CODE BROWN: EMERGENCY SURGICAL AIRWAY REVISITED

Just do it iconI lost my cric virginity to a man on a beach in Australia. The story told here. After this, I’ve been looking into making crics simpler and safer. Talking to colleagues, reading articles, practicing on cadavers and animals – not sure if I would ever need to do a cric in anger again. The method I’ve found is simple and easy. And the other day I got to put it to the test.

Déjà-vu all over again
I was called by my junior registrar to an in-hospital cardiac arrest. My first cric was due to facial trauma and excessive bleeding in the mouth. This was similar. The patient had nearly bitten off his toungue during his arrest/fall to the floor and was lying in the dark on the floor in a corridor on a ward not used to cardiac arrests or emergencies. The HLR team was doing their thing.

The patient had profuse bleeding from the mouth and my junior anaesthetic registrar hadn’t been able to see anything when trying to intubate, despite an indwelling suction catheter. There were copious amounts of blood on the floor around the patient’s head. Mask ventilation hadn’t been very successful due to all the blood. My junior registrar had called me before he started his intubation attempt, so only minutes had passed since the arrest.

Seeing this scene on my arrival, I quickly decided another intubation attempt or airway manipulation would probably be unsuccessful and lose valuable time until oxygenation. Trying to bag a man with his mouth full of blood wouldn’t accomplish much, except pushing more blood into his airways. My junior registrar had also foreseen this, and asked for a scalpel. No other tools were immediately available in this ward far away from ED, OR or ICU.

Cric time
So I decided to go straight for a surgical airway. The procedure was quick and successful. It was over in 20 seconds. Palpate the cricothyroid membrane (CTM), horizontal knife incision, put finger in incision to verify position, the finger feeling the CTM, and that the scalpel had perforated the CTM. I put the scalpel back in to widen the cut in the CTM, then put my little finger back in to penetrate the CTM and feel the smooth inside of the larynx and trachea. Then withdrawing the little finger slightly to allow for the tube to pass while still maintaining my finger in contact with the CTM allows for feeling the ETT passing through the right stoma, into the right place.

A bougie is optimal for this, as its small diameter allows for the little finger to stay through the CTM, and inside the larynx/trachea, to confirm correct passing and placement. Passing the tube directly is the next best thing, and needs to be practiced. You might not have a bougie available for your emergency cric. I asked for one here, and got blank stares. Don’t let one missing piece of equipment stop a life-saving procedure like this! Practice for a minimal equipment scenario.

Successful procedure, bad outcome
As the tube cuff passed through the CTM, I stopped, inflated the tube and bagged with capnography. Success. EtCO2 fell from 6 to 2,5. On subsquent ABG, PaO2 had risen from very low to supranormal values. It’s not all well, though. We never managed to get ROSC and save the patient. So, a successful procedure, but in the end, a bad outcome.

Every code that doesn’t have ROSC is a downer, although I always take satisfaction in a code well run, no matter the outcome. The same in this case. The code was well run, and securing the difficult airway had been quick and successful. That’s something to take along for the next arrest.

surgical airway2
My anaesthetic nurse with the tube.
Blood from patient’s mouth bleed, not from my incision.

Training and Brain simulation
Practice makes perfect. The problem before my first surgical airway was that I wasn’t sure what exactly I was practicing for, nor in detail what I needed to practice. The first surgical airway encounter exposed that brutally. In a good way. Now I knew. Therefore I feel a need to pass it on. So here are my thoughts for what they’re worth:

For training, I train on cadavers and animals every chance I get. For simulation, your brain is the best simulator. But as any computer, the output depends on your input. If you don’t give it the necessary details and possible problems, the brain can’t simulate it for you. You’ll run an imperfect simulation.

You fight how you train, so train how you’ll want to fight. As Dave Grossman says:

“You don’t rise to the occasion, you fall to the level of your training”

Brain cric simulation v1.0
Just as combat, it can be hard to know exactly what the real deal is going to be like. What I didn’t anticipate in my brain cric simulation v1.0: Some things I hadn’t been taught or prepared for:

  • Complete loss of visual guidance due to bleeding.
  • Loss of tactility through instruments.

In my opinion, these are the inadequacies of the standard methods from ATLS and the 4-step approach.

There were also some steps I hadn’t incorporated into my brain simulation, even though I knew they were part of the cric: Even though I always used a capnograph for all other intubations, a capnograph wasn’t part of my cric simulation. It only focused on the actual cric. I also didn’t focus on passing the tube only just passed the cuff, even though I knew this was important. My simulation only focused on the actual cric. I knew that I knew all that other stuff, so I thought I just needed to simulate the actual cric. But you need to simulate the entire procedure. Because in a high stress situation, you will only do what you trained to do, and leave out the rest.

Brain cric simulation v2.0
It took my first cric to realise my mistake. I fell to the level of my training. And it hadn’t been adequate. Although I saved that patient, there was definitely room for improvement. So all of the above points, and more, were incorporated into my brain cric simulation v2.0. I went through it again and again, and adapted it to small problems encountered in cadaver training. Then, for this next patient I knew exactly what to do. From beginning to end. Once again, I fell to the level of my training. And this time the training had been good, so I felt good, and it went smoothly.

So train and simulate. And think hard about what you’re actually training and simulating for. It will pay off when the day arrives. And for crics, just remember: There will be blood – and your finger can see.

—————————————————————-

On the finger cric:
“Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel–finger–tube’ method” – Bruce R Paix and William M Griggs, EMA, 2011.

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7 Responses to CODE BROWN: EMERGENCY SURGICAL AIRWAY REVISITED

  1. James DuCanto, M.D. says:

    Good post.

    2 ways to look at this
    —how to improve this procedure with the equipment you already have available to you (scalpel, bougie, Available commercially prepared kits)

    —Technological advances that make good sense (get an optical stylet to use in lieu of a bougie). The 5 mm adult optical stylets fit the 5 mm cric catheters from Cook Medical.

    I have a bias in that I am one of the co-authors on the optical stylet cric paper.
    [Resuscitation 80 (2009) 1066–1069]—Development of a rapid, safe, fiber-optic guided, single-incision cricothyrotomy using a large ovine model: A pilot study.

    This technique has been re-worked by a colleague to produce a new tool for the US Military for in-field crics. His technique uses the tactile feedback from an anterior facing stylet to click between the rings.
    http://storify.com/TBayEDguy/scalpel-bougie-open-cric-trach-tech

    Anyway, I commend you on your discussion of this important topic.

    • Thomas D says:

      Thanks for your comments, Jim! Very much appreciated!

      An optical stylet sounds great for a procedure like this, and the kit in your link looks both sleek and very useful! I’ve also read your article, and the procedure is convincing – as long as you’ve got the right equipment. My take is still that an emergency surgical airway should be as basic, simple and reliable as possible. So I believe the scalpel-finger-tube method is by far the best one out there to have in your arsenal for an unexpected CICO.

      One of the great things about a basic procedure like the scalpel-finger-tube method is that it can also easily be modified on the fly with useful available gear, from adding a tracheal hook, bougie – or a kind of optical stylet.

      What I’ve learned from my n=2 emergency surgical airways is that I don’t always have all the equipment I’d want, and I don’t want to be in a situation where I feel unable/unsure to do a cric due to a missing piece of specialty tool or kit.

  2. Nice one. They DO get easier don;t they? And mental rehearsal plus the shared knowledge of the FOAMed community helps consolidate

    My first – a bloody mess, using seldinger technique – was over 10 yrs ago. Whilst patient survived, it cemented my desire to do better. Now at v5.0 and STILL learning.

    Key thinks to consider

    (i) vertical vs horizontal incision. I’ve moved to vertical, reason is ID CTM can be difficult (seen a paper where FANZCAs were inaccurate when asked to ID on volunteers using indelible marker)…unless pre-marked with easy anatomy or USS.

    Vertical cut means just that little bit easier to identify in case go too high/low – and in the ‘no identifiable anatomy’ can easily convert to a finger-scrabble-cut approach.

    (ii) bougie and kit on ward

    There was no bougie available. Whilst not unreasonable to practice for this scenario, it would be more reasonable to ensure that a MINIMUM of airway kit is available wherever airways are going to be managed – which means a certain minimum kit inc NPO/OPA/MAc blades #3,4 stylet, Frova bougie, cLMA, sLMA, iLMA and CICO options.

    We’ll all be waiting for the cric-key…and DuCantos option of stylet thro’ CTM or even thro LMA is commendable, but latter has a steep learning curve.

    Having a few Frova’s on each resus trolley isn;t expensive – nor is a brace of the PocketBougies. I have some stashed with my CICO kits (needle and knife)

    Standardise gear across the hospital : OT-recovery-ED-ICU-ward.

    Sure, keep the fancy fibreoptics for OT-ICU and perhaps ED. But no excuse for not having a bougie IMHO

    …oh, and sim, sim, sim. I know you do this already.

    Anyhow, well done and thanks for sharing. Minh will be along in a minute…

    …just don’t mention checklists!

  3. Thomas D says:

    Thanks for commenting, Tim! They do seem to get easier, mostly for being prepared! And thanks for your thoughts on crics and emergency airways. We also wrote on the difficulty on finding the cricoid here: http://www.scancrit.com/2012/05/23/find-the-cricoid/

    i) horizontal vs vertical. An eternal debate. I just had the same discussion with Taylor Zhou on Twitter. I see pros and cons for both, and in the end I’m not sure if it affects outcome. I think it’s more important to make a decision beforehand, which cut to use when you train and sim, so you know what to do in anger. Also, know the cons of the cut you choose, so you know how to rectify if something goes wrong. I’m thinking horizontal – keeps things nice and simple when everything’s horizontal. Skin is quite loose on the front of the neck, so you have some leeway. If that doesn’t work, I’d make a vertical cross into my horizontal cut to open it up. Bleeding would be the least of my concerns until tube is in place. Just my thoughts. Might or might not change when I’m at n=5.

    ii) Available equipment. I wholeheartedly agree with you here. Bougies, as well as other emergency airway stuff should be available, and it is, in all places we normally handle airways. The problem is places where airway management isn’t supposed to happen. It could be on the dermatology ward or down in the hall of the hospital. Even if they have the equipment, they might not find it for that cardiac arrest that happens every 10 years. So all the gadgets you listed would be relevant, but it’s just not realistic to always have them immediately available, unless you *always* carry them with you yourself.

    So, to be pragmatic, you can easily find yourself in a place where airway equipment isn’t readily available, but need to do a surgical airway. That’s why I love the minimalistic, but effective approach of the scalpel-finger-tube. I believe it is extremely important to have thought of ‘no-equipment’ scenarios like that, and prepare for them.

    • Thomas D says:

      Thanks, Cliff! And much thanks to you and Sydney HEMS, it’s your way of training, thinking and working that has been a strong influence for going forward with training for rare and urgent situations like this.

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