For ENT residents - how did YOU learn crash cric?

[europeman]

How do you learn your crash cric techniques? Often you are the ones called for airway backup, and I'm curious what your training and technique is for this crash procedure. thanks!

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[Pir8DeacDoc]

We spend a lot of time in conferences and also informally talking about airway management and difficult airways. We obviously perform quite a few tracheostomies and do a lot of airway surgery. We do not have a specific simulator at my program but I hear one is in the works. With all that in mind, one sort of learns how to do said procedure when put into that situation. Some attendings teach us to do a trach- it's what we do the most of so why do something different in an emergency. As a chief resident I have had two such situations- I did a trach in both situations and everyone lived to tell about it (even me). Getting in the midline and staying there is key. A vertical or horizontal incision will work. The small introducers on the anesthesia cric sets work well as a trach (I think they are a size 5.0) and can hook to the anesthesia circuit if a formal tracheostomy tube isn't available. Alternatively an endotracheal tube can work as well. A real key if possible is to have a headlight handy. No one wants to work in a deep dark hole without a light or suction. Good luck

 

[europeman]

Thanks for your response.

Interesting.

As a trauma guy we are trained to do it VERY differently in crash cric situation compared to elective trach. I do a lot of elective trachs as a general surgeon and a crash cric or trach for me is not in any way a similar procedure. In crash situation I don't need suction or retractors or an assistant. An elective one I need all of that.

Anyone else?

 

[resxn]

Thanks for your response.

Interesting.

As a trauma guy we are trained to do it VERY differently in crash cric situation compared to elective trach. I do a lot of elective trachs as a general surgeon and a crash cric or trach for me is not in any way a similar procedure. In crash situation I don't need suction or retractors or an assistant. An elective one I need all of that.

Anyone else?

I've had 4 slash trachs as a resident and 2 as an attending.

An elective trach trach takes me 15 mins avg and is very controlled, deliberate, slow with all the necessary equipment.

I've done slash trachs in as little as 30 secs, but it's rare I don't at least have suction. It's also rare that I don't have a headlight because I have one stashed in the ICU, ER, and obviously they are all over the OR. Vertical incision for me not horizontal when it's a slash.

I'll do a cric or a trach depending on the speed or the anatomy. Prefer to do the trach so I don't have to revise the cric a couple of days later. I didn't get practice other than lots of great education as Pir8DeacDoc describes as well as knowing the anatomy stone cold by many trachs and many laryngoscopies. Having done only 6 total, I feel I could do one in my sleep. If I was called this moment to do one, I already have my protocol in my head. I think preparation, even without the ability to truly practice, is the best thing someone can do for these situations. Don't panic, know your anatomy, be deliberate.

 

[OtoHNS]

I've done plenty of awake trachs in the OR, but have somehow managed to avoid a true patient-will-die-in-2-minutes-without-an-airway emergent cric thus far in my ENT career. *Crosses fingers/knocks on wood*

Since those situations are (fortunately) rare, I agree with Resxn that the key is to mentally prepare and go through the steps of what you would do. For a while in residency, I would consciously palpate the neck on routine trachs and other patients in the OR and think about how I would cric them if necessary.

In a true emergent airway situation (my definition = can't intubate AND can't ventilate, not just can't intubate...), my protocol would be vertical midline incision, cricothyroidotomy, insertion of an medium size ETT (~size 6) through the cricothyroidotomy for ventilation, switch to a Shiley tube once the patient's sats are stabilized. Assume that you'll have the worst possible conditions (bad lighting, no cautery, crappy bedside suction or no suction, no assistant, freaking out anesthesia/IM docs/nurses). The above can be done almost entirely by feel if necessary and you don't have to worry about a too-short Shiley tube in a big fat neck.

I would only consider doing a tracheostomy acutely in an emergent situation if I was already in the OR with all necessary equipment/good lighting/etc and it looked like a "chip shot" trach (skinny patient, thyroid isthmus/big veins not in the way). I'd much rather convert from cric to trach the next day than have increased risk for difficulty (or a dead patient) because I tried to trach them immediately.

 

[Pir8DeacDoc]

Thanks for your response.

Interesting.

As a trauma guy we are trained to do it VERY differently in crash cric situation compared to elective trach. I do a lot of elective trachs as a general surgeon and a crash cric or trach for me is not in any way a similar procedure. In crash situation I don't need suction or retractors or an assistant. An elective one I need all of that.

Anyone else?

Of course it's done differently- time necessitates that. But reality is you can do the same General thing with a blade, a suction, and a tube of some sort. Unless the patient is fat it can be a lot about feel. Find the midline of the trachea and get a hole in it. Clean up things after.

 

[Fah-Q]

1) Stand on patient's right and grab the larynx with your left hand like you mean it and pull up and don't let go.

2) Vertical cut with #10 blade in the midline through the skin, second cut through subcutaneous tissue down to airway, and third cut through the airway

3) Insert left index finger into the airway.

4) Insert 6.0 ETT into airway as you remove finger.

5) Hold pressure and secure tube.

6) Change pants.

This can be done in 30 seconds if you're nasty.

 

[resxn]

1) Stand on patient's right and grab the larynx with your left hand like you mean it and pull up and don't let go.

2) Vertical cut with #10 blade in the midline through the skin, second cut through subcutaneous tissue down to airway, and third cut through the airway

3) Insert left index finger into the airway.

4) Insert 6.0 ETT into airway as you remove finger.

5) Hold pressure and secure tube.

6) Change pants.

This can be done in 30 seconds if you're nasty.

well done, Fah-Q

 

[neutropeniaboy]

This is exactly how I've done it and how I teach it. I've avoided #6 in all situations, however.

1) Stand on patient's right and grab the larynx with your left hand like you mean it and pull up and don't let go.

2) Vertical cut with #10 blade in the midline through the skin, second cut through subcutaneous tissue down to airway, and third cut through the airway

3) Insert left index finger into the airway.

4) Insert 6.0 ETT into airway as you remove finger.

5) Hold pressure and secure tube.

6) Change pants.

This can be done in 30 seconds if you're nasty.

 

[pinipig523]

Old thread, I know.

But why a vertical incision and not a horizontal one?

And when doing a vertical incision - where do you start and where do you end?

 

[Pir8DeacDoc]

Vertical because your airway runs superior to inferior. Also because lateral to the trachea you can run into some serious bleeding quickly. With a midline vertical incision you are relatively safe.
Length is based on your knowledge of anatomy. Palpate the thyroid notch and cut from there inferiorly about 3" or so depending on patient size etc. In an emergency exposure is key. You can clean it up if it's too large later. Too small is asking for problems.

Good luck. In my last month of residency I had two of these come up. Take a breather and make sure to involve others. Going at it alone is not wise. I was grateful for the extra hands in my cases.

 

[resxn]

Going at it alone is not wise. I was grateful for the extra hands in my cases.

Everything you said was spot on, but I particularly wanted to emphasize your last point.

In an airway, when the ship is sinking, load the boat.

 

[neutropeniaboy]

Always vertical.
Airway runs up- down...not side to side.

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[Apollyon]

Vertical because your airway runs superior to inferior.

Always vertical.
Airway runs up- down...not side to side.

I definitely appreciate you guys. I have to tell you, though, that, when I was in paramedic school (1995-96), they taught transverse for the skin, then vertical through the platysma and cartilaginous tissues. Never did one as a medic, though (thank God).

Then again, they pressed transtracheal jet ventilation much more heavily than crash crics.

 

[resxn]

I definitely appreciate you guys. I have to tell you, though, that, when I was in paramedic school (1995-96), they taught transverse for the skin, then vertical through the platysma and cartilaginous tissues. Never did one as a medic, though (thank God).

Then again, they pressed transtracheal jet ventilation much more heavily than crash crics.

That's a reasonable thing for to do for an emergency trach--one in which you have a 1-2 minutes to get the airway, but not seconds. If you have only seconds, don't waste time thinking about layers. 1 cut down to trachea as much as possible (can't do that horizontally because of bleeding), 2nd cut through airway. In fat people or if timid, not uncommon need to 3 cuts or more, but more than 3 is wasting time.

 

[neutropeniaboy]

That's a reasonable thing for to do for an emergency trach--one in which you have a 1-2 minutes to get the airway, but not seconds. If you have only seconds, don't waste time thinking about layers. 1 cut down to trachea as much as possible (can't do that horizontally because of bleeding), 2nd cut through airway. In fat people or if timid, not uncommon need to 3 cuts or more, but more than 3 is wasting time.

Agreed.

I've never considered a trach or a cric to be a cosmetic procedure. I do a vertical incision through the skin and spread, spread, spread. In a cric, it's the same thing, but no spreading.

Besides, in the end, they're all circular scars and they look like **** when the trach comes out, regardless of incision.

Come to think of it, crics really only work in people with reasonable neck anatomy and lack of fatness since the landmarks are easy to find. In the fatties, they've always been "slash trachs" for me.

 

[sleepytime123]

Not a surgeon, ENT or otherwise, just an Anesthesia resident, but the one time I cric'd someone in a can't ventilate/can't intubate situation in someone with a very thick neck: vertical incision, blade horizontally through cricothyroid membrane, index finger, ETT worked. Suction stopped working, it was a bloody mess and everything was by feel. I needed to change my pants after that but the patient walked out of the hospital.