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deleted109597
Yes. Or suction.
Not in the ER typically. The portable unit won't last long enough, and we don't have the setups the OR has.
Of course, the last cric I did I didn't have suction either, so it was just scads of 4x4s.
Failed Airway
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Of course, the last cric I did I didn't have suction either, so it was just scads of 4x4s.
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deleted547339
I would start with surgicel- if that didn’t work I’d put in a suture or two.
Agree, the perc cric is a fairly absurd concept.
I’d be tempted to grab a bronchoscope and intubated from above once the dust settles and the patient has a pulse. If I couldn’t get it still, I’d probably PERC trach immediately.
Agree, the perc cric is a fairly absurd concept.
I’d be tempted to grab a bronchoscope and intubated from above once the dust settles and the patient has a pulse. If I couldn’t get it still, I’d probably PERC trach immediately.
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The incision and subsequent dissection bleeds too much for simple cautery and would slow you down. You never have an OR grade bovie around for these things and the battery powered ones would just fizzle as soon as you submerge them in blood. You just have to pack 4x4s in the wound either while you cut, afterwards for tamponade or both. During this one I didn't even have any 4x4s until near the end of the procedure, so it was a pool of blood the entire length of the incision and I was just going by feel. They do ooze, but I've found that if you pack the wound, and take care not to slice up the thyroid, you can get excellent hemostasis with 4x4s. Suction and surgicel would probably both help if you had them available. I typically don't suture these incisions for fear that the cannula will dislodge and I'll need to reopen though I guess it wouldn't take too much time to snip. (Ideally, someone really should be taking these to the OR STAT) One guy a few years back oozed for a few hours in the ICU until ENT got there but I'm pretty sure I cut one of his thyroid arteries.
If I can't palpate tracheal landmarks, I'd never consider the percutaneous method. All of our patients are blimps down here and they have necks of play-doh. At most, I'd want to slice down until I could palpate landmarks and then I would consider percutaneous but by that point you've really just wasted valuable seconds and probably could have cannulated the trachea and had an ETT in there by the time you threaded the wire. I'd like to try it sometime, but I doubt it's faster. Cleaner maybe...but not faster.
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There's always one.
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Hey now, it's worked for me :/
No matter how fat the neck is, the airway is midline and enough wire eventually gets through somehow.
Having said that, I'm just scraping the bottom of the barrel, obviously best treatment was keep the bed rolling into the morgue
No matter how fat the neck is, the airway is midline and enough wire eventually gets through somehow.
Having said that, I'm just scraping the bottom of the barrel, obviously best treatment was keep the bed rolling into the morgue
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If you can't feel the trachea, how do you know where you are stabbing? Are you having to re-direct the needle more than a couple of times? That's the problem I have with the perc. I can barely feel trachea in some of these people, much less cartilage and it's anyone's guess where thyroid or cricoid might be. I feel like I'd be stabbing around until I got air and even when I did...I wouldn't really know at what level I was at in the trachea. It's much easier in a skinny neck, but I don't seem to have that luxury in most of my patients. What's your technique?
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I assume the trachea is midline. Even in blubber land, I can generally tell the middle of a fat sea of pannus and stab. If I get air, I advance guidewire. if I get blood, I advance guidewire (I've had a couple of bloody airways I use this in, there is no vessel in the middle of the body so I assume any blood I get in the cath is in the airway, seems to work for me the two times it's happened).
I trained in a land of obesity, I feel robbed of a fellowship of obese emergency medicine. Thin necks were a privilege lol
And what level? Who cares. Obviously aiming for cricothyroid membrane but I could never feel or palpate such stuff in fatties with short necks. I probably went right through cartilage rings a few times. Didn't matter. All I needed to do was pass a guidewire and feed the tube in from the mouth.
This is the only reason i've never actually cric'd someone outside of a cadaver lab. I couldn't possibly find the membrane in fatties through dissection. They'd basically be a cadaver lab when I finally found it
Maybe I'm just in bizarro world, but if glidescope fails, miller + bougie fails (which you probably couldn't even do with that awful contraption), that's what my third line has been. If I'm cric'ing someone I may as well ask the nurse to page my groups lawyer
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deleted109597
It's not always.
Also, no.
A laboratory comparison of emergency percutaneous and surgical cricothyrotomy by prehospital personnel - PubMed
In an animal model, surgical cricothyrotomy appeared to be a preferable method for establishing a definitive airway over the percutaneous method. Further research is required to define the optimal approach in the prehospital setting for the invasive airway.
www.ncbi.nlm.nih.gov
Arch Guillotti
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Why? I have thankfully never had a true failed airway but if I do I am going straight to perc.
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I've only practiced surgical so that would be my choice.
I guess if I could do 5-10 perc crics in sim and recreate mental model...and there was a kit available, I'd keep it in the toolbox.
I guess if I could do 5-10 perc crics in sim and recreate mental model...and there was a kit available, I'd keep it in the toolbox.
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deleted109597
The data says they're crap (see above). More injuries, more failures, takes longer.
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deleted547339
Do you do perc trachs? Getting into the trachea is easily the most time consuming aspect. If someone is coding/peri-arrest, I would want to cut down to it in as least amount of time as possible.
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No but I have done plenty of transtracheal injections and am confident in my ability to find the trachea quickly with a needle.
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deleted547339
Well good on you (I don’t mean that sarcastically) - even feeling competent to do perc trachs, I wouldn’t feel comfortable doing that in an emergent situation.
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deleted109597
This...isn't one of those times to pull the US out. It just isn't. Sort of like doing finger thoracostomies for tension, or cracking the chest, or perimortem section. You just go.
And the kits aren't helpful when they've got swollen necks.
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I've never done trans tracheal injections, so I am not sure if doing lots of those would change my perspective. I also have only done one cric (surgical) on a patient. But I have done a lot of crics (both surgical and percutaneous) on cadavers, pig tracheas, and task trainers. I walked away from it feeling that while the percutaneous cric sounds good in theory, in reality it takes just too long. I am still on board with the percutaneous tracheostomies that some ICUs put in on a non emergent basis, but for can't intubate/can't ventilate situations the seldinger crics just don't hold up in a head to head comparison. It seems the available literature, such as there is, largely agrees with me. However, we all have different skill sets, so maybe your experience may vary. Next time you have the opportunity (like if you are doing a course for the residents) try comparing the two a few times. Would be interested to hear what you think.
Be careful about using cautery near an airway with 100% oxygen. We have these little disposable cautery sticks that work ok but nothing like real cautery. We use them for perc trachs in icu.
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For what it's worth, I watched an ICU doc one time with lots of perc trach experience (does 100% of the perc trachs in the ICU) stab and stab and stab in an emergent case unable to find trachea. He ended up cutting down to get better landmarks and then switching back to perc trach method. (An example of how difficult it is to override your training in these scenarios). I just remember afterwards thinking how much time he wasted on needles and wires. But hey, in the end...whatever works.
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deleted547339
Sure......but that’s also not the time to have someone to find an ultrasound and hope it’s charged and hope the right probe is plugged in and hope theirs jelly.....you get the point.
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And then the "for f***s sake, how long does this old M Turbo take to boot up."
did a scapel finger bougie the other day. couldnt feel anything so made a generous incision of what I thought was midline. Encountered a lot of bleeding from inferior aspect (probably anterior jugular vein arch?) and ended up getting it in but the venous bleeding really sucked during and after.
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Had a terrible airway this AM. It was the end of my shift, and the new doc came on. Overheard that EMS was bringing in a relatively young woman in PEA and they couldn't get a King Tube in due to a "stiff neck".
The main doc is running the code and asked me to intubate. We move the patient to the gurney and RT and I are bagging, a fair amount of resistance. During a pulse check I start with a glidescope 3 and just don't recognize the structures all that much in the throat. I barely see the epiglottitis and I really don't see anything else. No cords. The tongue is a little high but not all that high. I just don't recognize what's going on in there. I apply cric pressure and notice that I can't really move anything in the neck.
So I put in an intubating LMA and we start to bag her again. The code is still going on. We get pulses then lose them. This time I pull out the bougie, an Mac 3 / 4, and a few other airway gizmos and I try again, and again I just can't see anything. This time with DL, I'm able to freely move the neck around (the neck actually isn't stiff) and I see the tip of the epiglottitis, and try to pass an ET tube but it's getting stuck on something. For some reasons applying cric pressure doesn't do anything to the neck. It's like the structures are stiff or something. But the cervical facets are flaccid. Hmm.. ..So we stop, put in the LMA again and bag again.
By this time, the doc running the code talks to me and I'm saying I can't really get a good look, and we look at her neck and see evidence of a prior tracheostomy. The doc running the code said let's get anesthesia to come down, and I tried to express not wanting that as I wanted to use some other tricks but Anesthesia came down. Before that, I tried to intubate through the intubating LMA but the ET tube was getting stuck around the curve, it wasn't going well. Even had problems passing the bougie in the LMA.
Anyway...there was anesthesia, myself and another ER doc all at the head of the bed trying to intubate this poor gal. The main problem is all three of us are barking out orders to....nobody...."I need this", "get me that", etc.. Anesthesia was saying one thing, I was saying another, and the main ER doc was saying another thing. After awhile I just stop saying stuff. It's clear there are too many cooks in the kitchen at this time. It took awhile, and we were doing transtracheal jet insufflation, but basically we finally cric/trached her and finally got an airway. Sure did take a long time.
After everything settled down, we finally found some notes and she had multiple neck surgeries, history of thyroid cancer, unilateral vocal cord paralysis, neck radiation, and history of a tracheostomy. I think we couldn't move her neck structures because everything was scarred down.
I think the learning points for me are 1) there were too many docs in the room, there really has to be less and ideally just one, and 2) know your advanced airway equipment. I didn't know where everything was, I've never cric'ed anyone in the past, and some of these really advanced things like transtracheal jet insufflation (which worked well in my opinion) I just don't have practice doing. Some of this stuff is not even available at my main place of work, and this happened at my part time job. I was fiddling around with a few of them. It was kind of upsetting to me.
The main doc is running the code and asked me to intubate. We move the patient to the gurney and RT and I are bagging, a fair amount of resistance. During a pulse check I start with a glidescope 3 and just don't recognize the structures all that much in the throat. I barely see the epiglottitis and I really don't see anything else. No cords. The tongue is a little high but not all that high. I just don't recognize what's going on in there. I apply cric pressure and notice that I can't really move anything in the neck.
So I put in an intubating LMA and we start to bag her again. The code is still going on. We get pulses then lose them. This time I pull out the bougie, an Mac 3 / 4, and a few other airway gizmos and I try again, and again I just can't see anything. This time with DL, I'm able to freely move the neck around (the neck actually isn't stiff) and I see the tip of the epiglottitis, and try to pass an ET tube but it's getting stuck on something. For some reasons applying cric pressure doesn't do anything to the neck. It's like the structures are stiff or something. But the cervical facets are flaccid. Hmm.. ..So we stop, put in the LMA again and bag again.
By this time, the doc running the code talks to me and I'm saying I can't really get a good look, and we look at her neck and see evidence of a prior tracheostomy. The doc running the code said let's get anesthesia to come down, and I tried to express not wanting that as I wanted to use some other tricks but Anesthesia came down. Before that, I tried to intubate through the intubating LMA but the ET tube was getting stuck around the curve, it wasn't going well. Even had problems passing the bougie in the LMA.
Anyway...there was anesthesia, myself and another ER doc all at the head of the bed trying to intubate this poor gal. The main problem is all three of us are barking out orders to....nobody...."I need this", "get me that", etc.. Anesthesia was saying one thing, I was saying another, and the main ER doc was saying another thing. After awhile I just stop saying stuff. It's clear there are too many cooks in the kitchen at this time. It took awhile, and we were doing transtracheal jet insufflation, but basically we finally cric/trached her and finally got an airway. Sure did take a long time.
After everything settled down, we finally found some notes and she had multiple neck surgeries, history of thyroid cancer, unilateral vocal cord paralysis, neck radiation, and history of a tracheostomy. I think we couldn't move her neck structures because everything was scarred down.
I think the learning points for me are 1) there were too many docs in the room, there really has to be less and ideally just one, and 2) know your advanced airway equipment. I didn't know where everything was, I've never cric'ed anyone in the past, and some of these really advanced things like transtracheal jet insufflation (which worked well in my opinion) I just don't have practice doing. Some of this stuff is not even available at my main place of work, and this happened at my part time job. I was fiddling around with a few of them. It was kind of upsetting to me.
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Did you have a fiberoptic bronch available?
Also, did you have a transtracheal jet insufflation kit or did you jury rig it? If so, what did you use?
It's not straps, it's a metal clamp controlled by a wheel just above the top of the head.
Poor man's setup from the crash cart:
Catheter over needle from the central line kit (18 gauge needle strong enough to pass a guidewire through), 3 mL syringe (remove the plunger), 7.0 ETT-BVM adaptor (just pull it off the top of the 7.0 ETT).
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Freaking brilliant.
I've used the catheter over needle from the central line kit for needle decompression too.
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I don’t think we had fiber optic bronch available. Out of the ten different ways we were talking about tubing her that wasn’t mentioned.
We actually have the real hardware to do the jet insufflation. It’s actually kind of cool, however it’s a one way thing. You only push air (and at very high pressures from what I can tell) into the lungs, there is no exhalation. Maybe the compressions were exhalation....
The more I think about it there were people yelling out things left and right. It was a really sloppily run because it was way too chaotic. Everyone has excellent intentions...when there are three doctors managing the airway that is bound to happen.
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I don't think there is much exhalation with jet insufflation. In residency they always said not to think you were done after you start jet insufflation on the 3 year old you couldn't intubate because all you did was buy a tiny amount of time.
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Yea I've heard that too. This pt spent about 1 hr undergoing CPR with PEA with very poor oxygenation, not going to be a good outcome.
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It sounds like you handled yourself just fine considering the circumstances. Remember, the "correct" decision is often an exercise of retrospection and hindsight bias. I was asking about the bronch because it might have come in handy in a 2 man operator set up with one using video laryngoscope to drive the tip near the epiglottis and then operator 2 takes over and intubates over the bronch. If it's a disposable ambubronch, you can pass it though the intubating LMA, then cut it, pull the LMA and use it like a bougie. I actually learned that one from an ER doc from TX that was at an airway conference one time. Either way, don't be too hard on yourself. It sounds like it was a tough case. There's probably no scenario that would have gone smoothly.
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Our group has also discussed "sacrificing the scope" in an educational (M&M...) conference. We have the disposable Ambu scopes at some sites.
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Not really familiar with one of these beds or envisioning the position the patient was in, but did you have access to a disposable bronch that you could have loaded an ET tube on and done anything nasally?
...and, strong work.
...and, strong work.
