No RSI- Teeth clenched from Head Injury-WWYD

[Nervegas]

Honestly it's retarded to not have cric available to Paramedics that have to maintain an airway.

It's stupid not to have intubation (looking at you, Dallas FD)

Dallas doesn't tube? I was in the ER at the meth house the other day picking up a crazy gomer and Dallas rolled in hot with a guy tubed and an EJ in place.

 

[Shishkabob]

Hmm.. when I spoke to a couple of DFD FFs last year, they said they were losing ETI and just doing supraglottic airways.

I'll admit I haven't looked lately, but I do know BioTel allows each FD to adopt certain parts they want to, which is why some FDs have RSI and other do not.

 

[zzyzx]

I'm curious if anyone knows of studies showing the failure rate for ED and pre-hospital surgical airways. I would imagine that it's quite high, even in the ED.

 

[usafmedic45]

I'm curious if anyone knows of studies showing the failure rate for ED and pre-hospital surgical airways. I would imagine that it's quite high, even in the ED.

Why would you imagine that? Fear I am guessing?

Actually, the only study I can recall seeing the rate is far below that of ETI. It's not a Blalock-Taussig shunt for crying out loud. It's easier than putting in an IV on most people. From unpublished data I have seen, the rate is about 1-3% both in EMS and in hospital.

 

[usafmedic45]

Am Surg. 1995 Jan;61(1):52-5.
Emergency cricothyrotomy: a reassessment.
Hawkins ML, Shapiro MB, Cué JI, Wiggins SS.

The Medical College of Georgia Level I Trauma Center admitted 5603 adult trauma patients from January 1, 1989 through June 30, 1993. Cricothyrotomy was required in 66 of 525 patients who required emergency airway control but could not be intubated nonsurgically in an expeditious manner. There were three major complications (thyroid cartilage laceration, significant hemorrhage, and failure to obtain a surgical airway) involving two patients, but each resolved without sequelae. Twenty-six patients with cricothyrotomy survived their hospital course, of which seven had decannulation of the cricothyrotomy without further airway procedures, and 19 had conversion to tracheostomy. No patient had clinically significant morbidity from the cricothyrotomy, whether with or without a subsequent tracheostomy. Surgical cricothyrotomy remains an important technique with low morbidity for selected trauma victims needing emergency airway control.

A 1% failure rate.

 

[zzyzx]

Hmmm....a 1% failure rate at a trauma center, probably with a trauma surgeon doing the procedure. But I wonder what the failure rate would be by a paramedic or ED doc at a community hospital.

 

[Handsome Robb]

Never done one personally. But from my limited knowledge and experience, it seems much easier than tubing many people.

Just my 0.02

 

[usafmedic45]

Hmmm....a 1% failure rate at a trauma center, probably with a trauma surgeon doing the procedure. But I wonder what the failure rate would be by a paramedic or ED doc at a community hospital.

Well, I was a quality control officer and we tracked this. The rate in the field for surgical airways was between 1-3% for failure.

Once again, why the assumption when presented with evidence to the contrary? A literally five-step procedure (pull skin taut, locate landmarks, cut the skin, puncture the cricothyroid membrane, insert tube) is pretty simple. I'd be more comfortable teaching basic EMTs to do surgical airways than teaching them to intubate. Not that I think either is a good idea in light of availability of great non-visualized airways but the point that it's a very simple, very low risk procedure stands.

BTW, normally the ones handling the airways at trauma centers are the emergency physicians and RTs.

 

[EMS Patient Care Advocate]

Well, I was a quality control officer and we tracked this. The rate in the field for surgical airways was between 1-3% for failure..

What size was your service and how often was this procedure performed?

 

[usafmedic45]

What size was your service and how often was this procedure performed?

It was a pretty diverse group (final chart review was accomplished at the medical control level, not by the individual services) with a couple hundred medics (this was 10 years ago so forgive me for not remembering the exact figures) and perhaps five or ten crikes per year. The data set went back to the early to mid-1980s so there were records for approximately a hundred or maybe a hundred and fifty surgical airways. The order was that no patient was to be left with an uncontrolled airway without a damn good reason but not to jump idly into a surgical airway.

 

[CANMAN]

I agree with everything usafmedic45 said. The hardest part is making the decision and picking up the scapel. I have been lucky enough to have two field surgical airways under my belt. The first one I was slightly nervous ( I was a very green paramedic at the time ) but I was obviously in alot less distress then the paramedic who was originally going to do the procedure. His hand was shaking like a leaf, he had been a paramedic for 13 years and this was his first surgical airway or so he thought. After seeing how nervous he was a quick "give me that" and away I went. Went extremely well and pt. had no complications.

The above call made it much easier to go right ahead when it came time to do my second one.

 

[zzyzx]

I'm surprised that the failure rate is so low. We don't have that in our scope, so I'm not very familiar with the procedure, but my understanding was that it is difficult because as soon as you cut you have a lot of bleeding, making it hard to visualize the anatomy. That and the fact that it's so rarely don't by medics.

 

[usafmedic45]

but my understanding was that it is difficult because as soon as you cut you have a lot of bleeding, making it hard to visualize the anatomy

Not really. As long as you make a midline vertical incision, you shouldn't hit anything that will bleed at a significant rate. All the major vascular structures of the neck are lateral or posterior to the trachea. The idea that a crike looks like something out of Sweeney Todd is another one of those EMS myths that needs to die a quick death. I have four crikes to my credit and not one of those has involved a loss of visual reference. Not to mention that even if it were to occur, one could do the procedure completely by feel. Our medical director used to demonstrate that they could be done in tactical scenarios (read as: pitch darkness) by turning off all the lights and performing one on a pig trachea covered in skin.

 

[usafmedic45]

Published field data....

J Trauma. 1989 Apr;29(4):506-8.
Surgical cricothyrotomy in the field: experience of a helicopter transport team.
Miklus RM, Elliott C, Snow N.
Source

Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio.
Abstract

A retrospective analysis of 3,500 helicopter missions revealed 20 patients who required cricothyrotomy in the field for emergency airway access. Five patients who were in cardiopulmonary arrest succumbed despite cricothyrotomy, all with adequate airway control (Trauma Score, 2.8; ISS, 55.6). Seven of 12 patients with oral, maxillofacial, or cervical trauma survived (Trauma Score, 9.6; ISS, 48.25). There were no instances of bleeding, malposition, airway obstruction, or dysphonia after decannulation in the survivors. Autopsy revealed no serious airway pathology or compromise in those who expired. Surgical cricothyrotomy can successfully be performed in the field by a nurse/physician helicopter transport team. When conventional airway maneuvers are unsuccessful we recommend cricothyrotomy for emergency airway access.

 

[medicsb]

To add on to usaf's one abstract...

While bleeding should be relatively rare, it should be appreciated that many people have vascular anomalies whereby an artery or vein may pass over the area above the cricothyroid membrane. Additionally, there are some people who have a pyramidal lobe of the thyroid that can lay directly over the cricothyroid membrane. Also, there is a pair of muscles that extend from the cricoid cartilage to the thyroid cartilage, which could bleed alot if cut. Essentially, the procedure should be though of as one that is performed based more on feel than sight (as has been said before) because bleeding may obscure visualization of structures.

------

J Trauma. 1997 May;42(5):832-6; discussion 837-8.
Efficacy of prehospital surgical cricothyrotomy in trauma patients.
Fortune JB, Judkins DG, Scanzaroli D, McLeod KB, Johnson SB.
Source

Department of Surgery, University of Arizona, Tucson, USA.
Abstract
OBJECTIVE:

The use of surgical cricothyrotomy (SC) in the prehospital setting is controversial, and the need to teach this procedure to paramedics and intermediate emergency medical technicians remains unclear. The purpose of this study is to define the efficacy, complication rate, and overall survival after SC performed in the prehospital setting.
METHODS:

In our region, emergency medical technicians receive training in this technique using an animal model with bi-annual updates required. We retrospectively reviewed data in our regional trauma register (15,686 injured patients) for the years 1991-1995.
RESULTS:

Prehospital emergency airway intubation was required in 376 patients, 56 of whom received SC. The primary indications for SC were facial fractures and deformities (32%) and blood in the airway (30%). In 79% of the patients requiring SC, attempted orotracheal intubation prior to SC was unsuccessful, with a mean of 1.9 attempts per patient. SC was judged to provide an adequate airway in the field in 89% of attempts. Complications at the scene included six failed attempts, one case of excessive bleeding, and one adverse patient reaction (agitation). When patients arrived at the trauma center, the SC was judged to be acceptable in 64%, whereas 16% were functioning with some question of adequacy and required airway manipulation (most commonly a mainstem bronchial intubation). Overall survival to hospital discharge was 27%; however, survival to emergency department discharge (an indicator of emergency airway adequacy) was 62%. Using TRISS methodology, there were five unexpected survivors and six unexpected deaths. Only three patients were discharged with a "good neurologic recovery."
CONCLUSION:

(1) Prehospital SC can be performed effectively with few complications after training on animal models (2) Good neurologic outcome is rare after the use of this procedure. (3) Although it is effective, clear indications must be developed and followed for the prehospital use of SC.

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J Air Med Transp. 1991 Dec;10(12):7-9, 12.
Prehospital cricothyrotomy in air medical transport: outcome.
Cook S, Dawson R, Falcone RE.
Source

Grant LifeFlight, Columbus, OH.
Abstract

In an attempt to determine outcome, this study reviewed the records of air medical patients undergoing prehospital cricothyrotomy (CRIC) from 1987 through 1989. The study included initial airway management, Trauma Score (TS) before and after CRIC and on arrival to the hospital, outcome, and initiator of airway--either emergency medical services (EMS) or LifeFlight air medical crew (LF). There were 68 CRIC in 3285 completed missions (2%). Patients averaged 31.4 years old with 46 males and 22 females. In rural environments, 60/68 patients were injured, with 65/68 injuries by blunt mechanisms. CRIC was performed by EMS in 24/68 patients and by LF in 44/68 patients. TS before CRIC, after CRIC, and on arrival to the hospital was not significantly different, averaging 5.8, 5.8, and 5.2. There were three complications of CRIC: two bleeds and one failure to insert. Five CRIC were changed to another airway at the receiving facility. Twenty-one out of 68 patients survived to discharge. There were no statistically significant differences in complications or overall mortality between LF and EMS CRIC. Prehospital CRIC appeared safe and complications were infrequent. The CRIC, once placed, remained the airway of choice in most patients. The eventual outcome in this population suggested serious injury with the majority of patients (69%) dying.

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Ann Emerg Med. 1990 Mar;19(3):279-85.
Prehospital cricothyrotomy: an investigation of indications, technique, complications, and patient outcome.
Spaite DW, Joseph M.
Source

Section of Emergency Medicine, University of Arizona College of Medicine, Tucson.
Abstract

The records of all patients who presented to a Level 1 trauma center during a two-year period for whom a prehospital cricothyrotomy was attempted or ordered were reviewed. Twenty patients met the study criteria. The average age was 37 years (range, 11 to 65 years). Indications for prehospital cricothyrotomy were massive facial trauma (eight), failed oral intubation (seven), and suspected cervical-spine injury (one). Cricothyrotomy was attempted in 16 patients (80%), with the remaining four having the procedure ordered but not attempted. A successful airway was achieved in 14 patients (88%). Horizontal incisions were used in all cases and were anatomically correct in 15 of 16 attempts (94%). The overall immediate complication rate was 31%. Two patients (12%) sustained major complications (failure to obtain an airway). No hemorrhagic complications occurred, but 16 of the 20 were in cardiac arrest in the field. Long-term complications were not evaluated. All patients sustained major injuries (mean Injury Severity Score, 53.7), except one patient who suffered airway obstruction from food. Three patients (15%) survived; two of the three suffered permanent, severe brain dysfunction. These preliminary findings demonstrate that prehospital cricothyrotomy is being used chiefly in massively injured patients who are already beyond recovery. It is thus difficult to assess whether the procedure is either safe or effective. There is a need for further investigation to determine whether prehospital cricothyrotomy has any beneficial effect on outcome and, if so, in what setting.(ABSTRACT TRUNCATED AT 250 WORDS)

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Ann Emerg Med. 1991 Apr;20(4):367-70.
Can nurses perform surgical cricothyrotomy with acceptable success and complication rates?
Nugent WL, Rhee KJ, Wisner DH.
Source

Department of Nursing Administration, University of California, Davis Medical Center, Sacramento 95817.
Abstract
STUDY OBJECTIVE:

This study was undertaken to determine whether flight nurses can perform surgical cricothyrotomies with acceptable success and complication rates.
METHODS:

This case series examined the survival, success, and complication rates of surgical cricothyrotomy. A specially trained flight nurse retrospectively reviewed all prehospital, emergency department, inpatient, autopsy, and outpatient follow-up records.
RESULTS:

Fifty-five consecutive patients in whom surgical cricothyrotomy was attempted by a flight nurse during a two-and-one-half-year period were studied. Patients ranged in age from 9 to 76 years. The airway was not cannulated successfully by a flight nurse in two patients. In two patients, the tube was not in the cricothyroid space (one in the upper tracheal rings, and the other in the larynx). In three patients, packing was insufficient to stop bleeding from around the operative site; and in three the tube became occluded by blood in the emergency department. Finally, two patients developed subglottic stenosis.
CONCLUSION:

Surgical cricothyrotomy in the field can be performed reliably by specially trained nurses. Because only the most critically ill or injured patients with unmanageable airways are subjected to this procedure, a significant complication rate can be anticipated.

 

[Shishkabob]

"One adverse patient reaction (agitation)"?!


No crap, I'd be angry if someone came at my neck with a scalpel and I was still awake too!

 

[mycrofft]

History again, why we have been warned off crikes

Like tourniquets, they are done infrequently enough in civlian life that practitioners lack practice once taught, and teachers may lack real life experience. Laypeople were trying crikes with steak knives. Rookies were botching enough of them (both of them) that the high foreheads in Admin decided to take them away. So said my old-surgeon anatomy professor.

If a NG airway penetrates into the brain cavity but it was the only means left to try for an airway, then the pt was already doomed, either to hypoxia or a late diagnosis of a significant communication between brain and nasopharynx. The NG tube on the other hand is much longer and the reactive seizures as it tickles the forebrain etc. can be passed off as irritable reaction in a comatose pt.

 

[mycrofft]

Oops, sorry.

"If a NG airway penetrates into the brain cavity" should have read "If a nasopharyngeal airway...". New keyboard and computer, can't do a thing with them.