EMS World Expo Quick Take: Challenges and best practices in prehospital cricothyrotomy

NEW ORLEANS — A large percentage of airway difficulties in oxygenation/ventilation are manageable by basic or advanced techniques. Although rare in a prehospital environment, in some cases, traditional practices may not be suitable to provide adequate respirations to sustain life. Needle or surgical cricothyrotomy may be a last resort to obtaining a patent airway when treating patients with a severe injury or illness to the head, neck or face.

Cynthia M. Griffin, DO, NRP, flight physician at the University of Wisconsin Med Flight in Madison, Wisconsin, and St. Agnes Emergency Department physician in Fond du Lac, Wisconsin, presented a session called “Charlie Fox Cric and Common Pitfalls in the Surgical Airway” during the 2019 EMS World Expo.

Memorable quotes on prehospital cricothyrotomy

Here are some of the most memorable quotes from Griffin on the lessons she learned when faced with a challenging surgical cricothyrotomy in a prehospital setting:

“Trust your training.”

“It’s important to remember to cut low.”

“No longer are we saying it’s a failed airway. Now, it is the inevitable surgical airway.”

“Simulation is the key.”

Prehospital cricothyrotomy case study

Griffin shared a case, noting, “I want you to be successful when you do this.” The following case study inspired her to help others learn more about the unexpected complications during a prehospital cricothyrotomy and how to modify practices in securing a difficult airway. Some information has been changed to protect the identity and privacy of the patient.

Griffin presented the following case study encountered while working as a flight physician:

• 50 YO
• Male
• GSW to the head
• No further information

When the flight team arrived on scene, the following verbal report was given:

• GSW to the neck/chin/face
• Self-inflicted
• 6-minute CPR
• 3 epi,
• ROSC
• IO on the R
• 18G IVL
• Cric by EMS

Initial and secondary vital signs were as follows:

• Baseline: BP 116/61, HR 74, RR 17, 82% w/BVM, ETCO2 varied
• 1141: BP 161/88, HR 70, RR 4, 80% w/BVM, ETCO2 varied
• 1151: BP 102/56, HR 53, RR 2, 63% w/BVM, ETCO2 0
• Prehospital surgical cricothyrotomy re-positioned from anterior to lateral position*
• 1200: BP 155/68, HR 72, RR 15, 91% w/BVM, ETCO2 46
• 1205: SPO2 94%

An initial assessment revealed the following:

• Bougie directed cephalad
• Could not exchange tube
• SATS have been all over the place
• 2 providers holding tube
• Mannitol
• IVFs
• Needs a trauma center

Griffin explained an additional assessment of the airway revealed dried blood on the face, bright red blood in the mouth/nares, and distorted anatomy. Griffin initial observations discovered a submandibular deformity, transected tongue, and a copious amount of blood in the airway.

Breathing was prolonged with slow/deep respirations decreasing in number with no chest rise during oxygenation. Capnography showed an occasional waveform. Griffin advised that sudden drops in capnography could mean a leak in the system, partial disconnect, partial airway obstruction, or that the endotracheal tube is placed in hypopharynx.

Circulation was palpated with bounding pulses and warm skin. IV/IO was established to provide fluids.

Disability assessment rated the patient as a GCS 2T, no purpose of movement, unresponsive, bilateral raccoon eyes, and bilateral pupils 6 mm non-reactive.

After some troubleshooting, Griffin noticed the complication was contributed by a false passage. The anatomy of the neck shifted laterally due to the gunshot blast separating the muscles holding the trachea in place. Injury to the neck was extensive, causing the initial placement of the tube above the triangular cartilage of the cricothyroid membrane serving more as a supraglottic airway.

Photo/Courtesy Cynthia M. Griffin, DO, NRP

Top takeaways on prehospital cricothyrotomy

Here are some top takeaways from the case.

1. Stay calm. You got this!

Lauria et al. (2017) found that mental preparation is essential to reducing stress in medical providers during resuscitation of the critically ill or injured patients [1]. Griffin credits box breathing as a technique she uses self-encouragement and preparation for critical calls such as the one described above. It goes something like this:

• Breathe in for 4 seconds
• Hold your breath for 4 seconds
• Breathe out for 4 seconds
• Hold your breath for 4 seconds
• Repeat

Griffin explained the two major problems affecting success in the front of neck access is operator stress and anatomical distortions. In general, Hubble et al. (2010) conducted a meta-analysis of prehospital airway control techniques for alternate airway devices to discover the surgical cricothyrotomy had a 90.5% success rate compared to the 65% success rate in needle cricothyrotomy amongst the emergency medical services. Therefore, the study supports the use of surgical cricothyrotomy over needle cricothyrotomy in the field.

2. Landmarks and anatomy

The definition of a cricothyrotomy is the surgical placement of a hole in the cricothyroid membrane to insert a cuffed tube in the trachea to provide ventilations. Key landmarks in the anatomy aid medical practitioners in the proper placement of the incision to insert the intubation tube. Locating the proper landmarks may be challenging if the anatomy is distorted due to injury or edema.

Bair and Chima (2015) studied three techniques and success rates when locating the cricothyroid membrane (CTM) by general palpation (62%), four-fingered (46%) and neck crease (50%) [2]. Recent research conducted by Altun et al. (2019) and Siddiqua et al. (2018) suggests advanced technology in the use of ultrasound increases the success rate of CTM localization in difficult airways [3-4]. Drew, Khan, and McCaul (2019) discovered the insertion of an i-gel supraglottic airway device assisted in the 66% accuracy of locating the CTM in female patients [5].

Caution should be used to avoid major complications to the arteries, veins and muscles within the neck region.

Photo/Courtesy Cynthia M. Griffin, DO, NRP

3. Can’t intubate, can’t ventilate complications

Can’t intubate and can’t ventilate is often challenging to address in a prehospital setting. Griffin described a possibility of several complications when performing a prehospital surgical cricothyrotomy:

• Misplaced incision. As explained above, locating the CTM is paramount to the success of a surgical cricothyrotomy.
• Iatrogenic injury to thyroid/cricoid cartilage. Emergency cricothyrotomy kits and the accurate size of the bougie/intubation tubes are important to mitigate any further damage preventing the successful ventilation.
• Aspiration of blood/emesis. Suction-assisted laryngoscopy and airway decontamination (SALAD) technique may be used to minimize the risks of airway aspiration in patients.

• Tube occlusion with blood. Blood clots may have formed in the pharynx from prior intubation attempts causing an occlusion. Suction or inserting a bougie may break up clots to clear the tube.
• False passage. Displacement of the bougie or intubations tube could enter into the subcutaneous area or the right atrium (as seen in a swine model case) if there is anatomic distortions to the neck or excessive force applied.
• Retrograde intubation. Proper insertion of the intubation tube with the bevel up diminishes the risk of retrograde intubation.
• Main-stem intubation. Retract the intubation tube until equal bilateral chest rise is visible and secure tube.
• Excessive edema. A tracheostomy tube may not be long enough to provide adequate ventilation when edema occurs. Rapid intubation with an endotracheal tube is ideal to ensure placement in the trachea.
• Hemorrhage. The cricothyroid artery traverses the upper 1/3rd in 93% of cadavers, so Griffin suggests to “cut low” to avoid severing the artery.
• Posterior tracheal laceration. Avoid the posterior tracheal by inserting the scalpel perpendicular to the plane of the CTM and insert it straight back so that it will hit the posterior portion of the cricoid cartilage, thus avoiding the more inferior soft tissue. A bougie or intubation tube which may also cause a laceration to the soft tissues surrounding the posterior portion of the cricoid cartilage if inserted incorrectly with too much force.
• Inadvertent extubation. Securing the intubation tube to the neck is essential to maintaining a patent airway. In some cases, sedation may be required to prevent the patient from dislodging it due to excessive movement.
• Air leak. Make sure cuff is filled appropriately. You might need to use two BVMs to keep air from leaking from the mouth.

Photo/Courtesy Cynthia M. Griffin, DO, NRP

4. Simulation is key to help learn how to avoid some complications and adjust to challenges

Griffin advised the more bloody and realistic the training, the better prepared you will be to succeed in the field. Here are some key points she suggests when training as a team for a prehospital surgical cricothyrotomy:

BLS:

• Give encouragement

• Study the anatomy and educate yourself

• Master BLS skills (e.g., BVM, securing, equipment, personal protective equipment (PPE), etc.)

• PPE, PPE, PPE

• Prepare equipment

  • Position patient in a prone for unresponsive and sitting lateral for awake

  • Prepare O2, SPO2, ETCO2

  • Ready the primary and secondary suction

  • Prepare gauze

  • Select appropriate size bougie (pediatrics or adult)

  • New pants for the ALS provider

ALS:

• Review anatomy, prepare for complications, and train more

• Review cases with your OMD

• Use lidocaine or ketamine

• Get excited about ultrasound

• High fidelity simulation: Distractions, wet gloves, bloody airways, multiple tools

  • Position patient in a prone for unresponsive and sitting lateral for awake

  • Prepare O2, SPO2, ETCO2

  • Ready the primary and secondary suction

  • Prepare gauze

  • Select appropriate size bougie (peds or adult)

  • New pants for the ALS provider

RN:

• PPE, PPE, PPE, PPE, PPE
• Call respiratory or other additional resources
• Prepare equipment
  • Position patient in a prone for unresponsive and sitting lateral for awake
• Prepare O2, SPO2, ETCO2, suction (large and small)
• Know what your trauma bay has to improvise with
• Prepare ultrasound and gel linear probe
• Support measures include
  • IV access
  • Blood
  • TXA
  • Ketamine
  • Push dose pressers
  • PISA
• Document, keep track of time and attempts

Learn more about EMS airway management

Learn more about prehospital surgical airway placement with these resources from EMS1:

• Managing the difficult airway in EMS
• 4 tips for airway management mastery
• Airway management advances in the prehospital setting
• Research Analysis: Airway management better with the bougie
• Hocus POCUS: the magic and progress of prehospital ultrasound use by EMS

References

1. Lauria, M. J., Gallo, I. A., Rush, S., Brooks, J., Spiegel, R., & Weingart, S. D. (2017). Psychological skills to improve emergency care providers’ performance under stress. Annals of Emergency Medicine, 70(6), 884-890. doi:10.1016/j.annemergmed.2017.03.018
2. Bair, A. E., & Chima, R. (2015). The inaccuracy of using landmark techniques for cricothyroid membrane identification: A comparison of three techniques. Academic Emergency Medicine, 22(8), 908-914. doi: 10.1111/acem.12732
3. Altun, D., Ali, A., Koltka, K., Buget, M., Çelik, M., Doruk, C., & Çamcı, A. E. (2019). Role of ultrasonography in determining the cricothyroid membrane localization in the predicted difficult airway. Ulusal travma ve acil cerrahi dergisi= Turkish Journal of Trauma & Emergency Surgery: TJTES, 25(4), 355-360. doi: 10.14744/tjtes.2019.65250
4. Siddiqui, N., Yu, E., Boulis, S., & You-Ten, K. E. (2018). Ultrasound is superior to palpation in identifying the cricothyroid membrane in subjects with poorly defined neck landmarks: A randomized clinical trial. Anesthesiology: The Journal of the American Society of Anesthesiologists, 129(6), 1132-1139. doi: 10.1097/ALN.0000000000002454
5. Drew, T., Khan, W., & McCaul, C. (2019). The effect of i-gel® insertion on the accuracy of cricothyroid membrane identification in adult females: A prospective observational study. British Journal of Anaesthesia, 123(3). doi: 10.1016/j.bja.2019.03.012
6. Furin, M., Kohn, M., Overberger, R., & Jaslow, D. (2016). Out-of-hospital surgical airway management: Does scope of practice equal actual practice?. The Western Journal of Emergency Medicine, 17(3), 372–376. doi:10.5811/westjem.2016.3.28729
7. Hessert, M. J., & Bennett, B. L. (2013). Optimizing emergent surgical cricothyrotomy for use in austere environments. Wilderness & Environmental Medicine, 24(1), 53-66. doi: 10.1016/j.wem.2012.07.003
8. Hubble, M. W., Wilfong, D. A., Brown, L. H., Hertelendy, A., & Benner, R. W. (2010). A meta-analysis of prehospital airway control techniques part II: Alternative airway devices and cricothyrotomy success rates. Prehospital Emergency Care, 14(4), 515-530. doi: 10.3109/10903127.2010.497903