How to: Emergency Surgical Cricothyrotomy

hey guys my name's sam and welcome to print medic in this week's video we are discussing how to perform an emergency cricotherotomy [Music] a surgical cricothyrotomy is an invasive procedure that involves cutting the neck at a specific point and inserting a breathing tube in an effort to provide a definitive airway and bypass some of the structures of the upper airway in this week's video i want to discuss some of the indications contraindications anatomy and physiology and then finally we're going to be discussing how to actually perform this procedure which i will demonstrate on a model so without further ado let's get into the video the first thing we have to discuss today is the anatomy and physiology of the neck you have to be able to palpate the landmarks and identify the correct place to cut the neck or you could cause the patient some very serious ancillary problems besides their airway obstruction the first two items we're going to discuss in this week's video are the indications and contraindications in a crycothyrotomy otherwise known as when we're going to perform this and when we cannot perform this procedure so the indications in civilian ems are when you are unable to intubate or ventilate the patient intubation is the act of putting a laryngoscope into somebody's mouth and directly visualizing the vocal cords and dropping an endotracheal tube into that person to secure that airway we want to secure airways because that will inflate a balloon it will not allow any gastric contents to come out of the stomach into the airway it will also help us ventilate the patient so provide very good breaths as opposed to taking a bag valve mask and bagging them in which case some of their goes to the stomach contributes to gastric distension and in so doing increases the risk of regurgitation aspiration as well as constricting the space in the thoracic cavity when we provide those ventilations unable to ventilate is the second part of that indication which means that even though bag valve mask respirations are not ideal if we are able to give them bag valve mask respirations we will not be moving to a surgical crycotherotomy the two main contraindications for this procedure are one unable to palpate or visualize the correct landmarks in the neck so if you cannot correctly identify the cricothyroid membrane you risk cutting other large vascular structures and causing a lot of damage to the patient number two is going to be if it's a pediatric patient generally in the pediatric population the cricothyroid membrane is very small and it's very hard to insert an appropriately sized tube therefore at least in the pre-hospital environment if you're not an anesthesiologist we opt to go to a needle crycotherotomy which is less ideal generally but it will keep the child alive long enough to get to the hospital where a more definitive airway can be placed so now that we have discussed the indications and contraindications of the surgical cricothyrotomy we're going to go through some of the anatomy of the neck so you can appropriately identify the landmarks required for this procedure so right here i've got a small 3d printed model that has the major landmarks you need to know the first thing we're going to find is going to be the laryngeal prominence that's also known as the adam's apple to do this procedure is actually a lot easier to identify these landmarks on a male rather than a female because generally males have more prominent atoms apples as you come down here or right above that prominence you will find the thyroid cartilage that's either side of the adam's apple and that's going to be something you actually hold down to secure the landmarks in place if you come right over your adam's apple you're going to roll down into what's called the cricothyroid membrane so right here this is exactly where we're going to cut to insert the tube and it's a space with a membrane instead of hard cartilage like you have above and below and it does allow you to actually insert that tube with minimal effort below that you have the cricoid cartilage and then you have your tracheal rings these rings are going to be hard cartilage and then there is some tissue in between them but it is very hard to insert the tube and can cause more trauma than necessary if that's where you end up accidentally cutting now that we've discussed the indications and contraindications of a surgical cricothyrotomy we're going to go down to the table and i'm going to demonstrate two different techniques for doing this now there are an infinite number of techniques you could learn and all providers are going to have a slightly different nuanced approach to it there are a lot of different products out there to perform this procedure the two i'm going through are the two that i'm most confident with and the two that i was taught so to perform this procedure we need four main things the first thing we need is the tube now this guy here is a specialized crike tube this is made by north american rescue and i like using things that are actually made for this procedure because this prevents putting it in too deep it prevents cutting the tube down and causing any issues it's just a lot simpler now the second thing you're going to need is going to be some kind of introducer now i like to use bougies that's what this is now this one is a specialized one that actually comes with this tube pre-loaded on it from north american rescue this just allows you to get this in place and secure the tube and not lose your spot there is another device out there called the crite key which is actually what is recommended by the committee for tactical combat casualty care i will tell you that device is very expensive coming in about two hundred dollars you can get this combo here for about 27 i think without a pro deal and then you can get it actually for 11 if you're a professional and have a professional account with north american rescue so this is what i keep stocked in my kit and it's actually very similar to the crate key in that regard you'll need a scalpel there is some debate on what size scalpel you should use i use a number 10 scalpel for this it's what i've been trained on and what i routinely use and then lastly you need a 10 ml syringe to perform it like i said there are a lot of different devices for doing this procedure you can have a tracheal hook which can be used to make this a little easier i found that this kind of complicates the procedure and i don't generally use it although we can talk about its use a little bit later on in this video one thing to mention here that i kind of glossed over is when you're looking at the bougie to use you can use a normal adult et2 bougie i like the shorter ones for this because once again it's just a little less cumbersome so in true prepmatic fashion i have kind of jury rigged this trainer with a leather part of a leather glove to simulate the skin and then underneath that tape to simulate the actual membrane now the first technique we're going to do here is going to be kind of the traditional technique what i was taught originally in school and then the second one is a little bit more controversial and a little bit more new but it's what i have been trained to do on the helicopter so for this guy here it's the same tools we were talking about earlier i have the bougie pre-loaded in this i think that makes it a lot easier i don't have to feed the tube have a partner to do it so we're just going to have this off to the side ready to go we've got the syringe and then we've already tested the lumen on this to make sure it will actually hold when we put it in place textbooks will tell you that you're going to want to sterilize the site here in my experience if you're performing this procedure an infection after the fact is kind of the least of your worries you're just trying to get that airway so it is the right thing to do to sterilize that site however in hyper-emergent situations where you're just trying to get an airway that might not occur when we position ourselves next to the patient we make sure we are on whatever side is dominant we need to be on that side of the patient so if i'm right-handed i need to make sure i'm able to hold the scalpel in the right hand and i'm going to position myself on the right side of the patient if i'm left-handed same thing we're going to go to the left side of the patient so with my non-dominant hand i'm going to take my middle finger and my thumb and i'm going to find the actual thyroid cartilage so that's the cartilage to either side of the adam's apple we're going to press down and now this is to keep the skin and the trachea from moving irrespective of each other it's dangerous when you create a cut through the skin sometimes the tracheal will move and you'll actually lose the hole you put in the cricothyroid membrane and it gets very hard to see when it starts to become bloody so this is the first thing i'm going to do i'm going to come up here i can palpate my landmarks make sure i have my prominence here the adam's apple and then i come down and i can feel the actual cricothyroid membrane here and that's where i'm going to cut so this pointer finger here can kind of save my spot so these two fingers are making sure nothing moves it's just providing that pressure this finger is confirming where i'm at i've got my scalpel here now like i said this is the traditional technique so you can take the scalpel and the first thing we're going to do is we're going to start just above that membrane and we're going to come down and we're going to do a vertical incision through the skin but not all the way to the membrane we're not going through the membrane yet so this is not painting i'm not going to want to do a bunch of strokes we're going to come here through the skin and this is the first time i've tried it with this trainer and we're going to cut down i'm going to take my finger and i'm going to blunt dissect with that finger making sure that i can actually feel the membrane underneath it so if you actually see that there you can see the quote membrane aka the duct tape i have in place so we've blunt dissected down with that finger and that finger is going to hold that steady from this point on this procedure is actually a tactile procedure you do not need lights or even visual cues to tell you where it is that's really important because periodically these will become extremely bloody and you're going to have to kind of insert blind so through here i have that space i'm going to take this scalpel back up and now i'm going to make a puncture down into that membrane and i'm going to take it to the edge of the membrane now you will be stopped by the cartilaginous edge of the cricothyroid space i'm going to turn the scalpel and i'm going to cut the opposite direction we're going to remove this scalpel never put your finger in that hole with the scalpel still in place i'm going to take my finger and i'm going to put it in there i should be able to palpate the tracheal rings as a confirmation tool i can then take my tube with the bougie pre-loaded and i'm going to just take the bougie and i'm going to slide that in next to my finger as we go in that kude tip that little angled tip of the bougie should start bumping off the tracheal rings that's another confirmation technique as we put this in eventually the bougie if it's in the right place is going to hit what's called the carina which is the bifurcation where your bronchioles come off on to either lung that should hit that and it should stop i'm then going to take the tube and i'm going to feed that over it when you get to this opening itself you're going to have to twist it a little bit because it might get hung up and we only want to insert the tube just until the balloon is no longer visible once we're in this position we're going to hang on to that tube we do not want to let that tube go at all because we don't want to lose the airway and we're going to remove the bougie we're going to take our syringe we're going to inflate the cuff with 10 ml or whatever is recommended with the device you're using generally 10 is going to be just a little bit much and we're going to take a bag valve mask and we're going to bag over top of this you can take these wings if it's inserted far enough and you can actually tie this down on either side of the patient just make sure you're not providing too much circumferential pressure around the neck a couple important points with this procedure it is really important that when we make that first incision and then we make the second one that we are limiting the time that there is nothing in this orifice we have created because if we release that if we don't have a finger in there we could actually lose the through and through hole we have the skin could move and the trach could move in an opposite direction and in a stressful environment which this i guarantee you is a stressful environment you will be unable to find it again so it's really important to really maintain this pressure here and try to have kind of a place saver in place now that could be your bougie that could be your finger or that could actually be a tray cook now tray cooks can be inserted with your fingers still in i don't really care for that what they'll teach you is they teach you to take the hook point it away from your finger place it in take your finger out and you actually grab the top and you can provide a pressure up here that's actually going to kind of extend this and you're going to see the trachea come up in a real patient make it easy to insert like i said i do not use trach hooks i really haven't been extensively trained in them i think it's something that's a little bit cumbersome and i have better luck just using my finger as a placeholder and inserting the bougie on the other side all right so the second technique is a simpler version of the first one and this is actually how i was trained to perform this procedure on the helicopter it is slightly more controversial though so for this technique it starts the same we want to position ourselves on whatever side of the patient we are dominant so if i'm right hand dominant i'm going to be on the right side of the patient we're going to find the thyroid cartilage here and i'm going to palpate the prominence or the adam's apple with my pointer finger slide down and find my landmark for the cricothyrotomy the cricothyroid membrane right here i'm then going to take my scalpel and instead of making a first incision through the skin and a second incision through the membrane this one is one incision through the membrane and the skin at the same time the theory behind this is is that this will allow me to mitigate any issues that might arise once i cut through the skin if there's a lot of bleeding i don't have to rely on touch to find that landmark i have the landmark i can see the landmark hopefully and now we're going to use this so to do this one here we found the landmark sterilized the site as appropriate and i'm going to take the scalpel and we're going to make a cut down into the membrane i'm going to take it all the way to one side of the membrane and the skin it will stop once again i'm going to twist the scalpel 180 and i'm going to move to the other side we're then going to take the scalpel out and you can either blunt dissect with your finger or take the opposite end of the scalpel and make the hole slightly bigger insert your finger to the side once again we're palpating those tracheal rings i'm then going to take my tube with the bougie introducer i'm going to slide that in beside my finger hopefully feel those tracheal rings with the kuda tip and we're going to once again insert until we can't go any farther because it hit the crina and then insert the tube after it so we have the tube in place and granted i've blocked the end of this with duct tape um so it can't insert all the way but we want to make sure the balloon is all the way into the trachea but only so we can then take the bougie take that out make sure this is sitting right where it needs to be and then inflate the balloon with the recommended amount of air once we have that we can firm it the exact same way we would an endotracheal tube we want to put capnography on that we're going to take a bag valve mask start ventilating the patient and we're going to listen to lung sounds and we're going to listen for the absence of epigastral sounds one complication you may see with this that indicates a failed attempt at a cricothyrotomy is what's called a false lumen so if we didn't do a good job at place holding that orifice we created or if we missed and we didn't know it then there's a chance that this gets inserted between the skin and the trachea and as we start bagging them it will cause a lot of subcutaneous emphysema which is basically air bubbles under the skin it can also cause some very serious complications like pneumomediastinum and most of all you are not ventilating the lungs in this case so preventing that false lumen and confirming it's in the right place are of the utmost importance so if you are using an endotracheal tube and you do not have a crike specific tube to use there's a couple tips that i think will make this a little bit easier for you number one i like pre-loading the tube onto the bougie so here i've got the tube over the bougie and then i actually have the tip of the bougie going into the eyelet of langerhans at the bottom of the tube can be initially a little bit difficult to get in there what this allows you to do is it keeps the bougie and the tube in place it's not sliding around you can insert and when you have it inserted you can just take this with your thumb and you can get the bougie out and free one-handed if you don't have a partner to help you so just makes it a little bit easier when you're performing the procedure the other item is if you want to cut your tube down to not have all of this kind of hanging out in the middle of nowhere you know tempting somebody to pull it out of your patient you just saved you can cut these down however you have to be very specific where you cut it you have this tube that comes out that that is the inflation lumen for this guy down here that actually protects the airway and allows you to provide positive pressure so when we're doing this we want to make sure we cut right above it so what i can do is i can take my trauma shears i can cut right above that tube and then i take the top of this remove it and we can insert it right here once again this can be relatively difficult to do so make sure you are prepped for it and you can put that right in there and now we have a little bit of a shorter tube and this lumen will still work when we inflate it with our 10cc syringe i hope you guys found this video helpful or at the very least informative if you have any questions or comments please leave them in the comments down below and i will see you next week you

Channel: PrepMedic

Views: 45,031

Rating: 4.9698491 out of 5

Keywords: Surgical airway, surgical cricothyrotomy, surgical cric, cric, emergency airway, airway, ems education, EMT, Paramedic, Medic, Life saver, Critical care, Learn medicine, tracheostomy, trach, Emergency skill, ambulance, HEMS

Id: COz0bbpqqvg

Length: 19min 16sec (1156 seconds)

Published: Sun Apr 04 2021