Cricothyrotomy revisited

[mycrofft]

If it is not practiced enough, ancillary equip is not carried, and the risk potential is high, the procedure stands a better chance of ending n iatrogenic death.

Mandate refreshers and equipment*, then enforce it and it starts to make some real sense, and might be used more often too.

*How about mandatory ER time (mandatory for practitioner and for ER's receiving state or federal funds) to keep certification beyond basic EMT level?

 

[triemal04]

If it is not practiced enough, ancillary equip is not carried, and the risk potential is high, the procedure stands a better chance of ending n iatrogenic death.

Mandate refreshers and equipment*, then enforce it and it starts to make some real sense, and might be used more often too.

*How about mandatory ER time (mandatory for practitioner and for ER's receiving state or federal funds) to keep certification beyond basic EMT level?

Certainly. If someone is going to use any skill they need to maintain a minimum competency level, and the risk associated with that skill will increase or decrease somewhat depending on the level.

If you want to talk time in hospital to maintain an EMS cert we can, but it's going to be a very different conversation.

But again, to remove this specific skill because it is rarely done is a terrible idea. When a crich is really needed (and I doubt any provider is going to do it unless it really, really, really is needed due to the stigma attached to it) it's not farfetched to say that the patient is dead and doesn't know it until the crich is done.

It is a neccasary tool to have.

 

[Craig Alan Evans]

We use surgical kits with scalpel, dilator, hook, and tube. As a system we do about one a year. We train very often with deer trachs simulating blood flowing as we perform the procedure so the training is pretty realistic. We make sure every medic can do the procedure from cut to ventilation in under 30sec. Most do it under 15 seconds. The training is all muscle memory and I think the skill can be maintained very well with training such as this. Our assistant OMD is very hard core about our training and expects us to be able to do this procedure mindlessly and rapidly. He states, "when you have to do one of these you need it five minutes ago so you better be fast and efficient." I timed him at slightly less than 10 seconds from cut to ventilation. We have recently started training with introducing a bougie and then introducing the tube, skipping the hook step, but that has not been performed in the field yet. It's a valuable tool and when you need it there is no substitute.

I just attended the annual Virginia EMS Symposium and saw a lecture on difficult airway management from a Buffalo NY Doc and he preached that the skill was too difficult to maintain and that it was too dangerous, fraught with complications, and should not be performed in the field. He recommended needle cric kits.

When I asked him how he preferred to do the procedure he said, "I prefer a surgical cric, but that's me." He then went on to say he has only performed one in his many years of experience.

My experience with needle kits is they have more steps and working parts to remember than a simple cut, cut, hook, dilate, tube. When we had kits years ago keeping up the skill was very difficult and we never used one in the field, probably due to the confidence of the provider. Once our Asst OMD entered the picture and brought us up to speed we started performing about one a year without issue and all very appropriate.

I have performed one in the field, and since my job is to train other paramedics I don't plan on doing another until everyone on the call with me has performed one as well. With this being said I have been on two other surgical airway incidents in the mentor function and they went flawlessly and very rapidly. It's all about training. If you can't see the procedure in your mind and work through the steps rapidly and clearly then it's time to practice.

That's my take.

 

[Handsome Robb]

I will argue that a failed crich resulting in a death, unless that crich was in appropriately performed (read: not indicated) then you cannot call the death of the patient iatrogenic.

It's been said multiple times, a crich is a last ditch effort, these patients are on the brink of death to begin with. How could you reasonably call the death of a patient requiring a crich iatrogenic?

 

[mycrofft]

I will argue that a failed crich resulting in a death, unless that crich was in appropriately performed (read: not indicated) then you cannot call the death of the patient iatrogenic.

It's been said multiple times, a crich is a last ditch effort, these patients are on the brink of death to begin with. How could you reasonably call the death of a patient requiring a crich iatrogenic?

Even if you are working on a pt on their last three pulses, if you kill them between pulses number 2 and 3, it's iatrogenic if it caused death. (Technically, even if you do it right and it caused death, it is iatrogenic). With Crikey-thyrotomy, that could conceivably include lacerating a major neck vessel or transfixing through the trachea and esophagus and into the anterior spine.

We call that "seizing defeat from the teeth of defeat".

BUT, if crics get treated as something besides a last ditch hopeless Hail Mary, they would be done sooner, with proper pt anesthesia, and be more effective.

 

[triemal04]

Even if you are working on a pt on their last three pulses, if you kill them between pulses number 2 and 3, it's iatrogenic if it was done incorrectly and caused death.

We call that "seizing defeat from the teeth of defeat".

That would really depend on exactly what actually killed the patient, and to some extent, semantics.

If an improperly performed crich was the the DIRECT cause of death (say the provider decided to perform a very long, very deep horizontal incision and cut the jugulars and carotids) that is one thing.

If the patient is dying, and then does die due to a lack of an airway, it's harder to say that the crich, even if improperly done, was the cause of death. They were already going to be dead. They already lacked an airway. At that point an improperly done crich may have failed to resolve the problem, but it didn't cause it.

Like I said, semantics, and I have no doubt that, depending on those involved and who those people later talked, the provider still might face some problems.

 

[jwk]

We use surgical kits with scalpel, dilator, hook, and tube. As a system we do about one a year. We train very often with deer trachs simulating blood flowing as we perform the procedure so the training is pretty realistic. We make sure every medic can do the procedure from cut to ventilation in under 30sec. Most do it under 15 seconds. The training is all muscle memory and I think the skill can be maintained very well with training such as this. Our assistant OMD is very hard core about our training and expects us to be able to do this procedure mindlessly and rapidly.

No offense but there is no such thing as a mindless procedure. You can think quickly as you're doing a procedure, but if you do it mindlessly, that's when mistakes are made, especially with a procedure like this.

 

[Rialaigh]

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.

I tend to go the other way in thinking. If a cricothyrotomy has been shown to provide more good than harm then lets consider doing it. But I don't think that has been shown either.


Frankly this skill is done so rarely, good neuro intact outcomes are so rare when preformed as are completely botched attempts. Because of how rare all of this is to me it really doesn't matter whether we do it or not. We could spend this training time and time discussing or researching this on much more efficient and beneficial training and education.


My issue isn't the skill in and of its-self. It's how high the opportunity cost of properly training and educating on this skill is verse the actual benefit achieved.

 

[ExpatMedic0]

It is the hail Mary of airway plays, that is for sure. However, I can't help but notice (speaking from only my own experience), we do not get enough practical training on this. It is a rare skill, but if push comes to shove, during a 20 year career, it seems like a large portion of medics could be faced with the decision to preform it or not, even if only once or twice in a career. I think (strictly speculation) that the skill may be under performed due to provider level comfort secondary to lack of annual hands on training.

 

[Carlos Danger]

I tend to go the other way in thinking. If a cricothyrotomy has been shown to provide more good than harm then lets consider doing it. But I don't think that has been shown either.

Well, "if the benefits outweigh the risks, it should be in the protocols. If they don't, it should not" holds true for any procedure. And while I certainly agree that the intervention needs to prove itself and not the other way around, we are talking about something that has already been in the protocols for eons many places, not about adding something new that hasn't yet been fully proven.

I don't think anyone is arguing that a cricothyrotomy can't be a life-saving procedure in some cases, anyway. It's not like other very invasive procedures (chest tubes, pericardiocentesis) that have fallen out of favor because they have alternatives.....in a true CI/CV scenario, there simply are no alternatives.

In the example that I used earlier in this thread, my patient would absolutely have died on scene if I had not been trained in retrograde intubation. That's the only time I've used a surgical technique, but I've had several co-workers who have had to.

I just don't think the fact that it is very rarely needed is by itself justification to throw it out, and I don't think it is as difficult to maintain the skills as some claim, either.

I think (strictly speculation) that the skill may be under performed due to provider level comfort secondary to lack of annual hands on training.

I have the same speculation, and in fact I think used properly, it probably shouldn't be quite as rare as it is....

 

[Rialaigh]

Well, "if the benefits outweigh the risks, it should be in the protocols. If they don't, it should not" holds true for any procedure. And while I certainly agree that the intervention needs to prove itself and not the other way around, we are talking about something that has already been in the protocols for eons many places, not about adding something new that hasn't yet been fully proven.

I don't think anyone is arguing that a cricothyrotomy can't be a life-saving procedure in some cases, anyway. It's not like other very invasive procedures (chest tubes, pericardiocentesis) that have fallen out of favor because they have alternatives.....in a true CI/CV scenario, there simply are no alternatives.

In the example that I used earlier in this thread, my patient would absolutely have died on scene if I had not been trained in retrograde intubation. That's the only time I've used a surgical technique, but I've had several co-workers who have had to.

I just don't think the fact that it is very rarely needed is by itself justification to throw it out, and I don't think it is as difficult to maintain the skills as some claim, either.



I have the same speculation, and in fact I think used properly, it probably shouldn't be quite as rare as it is....

I agree it can be life saving. I guess my point was how much education and how little training is offered on this by most EMS agencies. Most agencies do not have access to labs that have this skill at all and realistic training is about near impossible to get most places.

If it took 20 hours a year to keep yourself competent on crics and we had that option to spend those 20 hours on early recognition and management of the sepsis patient (including the possibility of field antibiotics, etc) I would take sepsis training every time. Per 100,000 calls or however you want to measure it volume wise cric's are a very very low benefit skill. They benefit that one patient a lot but the number of patients benefited is microscopic. If given a choice on how to use that time for providers I think there are many more areas where we could see benefits that are ten fold or a hundred fold what we see for cric's in a year.

 

[mycrofft]

"That would really depend on exactly what actually killed the patient, and to some extent, semantics".

You just made every insurance company and will-drawing lawyer in America hiccough. :wacko:

Even if the pt is dying, if what you do is the proximal cause of death, you did it. Doesn't matter if I botched a crike, or Smith Klein gave a chemotherapeutic experimental to a dying cancer patient with six months to live and it ate away her liver.

I'm sure if the practitioner is trained and practiced and it is a reasonable thing to do it is taken into account. By everyone except the patient's family's lawyer.

 

[mycrofft]

Sidetrack:

By the argument being offered here that the measure's need is rare* but it ought to be still taught and used, then why do people want to absolutely stop using spine boards and KEDs?

*(and maybe it ought not to be if it were done better?)

 

[Craig Alan Evans]

No offense but there is no such thing as a mindless procedure. You can think quickly as you're doing a procedure, but if you do it mindlessly, that's when mistakes are made, especially with a procedure like this.

Sounds like semantics, but let's play this out. In my opinion all of the brainpower is spent in the decision to perform the procedure or not. Once you pull the trigger the process of doing it really is very simple. In these situations you do not have the luxury of thinking your way through it. You have to very quickly and deftly establish an airway. He who hesitates is lost. The only way to do that is with practice. Does a musician THINK about where his fingers are going when he plays the piano or the guitar? No, it all muscle memory and once you locate the landmarks it's a matter of two cuts a bougie and a tube, done. I'm not trying to downplay the seriousness of the event, but I think paramedics can be trained to a very high competency in the skills we perform. The whole procedure just isn't that complicated. There are only a couple of physical barriers to overcome to place a tube in the trachea and if you don't know the anatomy of the area you are cutting into enough to do it mindlessly then you shouldn't be doing it.

 

[Carlos Danger]

I agree it can be life saving. I guess my point was how much education and how little training is offered on this by most EMS agencies. Most agencies do not have access to labs that have this skill at all and realistic training is about near impossible to get most places.

If it took 20 hours a year to keep yourself competent on crics and we had that option to spend those 20 hours on early recognition and management of the sepsis patient (including the possibility of field antibiotics, etc) I would take sepsis training every time. Per 100,000 calls or however you want to measure it volume wise cric's are a very very low benefit skill. They benefit that one patient a lot but the number of patients benefited is microscopic.mIf given a choice on how to use that time for providers I think there are many more areas where we could see benefits that are ten fold or a hundred fold what we see for cric's in a year.

That is interesting, but if we are going to take the approach that we'll focus heavily on things that we see often and completely discard things that are rare, then our protocol books and training programs will look awfully different than they do now. If we are really going to go by what the evidence shows makes a difference, we'd probably get rid of all advanced airway management, for instance. Why spend time practicing something that statistically benefits very few people?

20 hours is an awful lot, IMO, to spend annually on any one topic, but if anything deserves that type of time it is airway management. I think things like sepsis and most other topics should be reviewed between transports or even on one's own time, and invasive skills should be practiced 3-4 times per year in skills labs. Plenty of time to practice this skill. You can take a small group of 10 paramedics, and in 60 minutes you can review the airway protocol, review the relevant anatomy, talk about a couple scenarios, and each do 2 or 3 crics on the manikin.

 

[mycrofft]

Sounds like semantics, but let's play this out. In my opinion all of the brainpower is spent in the decision to perform the procedure or not. Once you pull the trigger the process of doing it really is very simple. In these situations you do not have the luxury of thinking your way through it. You have to very quickly and deftly establish an airway. He who hesitates is lost. The only way to do that is with practice. Does a musician THINK about where his fingers are going when he plays the piano or the guitar? No, it all muscle memory and once you locate the landmarks it's a matter of two cuts a bougie and a tube, done. I'm not trying to downplay the seriousness of the event, but I think paramedics can be trained to a very high competency in the skills we perform. The whole procedure just isn't that complicated. There are only a couple of physical barriers to overcome to place a tube in the trachea and if you don't know the anatomy of the area you are cutting into enough to do it mindlessly then you shouldn't be doing it.

Money shot.
AND by not treating it as a last resort poor redheaded step cousin maybe it can be done better?

 

[jwk]

Sounds like semantics, but let's play this out. In my opinion all of the brainpower is spent in the decision to perform the procedure or not. Once you pull the trigger the process of doing it really is very simple. In these situations you do not have the luxury of thinking your way through it. You have to very quickly and deftly establish an airway. He who hesitates is lost. The only way to do that is with practice. Does a musician THINK about where his fingers are going when he plays the piano or the guitar? No, it all muscle memory and once you locate the landmarks it's a matter of two cuts a bougie and a tube, done. I'm not trying to downplay the seriousness of the event, but I think paramedics can be trained to a very high competency in the skills we perform. The whole procedure just isn't that complicated. There are only a couple of physical barriers to overcome to place a tube in the trachea and if you don't know the anatomy of the area you are cutting into enough to do it mindlessly then you shouldn't be doing it.

I'm not arguing that it shouldn't be done. There are certainly valid indications for it. However, I disagree with the "muscle memory" concept - I don't think this is analogous to playing a musical instrument at all. You do indeed have to think about where you cut - you use your fingers to identify the landmarks, but that doesn't mean you're not thinking about it. The cricoid membrane is easily identifiable, but besides that, you're also making sure you're in, and staying in, the midline, making an incision that is deep enough but not too deep, etc. I just don't think that's mindless nor is it automatic. Whether it takes someone 10 seconds or 20 is a negligible difference - it's not a contest - it just has to be done right the first time.

Of course different experiences play a role as well. We have Melker cric kits (a big catheter variation) on our airway carts - those may not be the best for field providers because there are several parts which you have to know how to put together and use. However, everyone in my group is intimately familiar with a modified Seldinger technique of catheter placement, and although I've not done a cricothyrotomy, I've done many cricoid sticks for other reasons. Combining those two makes a cric a relatively easy procedure - except you actually have to DO IT. I have no doubt that as many times as I've practiced it and taught it, the first time I actually have to do it I will take a deep breath and pucker up a little.

 

[triemal04]

"That would really depend on exactly what actually killed the patient, and to some extent, semantics".

You just made every insurance company and will-drawing lawyer in America hiccough. :wacko:

Even if the pt is dying, if what you do is the proximal cause of death, you did it. Doesn't matter if I botched a crike, or Smith Klein gave a chemotherapeutic experimental to a dying cancer patient with six months to live and it ate away her liver.

I'm sure if the practitioner is trained and practiced and it is a reasonable thing to do it is taken into account. By everyone except the patient's family's lawyer.

One more time, and very slowly.

There is a difference between CAUSING a death, and FAILING TO PREVENT a death.

If a patient does not have a patent airway, for instance due to severe trauma, and is unable to ventilate themself, they are going to die. The CAUSE of death would be the lack of ventilation. If attempts at placing an advanced airway fail, a BVM is ineffective, and a crich is ineffective, those did not CAUSE the death, they FAILED TO PREVENT IT.

This does not mean that there is no accountability, or that FAILING TO PREVENT a death means that everything was done right, it just means that the CAUSE of death was not the procedure.

If you refuse to understand that then it's the end of the conversation.

 

[Handsome Robb]

I'm glad someone understood what I was trying to say...

 

[Rialaigh]

That is interesting, but if we are going to take the approach that we'll focus heavily on things that we see often and completely discard things that are rare, then our protocol books and training programs will look awfully different than they do now. If we are really going to go by what the evidence shows makes a difference, we'd probably get rid of all advanced airway management, for instance. Why spend time practicing something that statistically benefits very few people?

20 hours is an awful lot, IMO, to spend annually on any one topic, but if anything deserves that type of time it is airway management. I think things like sepsis and most other topics should be reviewed between transports or even on one's own time, and invasive skills should be practiced 3-4 times per year in skills labs. Plenty of time to practice this skill. You can take a small group of 10 paramedics, and in 60 minutes you can review the airway protocol, review the relevant anatomy, talk about a couple scenarios, and each do 2 or 3 crics on the manikin.

Shouldn't we be going by what evidence shows makes a difference. Isn't that what we are striving for, better evidence based treatments. Statistically in the studies that have been done there is 0 difference in hospital discharge outcome between those ventilated with a king airway and those who are tubed prehospitally. Some studies argue the tube actually causes worse outcomes...but we continue to tube person after person after person....

Plenty of arguments for tubing someone...plenty of sound scientific reasons....and 0 evidence to back up any of it.


The reason I am not a fan of crics is because of how many other topics are out there that we could be training for using real evidence based practice to make a noticable difference in hospital stay and outcomes. If we were already doing everything else really well (The basics) then I would be all for doing advanced airway management better, but right now we don't even do the basics well, and the basics make a much larger difference in length of hospital stay and overall outcome.