the ASA Difficult Airway Algorithm, a surgical airway is at the absolute bottom of the list.

I think if we had some generalized strategy for airway management, with the appropriate precautions taken for plans A, B, C (etc), then we'd not necessarily have this issue.

At the last local trauma conference, I heard our service area (7 county trauma catchment) sees 1-3 crics per year in the field and another 1-3 in the ED's trauma bay. They mentioned that none of the field crics were for a failed airway that wasn't a predictable failed airway (i.e. massive facial trauma).

Could they have adopted other strategies to optimally manage the airway? Probably.

I don't think we spend the appropriate time, training, or resources on ensuring we follow an adequate plan for airway/ventilation management.

I'm enjoying the Vortex approach which is becoming a popular (AU/NZ) means of simplifying the ASA algorithm into an "all comers" approach. Then combine this with a checklist to maximize their chance of following all the right steps.

 

[Christopher]

I know that's why many services have gone to the QuikTrach. I've seen and played with the PerTrach, and that's painfully complicated to use as infrequently as we do. There's some argument to use a simple scalpel, spreader, and cut down ETT as well.

I was very unhappy with the QuikTrach and PerTrach in cadaver labs. Lots of posterior tracheal wall damage. Local providers who have used them also did not like them. We've gone to the scapel/bougie technique (had a pig lab the other day) to greatly simplify our approach. At the same time GVL's have been added to the trucks at one service. No data yet on if this changes anything.

 

[mycrofft]

Historically (back to the vaults for this one) they taught crics to first aiders! This (like ad hoc tourniquets) resulted in many botched ad hoc attempts resulting in severe bleeding (choice of onto the floor, into the airway, and into haematomas), thyroid injury, and most of all, failure. Having no resuscitation means once it was open, you needed a breathing victim to win, and that meant a very fast decision. This poisoned the use of this potentially very useful, if relatively rare, tool.

Or ought it be more frequently used when/since oral airway passage seems to be so fricking hard?

 

[EMT B]

one of the medics I work with said that both times he has needed a cric, he used a needle cric as a landmark to assist with the surgical procedure.

 

[Tigger]

While doing some research on another topic I came across this from the New Hampshire state treatment guidelines:

In summary: cricothyrotomy is a potentially dangerous procedure which does not save lives in New Hampshire. It draws resources away from other airway management skills which are more likely to be effective. The Board believes that the airway management skills of New Hampshire providers are excellent and that the record shows successful airway management is accomplished on a daily basis, even in the toughest cases, using the available non-cricothyrotomy airway modalities.

Thoughts?

The whole document with rationale is here.

 

[DesertMedic66]

In the last 2 years in my county we only had one patient that a cric was used on. Because of that our medical director decided to pull the skill from our scope. We are in the process of getting a new medical director so we will see if things change.

 

[Handsome Robb]

As a service we usually have one crich a year. We run about 65-70k a year. I don't think we've ever done a needle crich, only surgical. We make our own crich kits. Scalpel, trach hook, trousseau dilator and a 6.0 ETT. I cut my ETTs down to just above the pilot line when I'm getting ready to do the procedure then pop the BVM adapter off and wipe the male part that goes into the ETT with alcohol so it sticks.

I've never done a live one. We rep it a lot though. Every time I'm in education I make a point of doing it at least once but unless you take the initiative we do annual skills once a year and review it as a mandatory training.

 

[TheLocalMedic]

We only have needle crics available to us here. The kits used to include a scalpel, but the story goes that a medic made an oops a number of years ago that got them taken out of the kits… Never used one, never seen it used, and haven't even heard stories of them being used in this area.

 

[Carlos Danger]

While doing some research on another topic I came across this from the New Hampshire state treatment guidelines:



Thoughts?

The whole document with rationale is here.

"Even surgical residents have a hard time maintaining cric skills"? That is honestly one of the stupidest things I have ever heard.

Sounds like these board members had their minds made up about wanting to get rid of the skill, and looked for justification for it.

I sure hope none of them are ever one of those couple people a year who need it performed.

When it needs to be done, there is no substitute.

 

[triemal04]

I suppose the argument for not allowing a cricothyrotomy could be made depending on the conditions that people where allowed to intubate under, and depending on the type of backups they had.

It would be a piss-poor argument and not hold up under any real scrutiny, but I suppose I can see how someone might make a horrible decision and decide to make that argument.

If all those people are allowed to do is intubate without ANY type of pharmacological assistance (no paralytics, no sedation, no procedural sedation) and have easy access to multiple backup airways (King, LMA, igel, etc) and in fact generally use those as their primary airway, then I suppose I can understand where that stance comes from. I mean, at that point they will almost always be intubating people who are already dead.

Doesn't make it any less wrong though.

 

[Handsome Robb]

Does anyone carry a jet insufflator to use with their needle crich? We don't, I tried to bag through one the other day, talk about temporizing measure. We have some ER docs that advocate us doing a needle first to get a bit of oxygenation before cutting but I just don't see how there is much of any oxygenation through one of those things. I know it's purely that, oxygenation not ventilation but is the difference in FiO2 really enough to buy you any sort of measurable extra time?

 

[Christopher]

Does anyone carry a jet insufflator to use with their needle crich? We don't, I tried to bag through one the other day, talk about temporizing measure. We have some ER docs that advocate us doing a needle first to get a bit of oxygenation before cutting but I just don't see how there is much of any oxygenation through one of those things. I know it's purely that, oxygenation not ventilation but is the difference in FiO2 really enough to buy you any sort of measurable extra time?

Minh Le Cong (of the RFDS, writes PHARM) advocates using a simple O2 tubing, holding it to the hub for inspiration and removing it for exhalation.

 

[mycrofft]

Any surgical procedure with significant risk which is not actually practiced is potentially lethal.
If the saves per year are under ten (and no notation is made as to whether or how many iatrogenic crico-deaths occur), and the ancillary equip is not otherwise useful, then it makes sense not to do it.

The FIRST thing we all learn is what NOT to do. It doesn't stop at the first thing by any chance.

 

[Carlos Danger]

Any surgical procedure with significant risk which is not actually practiced is potentially lethal.
If the saves per year are under ten (and no notation is made as to whether or how many iatrogenic crico-deaths occur), and the ancillary equip is not otherwise useful, then not makes sense not to do it.

The FIRST thing we all learn is what NOT to do. It doesn't stop at the first thing by any chance.

If cricothyrotomy can actually be shown to cause more harm than benefit, than I would agree. But I don't think that has been shown.

I would go so far as to making the argument that perhaps the main reason more aren't done is because they are under-utilized. I can't tell you how many times I've seen folks high-fiving each other because "we got the tube", but they leave out the fact that it took many attempts over an extended period of time, and a cric may have been a better option than that 8th intubation attempt.

 

[mycrofft]

1. If cricothyrotomy can actually be shown to cause more harm than benefit, than I would agree. But I don't think that has been shown.

I would go so far as to making the argument that perhaps the main reason more aren't done is because they are under-utilized. I can't tell you how many times I've seen folks high-fiving each other because "we got the tube", but they leave out the fact that it took many attempts over an extended period of time, and a cric may have been a better option than that 8th intubation attempt. 2.

1. Agreed. The issue I have is that it is demonstrable that if a procedure is not taught refreshed and practiced it becomes stale, no matter how competent you feel.

2. Yeah, "It's Miller Time" but the patient has an appointment in autopsy first.

 

[triemal04]

Any surgical procedure with significant risk which is not actually practiced is potentially lethal.
If the saves per year are under ten (and no notation is made as to whether or how many iatrogenic crico-deaths occur), and the ancillary equip is not otherwise useful, then it makes sense not to do it.

The FIRST thing we all learn is what NOT to do. It doesn't stop at the first thing by any chance.

Risk vs reward.

Yes, any procedure needs to be practiced to maintain a minimum level of competancy, but, if a crich is only being used when appropriate, ie you are unable to use an advanced airway of some kind, and unable to manually ventilate the patient, then this is not as applicable.

When you have to crich someone, if you don't, they are in effect dead. The body may still technically be alive for a bit, but at that point the patient is not ventilating themself, and the provider is also unable to do so.

Simply because this is a rarely utilized skill does not make it any less important to have.