#8 Essential Emergency Airway Care- Surgical Airways 1 Andrew Brainard, MD, MPH, FACEM, FACEM

#8 Crash Cricothyrotomy Learning Objectives – Review Prep team/plan/room/equipment Discuss Difficult Airway Algorithm Describe a “Crash Airway” Declare: Can’t Intubate, Can’t Oxygenate! – Surgical Cric Locate equipment Double Setup Proper technique – Scalpel – Bougie – Tube Indications R40: 40 y/o M swollen tongue, difficulty breathing – Hx angioedema – Obtunded, GCS 6, SaO2 80% On Arrival – Sitting Up, Nasal O 2, rebreather 0 2 >15lpm – SaO2 75% and GCS 5 – LEMON Protruding tongue, Swollen face, , stridor – SHORT Short Neck – Consultant suggests Crash Cric Declare: Can’t Intubate, Can’t Oxygenate – Skip Checklist +/- sedation/paralysis Difficult Airway Call (888) Crash Cricothyrotomy – End scenario after tube confirmation

Locate Cric Kit 3

Cricothyrotomy Assessment Laryngeal Handshake Ultrasound SHORT S: surgery (previous) H: haematoma (swelling) O: obesity R: radiation T: tumor 4

Identification of Anatomical Landmarks 5 A F E D C B G A- Thumb and index finger, palpate the hyoid B- Palpate the lateral sides of the thyroid lamina and the midline thyroid prominence C- Find the inferior cornu of the thyroid D- The cricothyroid membrane is between the thyroid cartilage and the cricoid cartilage and above the softer tracheal rings E- Locate the cricothyroid membrane with the laryngeal handshake F- Stabilize the larynx with your non-dominant hand G- Rest your dominate hand on the patient’s sternum H- Cut H

Cant intubate, can’t oxygenate (CICO) When an experienced clinician thinks it will be safer than intubation from the top. Continue to attempt to ventilate from the top with an LMA/BVM Age cut-offs? – APLS suggests <12y/o – Some say <6y/o – Others say <3y/o – AKA: it depends When to Cric 6 Cricothyroidotomy

Preparation The “double prep” – Don’t wait until too late – Assess, clean, and mark neck early 7

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Equipment Simple Cric Kit – Scalpel – ( Bougie on Airway Cart) – 6-0 endotracheal tube (cuffed) – Dressing Pack Skin Marker Antiseptic KY 10ml syringe Blue pad Cook surgical-and percutaneous airway kit 9

Cric Technique Scalpel-Bougie-Tube Optimize patient Oxygenate with BVM/LMA Locate cricothyroid membrane Decide to CUT Vertical cut skin Horizontal cut membrane Bougie 6-0 ETT over bougie until cuff enters Confirm and ventilate Bougie Cric (7min) 10

Airway briefing and checklist 60y/o with head and face trauma. Who is not protecting his airway and not oxygenating. This is a predicted very difficult airway. We will Prepare “double setup” for cric and be ready for an emergent cricothyrotomy Declare an 888 airway emergency We will use 200mg of ketamine and 100 mg of Rocuronium if needed I’ll be team leader Linda as primary airway operator I’ll be the backup airway operator Joyce as airway assistant James also push the drugs The plan is: A- Direct/bougie/7-0 tube B- Video/7-0 tube w/ stylet C- I-LMA #3.5” D- Scaple-Bougie-6-0 Tube cric You can look for 1 minute as we assess and prepare the neck. If we can’t intubate and can’t oxygenate will will place an I- LMA, if that doesn’t work, we will perform a scalpel-bougie- tube cricothyrotomy Understand your roles Questions? 11

Brief Cric references Richard Levitan, ACEP now cricothyrotomy/ (accessed on 1/05/14) cricothyrotomy/ Richard Levitan, ACEP Now cricothyrotomy/ (accessed on 1/05/14) cricothyrotomy/ Darren Braude, EMrap TV, Bougie guided cric: (accessed on 03/06/2014) PHARM- PreHospital And Retrieval Medicine- Video of actual cric: video/(accessed on 05/06/2014) video/ PHARM- PreHospital And Retrieval Medicine- cartilaginous-cage/ (accessed on 05/06/2013) cartilaginous-cage/ The Melker Emergency Cricothyrotomy Catheter Tray: (accessed on 22/03/2013) 12