8 Essential Emergency Airway Care Surgical Airways Andrew

#8 Essential Emergency Airway Care. Surgical Airways Andrew Brainard, MD, MPH, FACEM http: //www. thesharpend. org/ abrainard 01@gmail. com 1

#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 • R 40: 40 y/o M swollen tongue, difficulty breathing – Hx angioedema – Obtunded, GCS 6, Sa. O 2 80% • On Arrival – Sitting Up, Nasal O 2, rebreather 02 >15 lpm – Sa. O 2 75% and GCS 5 – LEMON • Protruding tongue, Swollen face, 0 -3 -2, 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

Loca te Cr ic Kit 3

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

Identification of Anatomical Landmarks A B D C A- Thumb and index finger, palpate the hyoid B- Palpate the lateral sides of the thyroid lamina and the E 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 G F H 5

When to Cricothyroidotomy • 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 <12 y/o Some say <6 y/o Others say <3 y/o AKA: it depends 6

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 10 ml 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 http: //www. youtube. com/watch? v=w. VQFJR 7 qmr. Q (7 min) 10

Airway briefing and checklist • 60 y/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 200 mg 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 place an ILMA, if that doesn’t work, we will perform a scalpel-bougietube cricothyrotomy • Understand your roles • Questions? 11

Brief Cric references • Richard Levitan, ACEP now http: //www. acepnow. com/article/tips-tricks-performingcricothyrotomy/ (accessed on 1/05/14) • Richard Levitan, ACEP Now http: //www. acepnow. com/article/make-incision-insert-tubecricothyrotomy/ (accessed on 1/05/14) • Darren Braude, EMrap TV, Bougie guided cric: https: //vimeo. com/67187062 (accessed on 03/06/2014) • PHARM- Pre. Hospital And Retrieval Medicine- Video of actual cric: http: //prehospitalmed. com/2013/02/27/actual-emergency-cricothyrotomyvideo/(accessed on 05/06/2014) • PHARM- Pre. Hospital And Retrieval Medicinehttp: //prehospitalmed. com/2013/11/17/levitan-the-laryngeal-handshake-and-thecartilaginous-cage/ (accessed on 05/06/2013) • The Melker Emergency Cricothyrotomy Catheter Tray: http: //www. cookmedical. com/cc/data. Sheet. do? id=4815 (accessed on 22/03/2013) 12