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#8 Essential Emergency Airway Care - Surgical Airways

#8 Essential Emergency Airway Care - Surgical Airways. Andrew Brainard, MD, MPH, FACEM, FACEM http://www.thesharpend.org/ abrainard01@gmail.com. #8 Crash Cricothyrotomy. Learning Objectives Review Prep team/plan/room/equipment Discuss Difficult Airway Algorithm Describe a “Crash Airway”

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#8 Essential Emergency Airway Care - Surgical Airways

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  1. #8Essential Emergency Airway Care-Surgical Airways Andrew Brainard, MD, MPH, FACEM, FACEM http://www.thesharpend.org/ abrainard01@gmail.com

  2. #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 • R40: 40 y/o M swollen tongue, difficulty breathing • Hx angioedema • Obtunded, GCS 6, SaO2 80% • On Arrival • Sitting Up, Nasal O2, rebreather 02 >15lpm • SaO2 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

  3. Locate Cric Kit

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

  5. Identification of Anatomical Landmarks A B D C E • A- Thumb and index finger, palpate the hyoid • B- Palpate the lateral sides of the thyroid laminaand the midline thyroid prominence • C- Find the inferior cornuof the thyroid • D- The cricothyroid membraneis 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 larynxwith your non-dominant hand • G- Rest your dominate hand on the patient’s sternum • H- Cut G F H

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

  7. Preparation • The “double prep” • Don’t wait until too late • Assess, clean, and mark neck early

  8. Equipment • Simple Cric Kit • Scalpel • (Bougieon Airway Cart) • 6-0 endotracheal tube(cuffed) • Dressing Pack • Skin Marker • Antiseptic • KY • 10ml syringe • Blue pad • Cook surgical-and percutaneous airway kit

  9. CricTechnique • 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=wVQFJR7qmrQ (7min)

  10. Airway briefing and checklist • 60y/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 200mg 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 will place an I-LMA, if that doesn’t work, we will perform a scalpel-bougie-tube cricothyrotomy • Understand your roles • Questions?

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

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