As easy as 1-2-3-4!! #FOAMed #FOAMcc #difficultairway

Why blog this?

It’s possibly the most daunting of events to have to deal with as an ICU physician / Anaesthetist / Member of the ED team. The airway where all conventional management has failed! It will NEVER happen to most of us during our careers…..

It is a low volume, high impact occurrence we normally practise over and over in the simulation suite. It may be a tad stressful at the time, but we all leave knowing it was a drill and we didn’t kill the mannequin…well hopefully!

The Martin Bromiley video clip of a terrible chain of events is more then over familiar to all of us, but have another look. The first and most important decision to make is to recognise that a cricothyrotomy is necessary in the first place! This was the biggest mistake in the Bromley case.

Let’s get with reality now. It does happen…as it has to me twice!

Situation 1 – Routine Perc Trache that goes wrong!

Initially Present: 2x ODP, ACCS CT1, Myself (Cons and trache operator), 3x nursing staff, Staff Grade Anaesthetist, Medicine CT1 (bronchoscopist)

Present at incident call: Cons ENT surgeon, Cons Anaesthetist / Intensivist

  • 13:10 – prepped and ready to perform the procedure. Neck scan NAD for vessels, paralysed and on 100% O2 with SPo2 100%. Sedation running (propofol and Alfentanil).
  • 13:15 – Start, area prepped and xylocaine with adrenaline infiltrated over 2nd / 3rd tracheal rings.
  • 13:20 – Horizontal Incision and blunt dissection down to pre-tracheal fascia with concomitant direct bronchoscopy down ET tube
  • 13:25 – good view of trachea and carina. Tube pulled back under my instruction until indentation could be seen on ant. wall of trace at bronchoscopy
  • 13:30 – Various entries successful into the trachea and bubbles seen in syringe, but wire tricky to feed. So tube pulled back further again. Again, easy needle entry with bubbles, but no wire visualised.
  • 13:35 – bubbling seen in mouth, therefore ET tube pretty much out. Attempt at expeditious dilatation and passage of white rhino dilator. Failed.
  • 13:40 – patient desaturating now with loss of control of upper airway.
  • 13:43 – trache abandoned and staff grade anaesthetist asked to secure upper airway. Attempted to re-intubate. Passes bougie and verbalises he sees it passing through cords. Connected, but no chest movement seen and no CO2.
  • 13:45 – Patient being bagged vigorously, but SPO2 not increasing. Now 55% and patient cyanosed.
  • 13:47 – Direct laryngoscopy done by myself. Unable to see epiglottis or cords with upper airway secretions ++. Patient’s BP dropping and CPR commenced.  100mcg adrenaline injected as well. Arrest call placed.
  • 13:49 – Help requested from another Intensivist and ENT surgeon requested as emergency. Quick track tube requested and preparation to access the airway from the neck. (Can’t intubate, can’t ventilate scenario). CPR stopped, BP now up. Via the same incision point, attempt 1 and 2 to pass Quicktrac fail.
  • Scalpel blade tip inserted, and over this, size 6 COETT is passed successfully into the trachea. Bag ventilation successful via the quick track, chest wall movement and obtained with CO2.
  • 13:50 – SPO2 now 98% and holding on bagging.
  • 13:55 – situation controlled, BP stable and SPO2 stable.

The patient made a full recovery and was made aware of the events by myself as part of a  duty of candour.

Situation 2 – Emergency Airway intervention and CICV!

I was consultant in charge on ICU. My colleague who had been on over the preceding 24h recounted a story regarding one of our HDU patients. He was a chap with quadriplegia after a RTA many years ago and was being treated for pneumonia. He had been suffering from a gradual respiratory deterioration and was failing NIV trial.

I immediately prioritised this patient, reviewing them and formulating a plan. On seeing them, it was clear they were in extreme respiratory difficulty and had deteriorated rapidly. PaO2 in their boots, rising PaCO2, falling pH and GCS certainly not 15!

The plan –  bring them through to our Level 3 area next door for intubation.

The chap was a large afrocarribean man, thick neck and muscular build. I had no further info. on his intubation grade or previous problems; he was getting bluer by the minute!

Team mobilised including 2 experienced trainee anaesthetists, 2 ODP’s and the nursing staff.

We commenced RSI and the trainee immediately shouts that there is no view at laryngoscopy. I take over, look with the laryngoscope – no view. I use a McGrath and I am unable to see anything as his neck is immobile. I am then told by another trainee his C-spine is fused C3-C5 and he was a previous grade IV.

He has sats of 75% and becomes bradycardic…the drill has failed (we can’t bag him, LMA won’t sit and we are not going to re-attempt intubation).

You know where this is going…

CPR is now commenced as he becomes so brady, we are losing cardiac output…adrenaline given. Output back and BP recorded now. We have to get in via the front as the has severe pneumonia, no airway and no means of oxygenation!

I call for immediate help from a colleague who appears swiftly. Lucky for me it’s Dr French, the man who teaches the 3/4 stage technique. He has clearly already assimilated the situation in his mind, as I have, and we both know what needs to be done. I have never had to do this, but he has. ‘Off you go’ he says reassuringly. I make the vertical incision, having attempted to feel the CTM….but he has such a swollen neck so its pretty much impossible to palpate. I have to say, a lot of blood is coming out of the wound (normal with hindsight). Time is ticking and I am still not into the airway. I ask him to take over, he finds my incision, extends it a bit and takes the scalpel blade. He puts his finger into the hole created and passes a size 6 tube in with some difficulty. We connect the bag, CO2, Sats coming up and the chap pinks up.

Reflecting on this, he was a legend to have around, but had he not been there I would have had to persist and I hope would have gained access. He stated to me ‘you were there, you just bottled it as I was there!’ Very humbling! The ENT surgeon now appears…stating, ‘well you didn’t need me then!’

So…how do we think it should be done?

In my experience, the Quicktrac is loaded with problems; tissues moving all over the place below the point of contact, small diameter, local trauma (it’s a wide bore needle)! We are still teaching passing a Quicktrac as part of ATLS…but I have to be honest, I do not personally favour this at all, having tried to use them in vain.

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Credit to Dr Tor Ercleve for art work and Dr Natasha Pirie-Burley for original design concept. Image adapted by Dr Jonny Wilkinson. This logo design is distributed under Creative Commons Licence.

What’s the technique then?

It’s the well described 4 stage technique:

  1. Scalpel
  2. Finger
  3. Bougie
  4. Tube

This is shown here on a cadaver:

Here it is being done on a live patient!

Some history behind the discussion

Dr Gordon French (Northampton General Hospital, Consultant Anaesthetist)

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I have to give thanks to my friend and colleague Gordon French for all of his work with us at the trust on this subject. He runs a fabulous course on this and it continues to escalate in popularity.

Want to know more about his course…mail the organisers:

It may, at some point, save your bacon! He has also kindly provided his presentation which can be downloaded here. The case he describes on slide 6 was our real life scenario 2 above.

In 1983′ while Gordon was a surgical sho in Birmingham, a spate of serious rectal foreign body injuries presented to his unit. His boss suggested he should write this up and in visiting the library, he discovered a paper from the US military whose message, (to always insert a large pre sacral drain whenever any rectal injuries were present), had not been widely adopted since the Vietnam war.

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Rectal injuries were more common during that conflict due to the development of pineapple landmines which explode at pelvic height. These were designed to cause maximal damage but not immediate death, and so tie up enemy resources more. The resulting paper is an amusing ditty but had a serious message. It also seemed to demonstrate that lessons from military conflicts were not always translated into civilian practice.

Throughout his anaesthetic career, he was always aware that few of us had ever been involved in an emergency cricothyrotomy scenario and that in his experience as a surgeon (at the time), he had only performed the technique twice. Once in a child and once in an adult.

Every anaesthetist knows that someday they might be faced with the need to perform this technique but evidence has emerged that needle cricothyrotomy fails in circa 60% cases, even in experienced hands.

Remembering his previous lesson from the miltary, he investigated what the US were doing in the field and discovered a three stage technique that had been tested in a battle simulated darkness and found to be reliable. It is now the technique of choice to get injured soldiers off the battlefield quickly and therefore reducing the time of exposure to enemy fire.

The technique only requires a bougie, tube and knife and is successful in over 90% of cases. Evidence from most “experts” regarding the superiority of knife over needle has been from simulated dummy training and is frankly difficult to find.

This technique was trialled in the dark on cadavers, with night vision goggles and was the most successful. Therefore we found some videos and designed a training course which has been running for more than 5 years. It is multiprofessional, highly successful and feedback suggest that the technique takes the fear out of the situation for most participants. The author has used this in an emergency in ITU and it was successful in seconds.

The way of the ‘French’

  • Can identify cricothyroid membrane
    • Simply push the blade through the skin, while stabilising the larynx with the other hand.
  • Can’t identify cricothyroid membrane
    • Make a 2 cm midline vertical incision over the cricothyroid region
    • Remove the knife
    • Feel in the wound for the cricothyroid membrane with the index finger of the other hand
    • Once found, make a horizontal incision in the CT membrane. IF patient breathing, there will be a spray of blood as they exhale out of wound.
    • Take knife out and then place the finger in hole (it wont disappear!)
    • Slide bougie in
    • Place 6 mm tube over the bougie. ! There will be blood which lubricates things!
    • Inflate balloon check for CO2.

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All of this is very similar to what DAS says.

We have a few further points o the DAS algorithm though:

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What do the military do??

If you are out on the battlefield, your man is down and you are there as 1st response…picture the scene.

He is unconscious and the upper airway is completely obstructed. There is simply no way in at the top, there are bullets flying, noise all around and a casualty you can’t floodlight up to see what you are doing! You have to know a technique you can do in poor visibility and sub-optimal circumstances. Therefore it has to be tried and tested…so you could almost literally do it with your eyes closed.

Their evidence

MacIntyre A  et al (2007) Three-Step Emergency Cricothyroidotomy

This is one of the papers describing what the special forces are trained to do, pretty much in the dark! Yes…the 3/4 stage technique.

The steps involve:

  1. the traditional skin and cricothyroid membrane incisions
  2. but add the use of an elastic bougie as a guide for
  3. endotracheal tube placement.

We have discovered that the bougie not only provides an excellent guide for tube placement but also eliminates the use of additional equipment, such as tracheal hooks or dilators. Furthermore, the bevel of the endotracheal tube displaces the cricothyroid membrane laterally, which allows placement of larger tubes and yields a better tracheal seal.

Combat medics can perform the three-step surgical cricothyroidotomy quickly and efficiently in complete darkness. An elastic bougie is required to place a larger endotracheal tube. No additional surgical equipment is needed.

The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective.

(92%) of all surgical airways were successfully inserted. (93%) of these procedures were performed either by combat medical technicians or General Duties Medical Officers (GDMOs) at the point of wounding or Role

Here is a great paper discussing various techniques in the military setting.

Of the techniques and cannula types reviewed in this paper, we recommend an open technique via a vertical, midline incision. This approach will maximize anatomic exposure, minimize bleeding, and allow for extension of the incision at either end if the initial incision is not optimally placed.The standard surgical approach (horizontal skin incision) is challenging for non-surgeons who are less familiar with external landmarks and anatomy.

What about in the hospital / pre-hospital setting?

A Meta-Analysis of Prehospital Airway Control Techniques Part II: Alternative Airway Devices and Cricothyrotomy Success Rates

In the above paper, Hubble et al describe various airway techniques, effectively used in the field. You will note at the end…

NCRIC (needle cricothyroidotomy) has a low rate of success (65.8%); SCRIC (surgical cricothyroidotomy) has a much higher success rate (90.5%) and should be considered the preferred percutaneous rescue airway.The patients these are being performed on are military personnel; young , disease free and the fittest.

Prehospital Cricothyrotomy: An Investigation of Indications, Technique, Complications, and Patient Outcome

Here is another paper which supports its usage, but describes an unknown safety profile. They also state that their incision was horizontal, as per the DAS guidance. We tend to do a vertical one.

A successful airway was achieved in 14 patients (88%). Horizontal incisions were used in all cases and were anatomically correct in 15 of 16 attempts (94%).

Efficacy of Prehospital Surgical Cricothyrotomy in Trauma Patients

This paper by fortune et al describes the efficacy amongst EMT personnel in performing surgical cricothyroidotomy.

In 79% of the patients requiring SC, attempted orotracheal intubation prior to SC was unsuccessful, with a mean of 1.9 attempts per patient. SC was judged to provide an adequate airway in the field in 89% of attempts.

NAP 4 state clearly:

—There was a high failure rate of emergency cannula cricothyroidotomy, approximately 60%. There were numerous mechanisms of failure and the root cause was not determined; equipment, training, insertion technique and ventilation technique all led to failure. In contrast a surgical technique for emergency surgical airway was almost universally successful. The technique of cannula cricothyroidotomy needs to be taught and performed to the highest standards to maximise the chances of success, but the possibility that it is intrinsically inferior to a surgical technique should also be considered. Anaesthetists should be trained to perform a surgical airway.’

So what are we saying

Its quick, its simple, it could save your patient … and your underwear! We should all be able to do it in our opinion. I have done many perc trache’s on ITU and would regard myself as competent…but this is a different league when you feel you are not in control!

So, get yourselves out there, come on a course or familiarise yourself with this easy lifesaving technique…you may need it one day, as I have twice now!

Also check out

LITFL Cricothyroidotomy here

Article on the emergency airway here

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