Even More on Surgical Cricothyrotomies

Long time friend of the show, Ram Reddy, has started compiling an excellent set of videos on youtube. One of them brings an ENT surgeon and Ram himself to a cadaver lab to explore all of the permutations of surgical cricothyrotomy.



For more videos from Ram, go to the EM London Ontario Youtube Site.



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  1. Minh Le Cong says

    love it! If I could I would mainline this stuff or directly inject it into my brain. cant get enough off this material on surgical airway technique. Similar issues get discussed…needle vs knife…horizontal vs vertical incision. Interesting Dr Fung advises using a needle and syringe to locate airway if trouble finding it which actually is an advantage of the percutaneous technique. But totally agree to keep things very simple and use minimum equipment. I believe retractors are even a luxury. prob the Kelly or forceps as well. I am participating in a surgical airway wet lab later this month in Brisbane using sheep. we dont use any forceps or retractors in that lab. scalpel bougie and needle cric. But I love seeing others teachings on this. its not black or white. Cut till air..that pretty much sums it up. once air found, getting a tube in is the next major hurdle.It is so easy to get that part wrong. thats where a retractor is fantastic..if you got it. herald the bougie!

  2. Tarek Loubani says

    As well, the videos are all released as Creative Commons, which makes them easy to remix, reuse and distribute. I can’t wait until somebody makes a ‘best of’ collection and posts it.

    tarek : )

  3. Leon says

    I really don’t like the method displayed on this video… the incision is *WAY* too small. In an obese person, in a trauma patient with in-line neck stabilization, and especially in a patient where you’re doing the cric in the heat of the moment, having a small incision like this puts you at way too much risk for actually putting the boogie or ET tube INTO a false lumen.

    I like the idea of an vertical incision…. but it MUST be larger and give enough room to HORIZONALLY cut into the cricothyromembrane and also be large enough so you can immediately save the space with your non dominant index finger.

    If you do not save the space with your finger and instead simply cut into the airway, and then assume that your boogie or tube will follow that pathway like this video shows, especially in the heat of the moment with adrenalin pumping, it’s just way too easy to push your boogie/tube into false potential spaces.

    There is no reason to be making small incisions here. I’m not saying you cut them from their chin to their sternum, but, this is saving someones life and not getting your airway device in with your FIRST attempt with a surgical technique because your incision was too small to feel landmarkes/save-space-with-your-finger/navigate airway into the trachea is just not acceptable.

    It’s really not that difficult. Cut vertical… feel the space under the thyroid cartilage and cut horizontal to air, save the space with your finger (maybe dilate it a little with your finger if possible), and figure out how to get a tube in (with bougie, or with tracheal hook, or with a dilator, etc). I personally believe Weingart’s video where he shows one method demonstrating on a video using ventilator tubing is the best/safest way of securing an airway. It’s how most of the guys do it at Shock Trauma, and it’s how a lot of the military trains their medics. I’ve successfully done an emergency cric using that method on an extremely obese female for anaphylaxis, and while it went pretty smoothly, I’ll tell you that without a large vertical incision with her soft fatty neck, there’s no way i would have secured a tube with the type of incision demonstrated in this video. Absolutely no way.

    If your vertical incision is too small, and you can’t have enough space to work/feel, then every step after this is at risk.

    Obviously with a perfectly positioned patient with neck extended who is skinny with thyroid cartilage yelling at you, you can probably throw a dart into your landmark and get a tube in no problem. The problem is that these generally aren’t the patients that are ending up with surgical crics. They, instead, are DIFFICULT airways or not ideally positioned i.e. trauma neck stablization).

    I’ve seen some other videos demonstrating ultrasound guided approaches to emergency surgical crics. I love ultrasound, don’t get me wrong, but this has ABSOLUTELY no place in the second to second crash cric scenario.

    General Surgery Resident

    • says

      Must say I agree with all Leon has expressed. Dainty, pretty incisions are for elective situations. It has been the main source of chest tube misplacement and causes similar problems with crics. I go from the bottom of the thyroid to the bottom of the cricoid.

      • says

        Some would argue that the main role of the anesthetist, apart from keeping the patient alive, is to tell the surgeon to cut a bigger hole so that the operation will be over quicker…

    • Minh Le Cong says

      spoken like a true surgeon! If in trouble, extend the incision..I like your style!
      You must consider the psychology of surgical airways though. This is the assassins territory, cutting the throat is often equated with killing someone as opposed to a life saving procedure. Many will hesitate, particularly if they are not used to wielding scalpels on a daily basis. I have seen a vertical incision from the sternal notch right to the floor of the mouth. It looks like a bloody mess but it can all be repaired in the OT. And that patient made a full recovery. For those of us who have done the procedure its easy to say to those who have not, dont worry, do this and that and expect blood but you should be fine. That is only half of the story. Mental preparation is probably just as important if not more. If someone is to perform a maximally aggressive technique at the right time, they must be psychologically trained. The USMC , the Australian SAS, in fact any elite organisation knows this of training individuals to have controlled aggression. It is a martial skill. it is honed through continual practice and mental rehearsal. You need a creed, a belief that governs the skill and mindset.
      It had to be done, so I did it.

  4. Robert Fabich says

    Scott & Minh,

    I just wanted to let you two know that you both just received some mad props in a Surgical Airway lecture by William Hinckley, MD at CCTMC.


      • Bill Hinckley says

        Robert, thanks for the kind words, for attending the Critical Care Transport Medicine Conference, and for doing what you do. Great to meet you today. Scott and Minh, you guys are missing out. Love to see you at this conference next year in Austin, TX, April 8-10, 2013!

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