Needle cricothyrotomy

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rennex

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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?
 
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.
 
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?
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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)
 
I'm not exactly sure why you would ram the ETT as deep as it can go....
 
Merck said:
I'm not exactly sure why you would ram the ETT as deep as it can go....
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"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?"

8203W.jpg


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 .
 
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.
 
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.
 
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.
Click to expand...

Great minds think alike...and apparently simultaneously.
 
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)
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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.
 
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.
Click to expand...

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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"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?
 
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.
 
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.
Click to expand...

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:
 
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.
 
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?
 
Veneficus said:
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?
Click to expand...

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.
 
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
 
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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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.
 
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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