Needle cricothyrotomy

Yeah, the needle thing is not going to be too effective, I was just passing on what I've been told in the past about the needle cric.

The Melker set is great (and no, I have no disclosures). Used it twice both with success though of course there are still risks. Last was just a few weeks ago on a full obstruction at an eating contest.
 

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They used to include a scalpel in our cric kits to incise the skin over the cricothyroid membrane but recently took them out due to a few instances of "oops, looks like I cut right through that membrane, I guess the hole is big enough for me to slip an ETT in there now". :P
 
TheLocalMedic said:
They used to include a scalpel in our cric kits to incise the skin over the cricothyroid membrane but recently took them out due to a few instances of "oops, looks like I cut right through that membrane, I guess the hole is big enough for me to slip an ETT in there now". :P
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In a surgical cric aren't you supposed to use the scalpel to cut through the circothyroid membrane?
 
This reminds of a call I had recently. We were dispatched on a difficulty breathing call. Upon arrival we found a patient who had a trach but she could still breathe on her own. Her hospice nurse was there and said they just walked in to find her stoma hanging about halfway out and she was having difficulty breathing. You could tell that she was having very a difficult time breathing and her 02 sats were around 90-92%. My medic tried to reposition the stoma but was unable to do so. He ended up just pulling out the stoma and replacing it with one of our ET tubes and the patient was able to breath much easier and her 02 sats came up.

However, I began to start thinking... What would have been the appropriate action to take if after attempting to use one of our ET tubes, we were still unable to effectively ventilate the patient? Medics can do needle crics here, but I don't think that would have done anything. I asked my Medic after the call and he said he didn't know what he would have done.
 
Just for interest sake the kit we use includes a scalpel. After performing a perc needle cric you fee a guidewire then make some small incisions to help the introducer pass through the tissue. It's not actually for cutting the membrane down itself.
 
I feel like needle cric only exists as another means of allowing EMS to perform a skill they aren't properly trained/educated to perform fully (surgical trach).
 
mycrofft said:
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.
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I would think so...

But a lot of medical directors seem to think that the needle cric is a safer and more desirable procedure to give to their medics instead of the surgical cric. Because it sounds scary and they are likely not comfortable with doing it themselves.

Most places that I have seen or heard of that teach it do not even know automated equipment is required.

What is more shocking is it is often in a protocol and providers have no training on it at all.

In short, medical director fail.
 
WTEngel said:
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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Scary, but that is how people are being taught to do it all over the US.

(Which is technically good for me because I get paid to teach people how to properly do it.)
 
So much to reply to...

Chase said:
In a surgical cric aren't you supposed to use the scalpel to cut through the circothyroid membrane?
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There are multiple techniques, it is often thought that there is better healing when you bluntly dissect the membrane (how I was taught) compared to incising the membrane (another acceptable technique.) From the emergent standpoint, just get the tube in, because if the person dies they will not heal at all and the question of what heals better is moot.


NYMedic828 said:
I feel like needle cric only exists as another means of allowing EMS to perform a skill they aren't properly trained/educated to perform fully (surgical trach).
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A cric is an emergent procedure, a trach is not considered "emergent."

When you need an emergent surgical airway, the cric is usually the airway of choice. It is often later converted to a trach. (the fact that it can be is one of the reasons surgeons actually get to practice doing it.)

In the words of the surgeon who taught me: "People are tough and the point of this is to cut them, that is not a saw in your hands, it is a knife, use it properly."
 
So how many times have you guys done a cric in the field?
 
Achilles said:
So how many times have you guys done a cric in the field?
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0. Probably will always be 0.

We did surgical and needle in class that was it. Along with being shown how to make a Macgyver'ed jet insufflator.

Haven't needle decompressed anyone either. I've had the opportunity if I went by other people's guidelines but id rather let more educated folks jam needles into vital areas if I don't absolutely need to do it...
 
I just performed a needle cric less the 2 weeks ago for a GSW to the neck with a failed airway and ill give you some quick tips so if you have to do it yourself in the field you won't fumble through it.

First, you don't ventilate through a cric, you oxygenate so don't expect chest rise the way you would think but when performed correctly you should and will hear lung sounds and it will not be all that difficult to bag.

Jet insufflator would have been great but we don't carry them and a BVM works just fine attached to a 15mm adapter off of a 3.0 ett. This brings up a very important point. Practice with your equipment, in training I always used a 15mm off of a 3.5ett but when :censored::censored::censored::censored: hit the fan I realized that they no longer worked because we switched vendors on our tubes and wasted a few seconds having to open another tube to grab the adaptor.

While not spelled out in protocols you as the thinking medic who understands physiology need to understand we need to be concerned with more then just oxygenation but also ridding the body and lungs of waste gasses IE CO2. So plan on inserting a second needle for off gassing as it will not occur though your initial cric with constant pressure of O2 already present. And there is plenty of space for the 12ga for the oxygenation and a 14ga for off gassing.

I can not stress enough that this should be practiced regularly in both a skills station setting, and but also in your head so the steps come naturally and without conscious thought should you ever have to actually perform one in an emergent situation
 
I've done about a baker's dozen in Afghanistan. Not sure if you count that though.
 
Doczilla said:
I've done about a baker's dozen in Afghanistan. Not sure if you count that though.
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Why wouldn't you count that?

Given the conditions in Afghanistan, you should probably count each twice.
 
Veneficus said:
I would think so...

But a lot of medical directors seem to think that the needle cric is a safer and more desirable procedure to give to their medics instead of the surgical cric. Because it sounds scary and they are likely not comfortable with doing it themselves.

Most places that I have seen or heard of that teach it do not even know automated equipment is required.

What is more shocking is it is often in a protocol and providers have no training on it at all.

In short, medical director fail.
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Our protocols are surgical w/ bougie assistance. We had the quicktrach's, but nobody likes them and they're far more complicated in practice.

Something we've practiced, to ensure we have options, is using the bigger PTX needles for rescue oxygenation while you prep for the full cric. Dr. Minh le Cong, of RFDS/prehospitalmed.com, advocates for simple cannula thru cricothyroid membrane then intermittent application of 4-6 L/min O2 via simple tubing. Case reports are favorable as a rescue means. Effectively though, you're only using this as a bridge to a definitive solution.
 
Christopher said:
Our protocols are surgical w/ bougie assistance. We had the quicktrach's, but nobody likes them and they're far more complicated in practice.

Something we've practiced, to ensure we have options, is using the bigger PTX needles for rescue oxygenation while you prep for the full cric. Dr. Minh le Cong, of RFDS/prehospitalmed.com, advocates for simple cannula thru cricothyroid membrane then intermittent application of 4-6 L/min O2 via simple tubing. Case reports are favorable as a rescue means. Effectively though, you're only using this as a bridge to a definitive solution.
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Just my thoughts...

Because a highly skilled doctor or a few highly skilled practicioners can get something to work doesn't make it ready for everyone.

I have recently relearned never to underestimate the "art" of it.
 
Veneficus said:
Just my thoughts...

Because a highly skilled doctor or a few highly skilled practicioners can get something to work doesn't make it ready for everyone.

I have recently relearned never to underestimate the "art" of it.
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I don't disagree in its readiness, however, selection of the simpler O2-tubing to cannula hub technique is preferred (in my mind) to the syringe + ETT adapter + BVM "trick".

The more human factors deficiencies you remove from the technique the better (for high stress, low practice, low frequency events).
 
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