So I lost my virginity. I did my first prehospital emergency surgical airway. And just like losing my virginity, it wasn’t as big a deal as it’s made up to be, and it was over very quickly. And everybody asks me how it was. Here are a few points and an article.
When the patient paid a visit to the emergency room he was GCS 5. He was breathing inadequately and had a bad facial trauma with multiple facial and jaw fractures and multiple teeth missing. His airway kept filling up with blood quickly oozing from all sides after the facial trauma.
Luckily the patient was still saturating quite well with supportive ventilation. During larygoscopy, I could only visualize the epiglottis, no laryngeal structures. My blind bougie attempt failed.
The patient was not fit for transfer. He needed a secure airway. I decided to proceed to an emergency surgical airway.
The cric was done with a horizontal incision, I got a lot of blood, I saw bubbles, then placed a tracheal dilator in the opening, and put in the tube. It was not the right opening. It was too superficial. I created a via falsa. Realizing this, I pulled the tube out, put my finger in the incision and had an epiphany!
I could see with my finger!
It was so easy to move the finger around on top of the airway, feeling all laryngeal and tracheal structures. The blood and small, deep incision didn’t matter, my finger could see through all that. And between the larynx and criciod cartilage, very easily identifiable, it saw the cricothyroid membrane.
I popped the membrane with my scalpel, put a bougie in and railroaded the tube easily. The failure was quickly converted to a save.
Sometimes, with all our tools and technology, I think we forget to be tactile. I’ve also been trained with instruments to do the surgical airway, and not really incorporating tactility after having felt for the cricothyroid membrane through the skin. So I hadn’t incorporated it into my visualization of a surgical airway.
It was only after the initial failure that my improvisation led me to do something different from the first attempt, and use my finger.
My personal learning points from n=1:
1. There will be blood.
2. If you’re in doubt, you’re not in the right place.
3. Your fingers can see – use them!
This happened in november. In december, an article was published by two experienced anaesthetists/retrieval doctors with 24 emergency surgical airways between them(!) in the Journal of Emergency Medicine Australasia covering just these points:
As the title suggests, they’re advocating a simple scalpel-finger-tube method, actually putting the little finger into the incision and through the cricoid membrane and feel the inside of the trachea, as you would with the pleura in a thoracostomy. Then place the tube.
The paper is well worth a read for anyone doing airway management and having to be prepared for an emergency surgical airway.