Unique scenario leading to cric

[captaindepth]

Here is a cool video of a cric and a discussion to follow the procedure.

http://paramedictv.ems1.com/videos/2160063-doctor-performs-mind-blowing-cricothyrotomy/

I am wondering how you guys would have handled this scenario? Was the cric necessary? Why not nasally intubate? Was it appropriate for the field crew to BLS the airway?

Just curious thoughts on an interesting situation.

 

[usalsfyre]

A more sure approach, depending on where the jaw was broken the possibility of basilar skull involvement and the fact that he's likely to end up trached anyway are all reasons not to bother with a NTI attempt.

Surgical airways should never be the first option but are not nearly as invasive as we make them out to be at times. Think of the number of people who have tracheostomies placed, and realize those are usually a bedside, not OR, procedure.

 

[CANMAN]

This video has come up a bunch of times on the forum, and surprisingly the discussion about it has been somewhat weak. The video poses a unique situation that was managed with a successful airway placement, however, it wouldn't have been my first choice, and his technique could stand for some improvement.

It was completely appropriate for the field crew to BLS the airway until arrival at the hospital. In the video it states the guy was pretty hemodynamically stable and wasn't hypoxic. Therefore heading to a spot that can provide more tools and help was the right call in my opinion. Remember you do not have an airway emergency if you can oxygenate and ventilate the patient.... Because there wasn't an airway emergency, and this was an elective procedure, I absolutely would have attempted NTI for my first attempt with the surgical being my backup option. It sounds like they had time on their side so I would have involved anesthesia early on and been thinking about an elective awake nasal fiberoptic intubation. The incidence of a basilar skull fracture associated with a mandibular fracture is extremely low, like less then 5%, therefore I wouldn't have that deter me from attempting the NTI first. My guess is since the patient had a "beautiful neck" lol he would have been a fairly easy NTI with a trigger tube. A surgical airway, although not difficult, is certainly invasive and shouldn't be taken lightly. I think I get where you're coming from in the fact that alot of people are scared of pulling the trigger on doing the actual skill, but that certainly doesn't discount the level of invasiveness. If this guy does poorly in the ICU after a week or so, sure take him down and place a trach, but in my opinion it wasn't needed right off the bat.

None the less the video shows a high acuity, low frequency skill being performed, that most people don't get to see. It's difficult to related that video to an average field surgical airway scenario though. In the field when you pull the trigger on performing a surgical airway you will not have that kinda of time, and will often be behind the 8 ball when dealing with hypoxia. Can't intubated, can't ventilate right.... Nothing comes out of the hole without something going in the hole first. In someone who has less then ideal body habitus you aren't going to be able to take something out and just palpate landmarks through adipose tissue that easily to find your incision again. There's no reason this guy couldn't have inserted bougie before removing scalpel.

Just my 0.02 cents. This is one of those situations where you could ask 5 paramedics, or 5 MD's how they would manage this patient, and likely you would get 5 different answers. As long at the patient gets an airway AND doesn't have a hypoxic event in the process we have accomplished the mission.
Cheers

 

[jwk]

Emergent airway management of a patient with his jaws "wired shut", especially in-hospital - cut the wires, VL or DL, place tube. I'll admit I didn't listen to the whole 15 minute video - but IMHO this patient did not have indications for a cric. There was time to consider more conservative airway management without cutting this guy's neck (and agree it was poor technique).

Cric's should be a rare event. I teach them in my airway classes. There are almost always alternatives. There is a huge pucker factor when doing one but it's relatively straightforward even if you've only practiced on mannequins. If you do have the equipment to do it, get plenty of practice. Most of the ones we see that come to the OR have been done unnecessarily by someone with less than great airway management skills that gets in trouble.

 

[medicsb]

Oh man, to have a camera over the shoulder of the person performing a cric every time it is done. The technique was fine for this cric. It may not have been textbook, but I'm doubtful very many crics are ever textbook in performance. (I know, you all do them perfect everytime on a manikin, though.) I've done 3 now, and fortunately only one was captured on video from a camera on the ceiling. I can imagine what the surgery resident said about one that he walked in on when I was in the middle of it (actually, I don't have to imagine much since I read his note). *jerk-off motion*

And though critiquing something like this is necessary, lets not pretend that it really would have gone so much better if it was one of you (or me).

Anyhow, being that we know the name of the doc who did this procedure and can determine how long he has been practicing, I would not be at all surprised if this was his first. I work with many EM attendings who have been practicing 20-30 years and many have only participated in 2, maybe 3 crics. Some none, actually.

Can't intubate, can't ventilate is relative to the person managing the airway. What is a CI/CV situation for you, may not be for me, and what is for me may not be for someone else. None of that really matters unless that other person is there. The best way to determine the necessity of a procedure is to consider the situation with only the information that operator had at the time of the procedure. In the ED, there's stuff we do that gets criticized by in-patient docs because we didn't have the right diagnosis (even though it took them 5 days of gyrations to come to that diagnosis themselves; or classically, they criticize an antibiotic choice and change it when they hit the floor... only to have the culture results show that the first regimen was actually fine).

Anyhow, I wouldn't necessarily oppose an attempt at NTI for a patient like this, but it is also a risky procedure. I could argue that it could be riskier since you have to completely stop assisting ventilation and providing O2 will be hindered if not completely halted. NTI is now a very rare procedure and I'd be willing to bet that most folks would be more comfortable with a cric than a blind nasal intubation. Few EDs carry intubating NPLs (mine is finally getting one soon) or bronchoscopes. Calling anesthesia is a fine option if there is already a plan in place for something like this (there is at my institution, and even then I think it takes them too long to respond especially since they have to fetch their bronchoscope from some closet, then push the cart down various hallways to an elevator to take to the ED and then push the cart down another hallway and then to the room is in the ED where they're needed. And if the anesthesia person carrying the difficult airway pager is busy, they gotta call someone to take over for them or call someone else to respond or finish what they're doing really quickly. This is all why anesthesia lost the privilege to intubate in virtually every ED in the US.)

Anyways, I may not have done the same thing. But they made a plan and executed it well with the desired results they wanted. So for that, I commend them.

 

[SpecialK]

From an ambulance perspective I'd have put in a nasal airway if need be and just give him a good jaw thrust. Achieving normoxaemia is important, how it is achieved is less immediately important, at least in the pre-hospital setting anyway where the average ICP is intubating approximately one person per month (or less).

As for the cricothyrotomy, I have never done one and most ambulance personnel, and indeed probably most emergency and ICU doctors, will only do a handful of them per career. We no longer use a large bore IV cannula for doing them and moved several years ago to using the surgical technique.