How to: Emergency Surgical Cricothyrotomy

Hi guys, my name is Sam and welcome to Print Medic. In this week's video, we are discussing how to perform an

emergency

cricoterotomy. 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 upper airway structures. In this week's video I want to discuss some of the indications, contraindications, anatomy and physiology and finally we will discuss 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 must be able to palpate landmarks and identify the correct place to cut the neck or you could cause the patient some very serious ancillary problems in addition to airway obstruction.

The first two items we will discuss in this week's video are the indications and contraindications in a

cricothyrotomy

, also known as when we are going to do this and when we can't do this procedure. The indications in civil ems are when the patient cannot be intubated or ventilated. Intubation is the act of putting a laryngoscope in someone's mouth and directly visualizing the vocal cords and placing an endotracheal tube in that person to secure the airway that we want to secure. Because that will inflate a balloon, it will not allow any gastric contents to exit the stomach into the airways.

It will also help us ventilate the patient, so you have to provide very good breaths instead of taking a bag valve mask and putting it in a bag, in which case some of its goes to the stomach contributes to gastric distention and by doing so increases the risk of regurgitation aspiration in addition to restricting the space in the thoracic cavity when we provide those ventilations not being able to ventilate is the second part of that indication which means that although valve and bag mask respirations are not ideal. If we can give them bag-valve mask breaths, we won't move on to a

surgical

cricoterotomy.

The two main contraindications for this procedure are the inability to palpate or visualize the correct landmarks in the neck. If you cannot correctly identify the cricothyroid membrane, you risk cutting other large vascular structures and causing a lot of damage to patient number two, if it is a pediatric patient, generally in the pediatric population the cricothyroid membrane is very small and it is very difficult to insert. an appropriately sized tube, so at least in the prehospital setting, if you're not an anesthesiologist, we opt for a needle cricoterotomy, which is generally less ideal, but will keep the child alive long enough to get to the hospital, where the definitive airway can be placed, so now that we have discussed the indications and contraindications for surgical cricothyrotomy, we will go over some of the anatomy of the neck so that you can properly identify the landmarks necessary for this procedure, so right here I have I have a small 3D printed model that has the main reference points you need to know.

The first thing we are going to find will be the laryngeal prominence, which is also known as the Adam's apple. To perform this procedure, it is actually much easier to identify them. reference points on a man rather than a woman because generally men have apples with more prominent atoms. As you go down here or just above that prominence, you're going to find the thyroid cartilage that's on either side of your Adam's apple and that's going to be something that you're going to really hold down. secure the landmarks in place, if you go just above the Adam's apple, you will roll into what is called the cricothyroid membrane, so this is exactly where we are going to cut to insert the tube and it is a space with a membrane. instead of hard cartilage like you have on top and bottom, which allows you to insert that tube with minimal effort, underneath you have the cricoid cartilage and then you have the tracheal rings, these rings will be hard cartilage and then there is some hard cartilage. tissue between them, but it is very difficult to insert the tube and can cause more trauma than necessary if that is where you end up accidentally cutting yourself.

Now that we've discussed the indications and contraindications for a surgical cricothyrotomy, we're going to move on to the table and I'm going to demonstrate two different techniques for doing this. Now there are an infinite number of techniques you can learn and all providers will have a slightly different nuanced approach. There are many different products available to perform this procedure the two I am going through are the two I am most confident with and the two I was taught so to perform this procedure we need four main things the first thing we need is the tube , now this guy is here. a specialized crike tube made by North American Rescue and I like to use things that are actually made for this procedure because this avoids putting it in too deep avoids cutting the tube and causing problems.

Now it's much simpler, the second thing you're going to need some type of introducer now I like to use spark plugs that's what it is now this is a specialized one that actually comes with this North American Rescue prefilled tube this just allows you to put this in place and secure the tube and not lose its place, there is another device called a crite key which is actually what the committee recommends for tactical care of combat casualties. I will tell you that this device is very expensive. two hundred dollars, you can get this combo here for about 27, I think, without a pro offer, and then you can get it for 11, if you're a pro and you have a pro account with North American Rescue, so this is what I have in stock. my kit and it's actually very similar to the box key in that sense you'll need a scalpel.

There is some debate about what size scalpel you should use. I use a number 10 scalpel for this, it's what I've been trained in and what I routinely use and lastly you need a 10ml syringe to perform it, as I said there are many different devices to perform this procedure. You can have a trach hook that can be used to make it a little easier. I found that this type of complicates the procedure and I generally don't use it, although we can talk about its use a little later in this video. One thing I should mention here that I overlooked is that when you look at the spark plug you are going to use, you can use a regular adult et2 spark plug.

I like the shorter ones for this because, again, it's a little less cumbersome, so in true prep fashion, I've fitted this trainer with a leather part of a leather glove to simulate skin and then underneath. that tape to simulate the real membrane. Now the first technique that we're going to do here is going to be kind of a traditional technique that I was originally taught in school and then the second one is a little bit more controversial and a little bit more. new, but it's what I've been trained for in the helicopter, so for this guy here it's the same tools we were talking about before.

I have the spark plug pre-charged on this, I think that makes it a lot easier, I don't have to do it. feed the tube have a partner to do it so we're going to have this on the side ready to go we have the syringe and then we've already lumen tested this to make sure it really holds up when we deploy it the textbooks will tell you they will say that in my experience you will want to sterilize the site here if you are doing this procedure, an infection after the fact is the least of your worries, you are just trying to get that airway so the right thing to do is to sterilize that site; however, in hyper-

emergency

situations where you're just trying to get an airway, that might not happen when we position ourselves next to the patient, we make sure we're anywhere.

Which 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 can hold the scalpel in my right hand and I'll stand on the right side. of the patient if I'm left handed the 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 on each side of the Adam's apple that we are going to press down and now this is to prevent the skin and the trachea from moving independently of each other.

It is dangerous when it creates a cut through the skin. Sometimes the trachea moves and you actually lose the hole that you put in the cricothyroid membrane and it becomes very difficult to see when it starts to bleed, so this is the first thing I will do. I will come. Up here I can palpate my landmarks, make sure I have my prominence here, Adam's apple and then I go down and I can feel the actual cricothyroid membrane here and that's where I'm going to cut so this index finger can save my point, so These two fingers make sure nothing moves, they just provide that pressure, this finger confirms where I am.

I have my scalpel here now, like I said, this is the traditional technique, so you can take the scalpel and the first thing. What we're going to do is start right above that membrane and we'll go down and make a vertical incision through the skin, but not all the way to the membrane. going through the membrane yet, so this is not paint, I'm not going to want to make a bunch of strokes, we're going to go through the skin here and this is the first time I've tried it with this trainer and I'm going to cut, I'm going to take my finger and I'm going to do a blunt dissection with that finger making sure that I can really feel the membrane underneath it, so if you really see that there, you'll be able to see the membrane quote, also known as the I have duct tape in place , so we have dissected with that finger and that finger will stand firm from this moment on.

This procedure is actually a touch procedure. You don't need lights or visual cues to tell you where you are. This is really important because periodically these will get extremely gory and you'll have to insert them blindly, so I have that space over here. I'm going to pick up this scalpel again and now I'm going to make a puncture. towards that membrane and I will take it to the edge of the membrane. You will now be stopped by the cartilaginous edge of the cricothyroid space. I'm going to turn the scalpel and I'm going to cut in the opposite direction.

I'm 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 there. You should be able to palpate the tracheal rings for confirmation. tool, then I can take my tube with the pre-charged spark plug and I'll just take the spark plug and slide it next to my finger as we go on that Kude tip, that little angled tip of the spark plug. You should start hitting the tracheal rings, that's another confirmation technique as we put this in. Eventually, the plug, if it's in the right place, will hit what's called the carina, which is the bifurcation where the bronchioles exit into whichever of the lungs should hit that. and it should stop, so I'm going to take the tube and I'm going to run it over it.

When you get to this opening, you will have to turn it a little because it could hang up and we just want to insert the tube until the balloon is no longer visible. Once we're in this position, we're going to hold on to that tube. We don't want to let go of that tube at all because we don't want to lose. the airway and we're going to remove the spark plug we're going to take our syringe we're going to inflate the cuff with 10 ml or whatever is recommended with the device that you're using generally 10 is going to be just a little bit a little too much and we're going to take a mask with a bag valve and we are going to place it on top.

You can take these wings if inserted far enough and you can tie this to either side of the patient, just make sure you are not putting too much circumferential pressure around the neck. A couple of important points with this procedure is very important that when we make the first incision and then the second, we limit the time so that there is nothing in this hole. that we have created because if we let go, if we don't have a finger there, we could lose the through hole that we have, the skin could move and the tracheostomy could move in an opposite direction and in a stressful environment that this is We guarantee you that it is an environment stressful and you won't be able to find it again, so it's very important to keep this pressure here and try to have some kind of place protector now that could be your spark plug, that could be your finger or that could actually become a chef. tray now Tray cooks can be inserted with fingers still inside.

I don't really care about that. What they will teach you is that they will teach you how to remove the hook. Point it away from your finger. Place it. Take out your finger. and you actually grab the top and you can put pressure up here that's actually going to 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 don't use tracheostomy. hooks I haven't really been trained much on them, I think it's something that's a bit fiddly and I have better luck just using my finger as a placeholder and inserting the plug into the other side, so the second technique is a simpler version . of the firstand this is actually the way I was trained to perform this procedure in the helicopter is a little more controversial, so for this technique it starts the same way: we want to position ourselves on whichever side of the patient we are dominant on, so 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 index finger, I'm going to slide down and I'm going to find my reference point. for cricothyrotomy, the cricothyroid membrane.

Right here I'm going to take my scalpel and instead of making a first incision through the skin and a second incision through the membrane, this is an incision through the membrane and the skin at the same time, the theory behind This is that This will allow me to mitigate any problems that may arise once I cut the skin. If there is a lot of bleeding. I don't have to rely on touch to find that reference point. I have the reference point. I hope to see it and now we are. I'm going to use this, so to do this here we find the landmark, we sterilize the site accordingly and I'm going to take the scalpel and we're going to make a cut in the membrane.

I'm going to take it all. The path to one side of the membrane and skin will stop once again. I'm going to turn the scalpel 180 and move to the other side. Then we'll get the scalpel out and you can do it. dissect forcefully with your finger or take the opposite end of the scalpel and make the hole a little larger insert your finger to the side once again we're palpating those tracheal rings then I'm going to take my tube with the plug introducer. I'm going to slide it next to my finger, hopefully feel those tracheal rings with the Kuda tip and we'll insert it one more time until we can't go any further because it hit the mane and then we'll insert the tube after so we have the tube in its place and granted, I have blocked the end of this with tape, so it can't be inserted all the way, but we want to make sure that the balloon is completely inside the trachea, but only so we can then take the tube. take it out, make sure it's right where it needs to be and then inflate the balloon with the recommended amount of air, once we have it we can firm it up exactly the same way we would do with an endotracheal tube that we want to put capnography on.

We're going to take a bag valve mask, we're going to start ventilating the patient and we're going to listen for lung sounds and we're going to listen for the absence of epigastral sounds. One complication that you may see with this that indicates a failed attempt at cricothyrotomy is what is called a false lumen, so if we didn't do a good job maintaining that hole that we created or if we failed and didn't know it, then there is a possibility of this getting 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 such as pneumomediastinum and, above all, in this case the lungs are not ventilated, so that false light is avoided and Confirming that it is in the right place is of utmost importance, so if you are using a endotracheal tube and you don't have a Crike specific tube, there are a couple of tips that I think will make this a little easier for you. The number one that I like. Preloading the tube onto the spark plug, so here I have the tube over the spark plug and then I have the tip of the plug going into the Langerhans eyelet at the bottom of the tube, it can be a little difficult to get at first.

There, what this allows you to do is hold the spark plug and the tube in place, it doesn't slide, you can insert it and when you've inserted it, you can take this with your thumb and you can pull the spark plug out and release it. It can be delivered if you don't have a partner to help you, so it makes it a little easier when you do the procedure. The other element is whether you want to cut the tube so you don't have all these kinds of problems. In the middle of nowhere, you know, tempting someone to take it from your patient you just saved.

You can cut them, but you have to be very specific where you cut it. You have this tube that comes out and that is the inflation lumen for this type. down here that actually protects the airway and allows you to provide positive pressure so when we do this we want to make sure we cut right above them so what I can do is take my trauma scissors and I can cut right above that tube . and then I take the top part of this, remove it and we can insert it here once again. This can be relatively difficult to do, so make sure you're prepared for it and you can put it right there and now we have a little bit of a shorter tube and this lumen will still work when we inflate it with our 10 cc syringe.

I hope you found this video useful or at least informative. If you have any questions or comments, leave them in the comments below and I'll look into them. you next week you