Needle Airway

[seamonkey]

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I have seen this mentioned on this thread before, but would love some expert advice.

As a PGY-1 in the ED right now, have seen an attempted surgical airway go to **** in a minute. Asked ED attendings about the use of a large-bore needle airway to buy them time and they tell me it is only useful in kids, not morbidly obese people like the patient I speak of.

Are they right, or is it worth a shot in a 400 lb patient with an neck like a tree trunk and no airway at all?

Saw 3 diff. ED attendings cut this neck to **** and nobody found the trachea. Surgical house officer showed up (eventually) and tried but no joy.

If so, my little community hospital can only muster an 18, maybe 16 gauge in a flash in the ED.

I figure at that point, a sharp stick in the middle can't make it worse, but they say it is worthless for an adult, and I may create a false airway anyways.

Please give your thoughts on how to deal with this kind of ED ****storm.

I start as a CA-1 in about a month.

 

[RussianJoo]

What about having your ER stocked with emergency cricothyrotomy kits? they seem easy enough to use.

http://www.metropolitanmedical.com/prod/Quickt_1.htm

 

[Planktonmd]

I have seen this mentioned on this thread before, but would love some expert advice.

As a PGY-1 in the ED right now, have seen an attempted surgical airway go to **** in a minute. Asked ED attendings about the use of a large-bore needle airway to buy them time and they tell me it is only useful in kids, not morbidly obese people like the patient I speak of.

Are they right, or is it worth a shot in a 400 lb patient with an neck like a tree trunk and no airway at all?

Saw 3 diff. ED attendings cut this neck to **** and nobody found the trachea. Surgical house officer showed up (eventually) and tried but no joy.

If so, my little community hospital can only muster an 18, maybe 16 gauge in a flash in the ED.

I figure at that point, a sharp stick in the middle can't make it worse, but they say it is worthless for an adult, and I may create a false airway anyways.

Please give your thoughts on how to deal with this kind of ED ****storm.

I start as a CA-1 in about a month.

Every ER Physician and Every ER department should be able to establish some sort of surgical airway otherwise they should not be open for business.
The best way to do that is to use a cricothyroidotomy Kit and to get some basic training on how to find the trachea: (It's usually the big hose in middle of the neck).

 

[Idiopathic]

you wont reach it with a needle, ive seen this before. if you create subcutaneous air in this patient (likely already happened), then you may never get an emergency airway. with that said, if you can access the trachea, consider retrograde wire so he can be intubated until formal trach. id much rather have an oral ETT in when transitioning to formal trach than have a preexisting trauma trach that has to be revised, also those airways are notoriously unstable in the large patient who may be devloping swelling and subcutaneous air

 

[2ndyear]

I have seen this mentioned on this thread before, but would love some expert advice.

As a PGY-1 in the ED right now, have seen an attempted surgical airway go to **** in a minute. Asked ED attendings about the use of a large-bore needle airway to buy them time and they tell me it is only useful in kids, not morbidly obese people like the patient I speak of.

Are they right, or is it worth a shot in a 400 lb patient with an neck like a tree trunk and no airway at all?

Saw 3 diff. ED attendings cut this neck to **** and nobody found the trachea. Surgical house officer showed up (eventually) and tried but no joy.

If so, my little community hospital can only muster an 18, maybe 16 gauge in a flash in the ED.

I figure at that point, a sharp stick in the middle can't make it worse, but they say it is worthless for an adult, and I may create a false airway anyways.

Please give your thoughts on how to deal with this kind of ED ****storm.

I start as a CA-1 in about a month.

I think you should give us more details, sounds like an intersting case for sure!

 

[jennyboo]

At our place, the urban legend MacGuyver solution is a 14 gauge angiocath hooked up to the end of a 3cc syringe without the plunger... you can then play around with various connections (I forget which) which eventually connect you to some regular O2 tubing, which you then plug straight into the O2 source AT THE WALL. At the wall, you're supposed to detach the Christmas tree/flowmeter and hook the O2 tubing straight up to the source (50psi).

Never seen it work. We did have one guy a while ago who found the right place with the angiocath, but hooked it up to the ANESTHESIA MACHINE CIRCUIT and COULD NOT VENTILATE. You need the 50psi wall pressure, and cannot do regular low-pressure positive pressure ventilation -- it is passive oxygenation only. And you have to know ahead of time to remove the flowmeter from the wall O2 source.

The right answer is still LMA for rescue to buy time if needed, and to use a real crike/trach kit if possible.

 

[Bertelman]

At our place, the urban legend MacGuyver solution is a 14 gauge angiocath hooked up to the end of a 3cc syringe without the plunger... you can then play around with various connections (I forget which) which eventually connect you to some regular O2 tubing, which you then plug straight into the O2 source AT THE WALL. At the wall, you're supposed to detach the Christmas tree/flowmeter and hook the O2 tubing straight up to the source (50psi).

Never seen it work. We did have one guy a while ago who found the right place with the angiocath, but hooked it up to the ANESTHESIA MACHINE CIRCUIT and COULD NOT VENTILATE. You need the 50psi wall pressure, and cannot do regular low-pressure positive pressure ventilation -- it is passive oxygenation only. And you have to know ahead of time to remove the flowmeter from the wall O2 source.

The right answer is still LMA for rescue to buy time if needed, and to use a real crike/trach kit if possible.

Good luck with that. Tomorrow, look on the wall where your machine hooks up to the wall source. It's called a DISS. I'm not sure how you could remove the flowmeter from the wall source and MacGyver a solution that gets you 50 lpm O2.

Better yet, look on the back of your machine, where there should be a jet ventilator kit, which demonstrates what is required to get that wall source O2 to the Pt.

 

[psychbender]

At our place, the urban legend MacGuyver solution is a 14 gauge angiocath hooked up to the end of a 3cc syringe without the plunger... you can then play around with various connections (I forget which) which eventually connect you to some regular O2 tubing, which you then plug straight into the O2 source AT THE WALL. At the wall, you're supposed to detach the Christmas tree/flowmeter and hook the O2 tubing straight up to the source (50psi).

O2 tubing from an NRB, with a little tape around the end to make a tighter seal will fit right in to the back of the syringe. You can also cut a hole into the tubing, to occlude with your thumb, for control. I don't know how well it would actually work (we carry both TJI and crich kits on my truck), but that's what we did in lab.

 

[seamonkey]

Thanks for the input.

The problem with this case is that a crich kit was indeed used by the ED attendings, and then even the general surgeon who came down could not find the airway either. Somewhere in all that cutting they nicked a small bleeder, which certainly did not help.

The details i have are sketchy, basically a morbidly obsese woman in mid-40's rolls in i full arrest, and nobody can bag her or see anything, even with the glidescope. I don't think an LMA was attempted. As they were cutting, they were never 100% sure that they had found the trachea....that was the problem: where the hell was it? This was indeed a neck as big as grown man's thigh.

I guess what I was thinking was that aiming blindly with a large gauge needle may at least help you find the airway and give you something to cut down next to....but then the chance of sub-cut air really does seem to imply that this would be a low-yield approach

 

[Planktonmd]

If someone comes in in full arrest and "no one was able to bag them" there is a very good chance that no matter what you do they will continue to be dead.
That said, I think that the skill that they should teach ER Physicians (and no one ever does) is to how properly do mask ventilation and if that fails how to place an LMA.
My dream before I die is to see one person who is not trained in anesthesia who actually knows how to mask ventilate.

 

[OB1🤙]

The details i have are sketchy, basically a morbidly obsese woman in mid-40's rolls in i full arrest, and nobody can bag her or see anything, even with the glidescope. I don't think an LMA was attempted. As they were cutting, they were never 100% sure that they had found the trachea....that was the problem: where the hell was it? This was indeed a neck as big as grown man's thigh.

Why bother? I mean, it's not like it's on the difficult airway algorithm or anything.

Oh wait...

 

[Breezee]

Why wasn't an anesthesiologist present at this code/airway emergency? Seems like that should have been one of the first people called.

 

[Bertelman]

Why wasn't an anesthesiologist present at this code/airway emergency? Seems like that should have been one of the first people called.

Probably that part about the little community hospital.

 

[bluewater]

Another option to cric (and I have only been there once), is to use a triple lumen central line kit and a small diameter tube to perform a perc trach. Now in the case mentioned above this may not have been possible given the woman's size.

For the TLC- insert the long big mother needle through the cricothyroid membrane if palpable, if not go midline in the ball park, aspirate continuously until you get air, when you do, insert the guide wire, use the scalpel to nick the skin, then dilate and insert a small diameter ETT over the guideire.
Alt- if you get lucky and the wire comes out of the mouth, then go retrograde.

Neither of these techniques are super fast, but given the right situation they may save you. (Ex- ED team induces and gives 100mg Roc, pt has laryngeal mass unable to ventilate/intubate, no go with the LMA, trauma surgeon nowhere to be found, pt is arresting.)

 

[xjohns1]

my opinion as a ca-3 who has never had to personally resort to an emergency surgical/needle airway (but has heard reports of many attempts by colleagues at my institution during my training) is that what you describe is an important lesson: emergency surgical/needle airways are often highly morbid procedures with many potential life-threatening complications (bleeding, false airways). granted, if one is considering such a procedure, the straits are often dire and it may be a last-ditch effort. often in these situations the anatomy is not straightforward (obesity, deviation, radiation, prior surgery, etc.). the point is that the airway algorithm should have been followed and an lma attempted way before even thinking about sticking anything in the neck. to not have attempted an lma is really below the standard of care for airway management in the hands of personnel trained in advanced airway managment. if lma were unsuccessful and one were available, i would have attempted a Combitube and probably blind nasal intubations before attempting surgical/needle airways. even if you got the needle in, unless you had a jet ventilator handy (doubtful in the ed), you're not going to be able to do much with a needle and no connection to a high-pressure oxygen source. if the needle was difficult to place, you can imagine getting even a small tube in would be very difficult. learn the airway algorithm, get good at the nonsurgical steps and do consider surgical airways when difficulty arises but realize they are highly morbid and that they should never be your first or second or third line maneuver for a difficult airway. you must not ever think in the back of your mind that the surgical airway is a sure way out of a difficult airway and it must never be part of a plan (if you have time for a plan and surgical airway enters your mind, you'd better be consulting ent). it trades one major problem for a whole lot of other major problems, often without solving the primary major problem (an uncontrolled airway).

 

[seamonkey]

First, thanks for all the great responses on this thread. I'm learning a lot.

I do want to clarify that I did not see the entire process as I kept being pulled away for other BS (was not on ER at the time, just happenned to be there), so it is possible that an LMA or combitube was attempted. I personally did not see these or hear of them being done, but that does not mean that they were not attempted. In no way do I want to imply that the ED staff at my current institution did not run the correct algorithm.

My question is focused on what to do when apparently all else goes to hell in a handbasket and you have to face the choice of cutting vs ?. The "?" part is what I have been curious about, if there are any other good options, or oprions to use when the surgical airway is also non-productive, as this case was bloody and bad and completely unsuccessful, even with the surgeon involved.

thanks again for the input

 

[Idiopathic]

im a big believer in the retrograde wire, especially in f***ed up situations like the one you described. ive only seen it twice but i can imagine several other situations where it would be my emergency airway of choice, and the situation you describe is one thats worth a try, especially given how tenuous a perc crich would be in this px.

i like the idea of the big 18g central line needle with the wire through it, especially because everyone has a central line kit and an ET tube, but not everyone has a retrograde wire kit

 

[Idiopathic]

Good luck with that. Tomorrow, look on the wall where your machine hooks up to the wall source. It's called a DISS. I'm not sure how you could remove the flowmeter from the wall source and MacGyver a solution that gets you 50 lpm O2.

they are referring to what is in the ED or the patient rooms, i.e. anywhere but the OR

 

[Bertelman]

they are referring to what is in the ED or the patient rooms, i.e. anywhere but the OR

I could be wrong, but the wall source is the same wall source no matter where you are. It's the same connection. It's the same flow rate.

 

[xjohns1]

im a big believer in the retrograde wire, especially in f***ed up situations like the one you described. ive only seen it twice but i can imagine several other situations where it would be my emergency airway of choice, and the situation you describe is one thats worth a try, especially given how tenuous a perc crich would be in this px.

i like the idea of the big 18g central line needle with the wire through it, especially because everyone has a central line kit and an ET tube, but not everyone has a retrograde wire kit

i think this is a reasonable approach to an airway where there is so much blood or secretions that management is impossible from the proximal airway, i.e., oropharynx, once other blind techniques (lma, combitube, blind oral or nasal intubation) have failed. however, in a case where there is difficult anatomy (obesity, prior surgery, tracheal deviation, masses, etc.), i think the principle that it is risky and difficult to get a needle (whether for a retrograde wire or a perc crich or ttjv) in the right spot still applies.

 

[Idiopathic]

my point is that if you are going for an percutaneous airway in this trainwreck patient i would rather have an oral ETT instead of a crich

until a formal trach could be secured that is