Cricoid pressure for oral board exam?

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OP,

Do you know how to improve the view that is worsened with cricoid while still maintaining cricoid pressure?

I never understood this band-wagon to abandon cricoid pressure.

Here is the argument. “Hey. Sometimes cricoid pressure isn’t hard enough and sometimes the esophagus isn’t in a good position for it to work well, so we should abandon the practice all together, even though it probably works most of the time.” It’s a weird argument to me.

Sometimes my A-line doesn’t work. I still use and promote it when appropriate however.

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OP,

Do you know how to improve the view that is worsened with cricoid while still maintaining cricoid pressure?

I never understood this band-wagon to abandon cricoid pressure.

Here is the argument. “Hey. Sometimes cricoid pressure isn’t hard enough and sometimes the esophagus isn’t in a good position for it to work well, so we should abandon the practice all together, even though it probably works most of the time.” It’s a weird argument to me.

Sometimes my A-line doesn’t work. I still use and promote it when appropriate however.

But the thing is... there isn't much evidence that cricoid "works most of the time". Just because a patient didn't aspirate or regurgitate when you applied cricoid pressure doesn't mean the cricoid pressure was responsible for this outcome.
 
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But the thing is... there isn't much evidence that cricoid "works most of the time". Just because a patient didn't aspirate or regurgitate when you applied cricoid pressure doesn't mean the cricoid pressure was responsible for this outcome.
Well this seems to be a valid point.
 
Honestly no, teach me your ways
Cricoid pressure makes the view worst (at least in most cases) because it causes a hinge effect and moves the vocal cords more anterior. It probably shifts it to one side as well.

So you can correct this sometimes by applying both cricoid and thyroid pressure (and wiggle the thyroid as usual to get the best view. People always talk about BURP, but I have found it isn’t always to the right.)

Some have studied this and found it to be true.
 

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Why on god's green earth would you make the orals your battlefield?! Just tell them what you want them to hear, not what you do in real life. The whole point of orals is to make sure you're not a m*ron and can actually communicate whatever you should be doing by the book. I don't do cricoid nor do I mask ventilate (unless I have difficulty after first intubation attempt), nor do I wait to push relaxant after pushing prop to "prove" I can mask ventilate. I didn't tell the oral board examiners that my logic is using pharm\physio understanding to time things accordingly yet I do what is still safe. They just want to hear the buzzwords, and move on to the next prompt, they have no reason to mess with you unless you're making your last stand on something nonsensical.
 
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Cricoid pressure makes the view worst (at least in most cases) because it causes a hinge effect and moves the vocal cords more anterior. It probably shifts it to one side as well.

So you can correct this sometimes by applying both cricoid and thyroid pressure (and wiggle the thyroid as usual to get the best view. People always talk about BURP, but I have found it isn’t always to the right.)

Some have studied this and found it to be true.

This was in a small pediatric study population. I wonder how applicable it is in adults, recognizing a significant difference in laryngeal anatomy.

I read a study where cricoid pressure worsened views, BURP improved views, and a combined cricoid-BURP maneuver also worsened views. I need to look for it and will post it when I find it.
 
Why on god's green earth would you make the orals your battlefield?! Just tell them what you want them to hear, not what you do in real life. The whole point of orals is to make sure you're not a m*ron and can actually communicate whatever you should be doing by the book. I don't do cricoid nor do I mask ventilate (unless I have difficulty after first intubation attempt), nor do I wait to push relaxant after pushing prop to "prove" I can mask ventilate. I didn't tell the oral board examiners that my logic is using pharm\physio understanding to time things accordingly yet I do what is still safe. They just want to hear the buzzwords, and move on to the next prompt, they have no reason to mess with you unless you're making your last stand on something nonsensical.
Some people just don’t get it.. guy I used to work with - self professed master of anesthesia took 3 tries to pass the written finally got to take the orals and came back telling us all about how he was “schooling the examiners on intranasal precedex”

Took him 2 more tries to pass the oral too.
 
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This was in a small pediatric study population. I wonder how applicable it is in adults, recognizing a significant difference in laryngeal anatomy.

I read a study where cricoid pressure worsened views, BURP improved views, and a combined cricoid-BURP maneuver also worsened views. I need to look for it and will post it when I find it.
There was a study but from what I remember, the used the BURP maneuver ON the cricoid. That made no sense to me.
 
I literally RSI every patient I intubate in the ICU, most of whom are desatting or hemodynamically unstable. I have never asked for cricoid. I've seen aspiration a few times and someone applied cricoid in those situations and lo, it did nothing except make the view even less possible. The feculent torrent continued despite this incredible maneuver because the gallons of gastric contents and the obese BMI 35++ abdomen is stronger than your hand.

Different situation than a planned intubation to be sure but I trust real life physics more than hypothetical stuff. Maybe in a planned scenario where you are dealing with a normal BMI with just some scant gastric contents and any degree of aspiration is unacceptable I can see that being touted as a standard but in the scenario where it could actually make a huge difference (bowel obstruction morbidly obese decompensating) I don't think it does at all.
 
I literally RSI every patient I intubate in the ICU, most of whom are desatting or hemodynamically unstable. I have never asked for cricoid. I've seen aspiration a few times and someone applied cricoid in those situations and lo, it did nothing except make the view even less possible. The feculent torrent continued despite this incredible maneuver because the gallons of gastric contents and the obese BMI 35++ abdomen is stronger than your hand.

Different situation than a planned intubation to be sure but I trust real life physics more than hypothetical stuff. Maybe in a planned scenario where you are dealing with a normal BMI with just some scant gastric contents and any degree of aspiration is unacceptable I can see that being touted as a standard but in the scenario where it could actually make a huge difference (bowel obstruction morbidly obese decompensating) I don't think it does at all.
In fact one could go as far as to say that it increases the chance of aspiration- cricoid has been shown to decrease the lower oesophageal sphincter tone and sellicks original paper had the highest incidence of regurgitation ever documented in the literature
 
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1. A patient who is actively retching should not get cricoid pressure due to risk of esophageal rupture (and probably shouldn't be induced right away)

2. I do wonder to what degree the lackluster outcome of cricoid pressure is due to poor technique. Whenever I ask a nonanesthesia assistant to perform cricoid they usually do so in a half ass fashion
 
1. A patient who is actively retching should not get cricoid pressure due to risk of esophageal rupture (and probably shouldn't be induced right away)

2. I do wonder to what degree the lackluster outcome of cricoid pressure is due to poor technique. Whenever I ask a nonanesthesia assistant to perform cricoid they usually do so in a half ass fashion
Had a thoracic surgeon put his hand on the manubrium to "help" with rsi... I also use the term "surgeon" for this individual liberally, more accurate description is clueless bozo
 
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Had a thoracic surgeon put his hand on the manubrium to "help" with rsi... I also use the term "surgeon" for this individual liberally, more accurate description is clueless bozo
your bozo thoracic surgeon must have learned alongside my clueless neurosurgeon who claimed a patient with right chest wall pain was from their endotracheal tube.
 
You could argue, legitimately that cricoid isn't necessary for the reasons mentioned above.

However, I wouldn't necessarily recommend it. Picking unnecessary battles in a time controlled oral boards where you have to spend extra time explaining why you didn't use cricoid may cost you in the end.

You also don't know how it will be received by the examiner. Will they perceive you as being cocky or argumentative? Even if you aren't, it's a risk that won't be likely to provide you any benefits and may end up hurting you a bit.

Oral boards isn't a great time to pick battles

I agree. But you can make a point, defend it, AND be astute enough to pick up on when the examiner wants you to reconsider and express the flexibility to choose another path when nudged.
 
I agree. But you can make a point, defend it, AND be astute enough to pick up on when the examiner wants you to reconsider and express the flexibility to choose another path when nudged.
Flexibility is the key. If they ask or prompt you further as suggested above, it’s likely they want you to consider or talk about a different treatment option or consideration. They have to ask the same questions to all examiners and are looking for certain answers. For the instance above, perhaps you don’t mention cricoid pressure, examiner might follow up with, “anything else you would consider doing before inducing”. They’re probably looking for you to at least mention that you thought about cricoid and made a decision one way or the other and reasoning.
 
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Release cricoid. “The patient aspirates. What do you do now?”

Anything you say can and probably will be used against you. Doesn’t mean it’s wrong to say these things per se, but be prepared to defend your answer and move on.

On high risk aspiration cases, I have the nurses do “cricoid pressure” which is almost universally done incorrectly, but the maneuver is institutionally ingrained in our practice and the moment something goes wrong, the first question will be “Why didn’t you hold cricoid?” Somehow, I doubt our hospital administrators would be receptive to “well, the literature says…”.

I do it, doesn’t seem to hurt, and provides reassurance to everybody else in the room.

if i remember our grand rounds on this topic accurately, the argument was that it is actually detrimental based on the fact that it worsened the quality of the view and lead to longer time to secure airway

very heated grand rounds and entertaining
 
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