Podcast 053 – Needle vs. Knife: Part I

Needle or the Knife for the Cricothyrotomy

In this episode, I debate Minh Le Cong, a retrieval physician from Australia. The question is what technique should we use in the can’t intubate/can’t oxygenate (CICO) situation.

Throughout the podcast, you will hear reference to Dr. Andrew Heard, who has written some fantastic papers on the subject. Perhaps most pertinent is his description of the formation of a CICO protocol based on his experience with a wet sheep airway instruction lab.

Heard AM, Green RJ, Eakins P. The formulation and introduction of a ‘can’t intubate, can’t ventilate’ algorithm into clinical practice. Anaesthesia. 2009 Jun;64(6):601-8.


Here is the algorithm from the paper (Click for full size)

Here is his video on the cannula cricothyrotomy technique

Here is his video on the scalpel-finger-cannula technique

Here is a video describing why Dr. Heard prefers the 14G Insyte Catheter for Needle Cric

Here is his preferred method for oxygenation through the cannula

The paper on the use of ultrasound to find the cricothyroid membrane is quite interesting.

See my prior posts on how to perform the bougie-aided cricothyrotomy and the cric show.

One of the best things Minh expressed is the need to say OUT LOUD: “This is a can’t intubate/can’t oxygenate situation.” Saying it out loud lets everyone in the room know, there will be no more screwing around with attempts at direct laryngoscopy.

Go to the Broome Docs Blog for more Minh Le Cong.

He is an incredible guy, expect to hear more from Minh on the podcast.

I also gave a shout-out to a new podcast, the Emergency Ultrasound Podcast.

and now the EMCrit Podcast 53…

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  1. Minh Le Cong says

    Scott, thanks for giving the opportunity to debate the issue. Respectfully I want to suggest that the issue is not as black and white as it may seem. The two techniques of needle versus open surgical airway are not mutually exclusive. In answer to your concern about lack of feedback using the needle oxygenation technique that is true that devices like the Manujet jet ventilator do not allow any feedback to the provider at all which is I agree dangerous. The advantage of the three way stopcock or T Piece or just holding the oxygen tubing onto the cannula is that you do get feedback as if there is resistance to the oxygen flow that will be immediately felt against your hand or finger depending upon which setup you are using. To answer your concern about lack of apnoeic oxygenation via needle to correct atelectasis and shunting in the critically ill, that is a valid point and the evidence here is scant to support one decision over another. I think this misses the point. The needle cric/surgical airway is only a temporizing measure to rescue oxygenate..it is a bridge to your more definitive airway. Why not just try to go and do your more definitive airway anyway is your point Scott rather than add another step into the decision pathway? My answer to that is that psychologically it is easier to use the needle as your first step towards a definitive surgical airway . In other words, you are more likely to do that first step. Clearly what many cases demonstrate is making the first step an immediate surgical incision of the neck is so daunting that many docs just choose not to proceed with any thing and keep trying to intubate orally or do something else. Now does that mean we just need to do more training in scalpel bougie surgical airway? yes and no. I still believe that having the two techniques and training in how in stepwise manner you can flow from one technique to the other is a more comprehensive approach than having only one technique trained.

    The elephant in the room is paediatric cases . I know you deliberately avoided debating that group but fundamentally does it not seem more logical to train a technique that works across all age groups? Are you not obliged to learn a technique that you can apply to an adult and a child? Scalpel bougie in a 6 yo? I am unaware of any cases in the literature, are you?

    • says

      I was perhaps not clear enough on my comment regarding ETCO2. It is not just that it confirms that the ETT or trach is in place, it confirms that the patient is oxygenating and ventilating and I know beyond a shadow of a doubt that they are getting better even if their pulse ox is lagging. The second I see that CO2 spike, I know I can relax. The feedback from a three way stopcock just tells me some oxygen is going somewhere, not if the patient will respond to it and improve or whether I’ll have to grab my scalpel in a minute.

      Yes peds needles needle cric, no argument here. If folks think that learning only one technique that works for adults and peds is a good idea, then it is a point for the needle cric.

  2. says

    Despite many years teaching how to perform needle cricothyrotomy from the text I’ve read, I haven’t had any great feedback on the ease or use of this technique when bagging a patient via Bag Mask Ventilator via the 14 or 16 guage catheter in the neck, and a 3cc syringe and the Endotracheal tube connector. You get too much resistance. I would need a Manujet in my experience for any true amount of oxygen to be delivered to the patient. I have heard those who do not teach or perform this technique quote the experts on its use. Amazing on how those who teach things never done. I want to teach things that I am learning to get better at. Not things not ever done. Just ask anyone how the hands feel when you bag via this small catheter with BVM. Your hands cramp up and start to try to fall off.

    You can keep persons alive with jet ventilation. At the SAM conference in Chicago, a physician in England who works on repairing damaged airways, demonstrated it was viable to keep patients alive during an operation with just jet ventilation. It wasnt used or demonstrated as a rescue oxygenation device, and that is the delimna. It has potential.

    And I have noted in the UK publications about their airway registry that was referred to in this website, of the great failure rate of this needle cric being performed in real live patients. I teach it but I always point the pitfalls of what can happen in real life, failure despite all intentions.

    • says

      I think the BVM through an ETT adapter is a guaranteed fail, b/c you don’t get enough gas flow to even provide apneic ox, much less ventilation. This has been shown in a few studies that can be found on crashingpatient.com.

      Jet ventilation is a great technique for controlled anesthetic cases with confirmed commercial catheters. I think the only acceptable ones are those with internal pressure cut-offs so in case the catheter is misplaced you know immediately.

      I was glad that jet went did not come up in the debate as I think in a failed airway situation it is the path to the grave.

  3. says

    Hi Scott
    Great debate. Gotta say – I am on your team – having seen a needle cric go horribly wrong. I am much happier with a scalpel-bougie technique. The relief of knowing you have a cuffed, definitive tube in place is my goal, I can squeeze on the trusty Air-viva bag and know I am moving air. It is the “money” as you say, there is no awkward pause waiting for the sats to come up or the EKG to go flat….

    If you want to hear from Dr Heard via Broome Docs – check out the link to my post on CICO @ http://wacdocs.csp.uwa.edu.au/2011/06/cant-intubate-cant-ventilate-the-low-down-on-code-brown/

    He was kind enough to answer a number of questions on the topic.

    Oh and last point – the “can’t intubate, can just ventilate but need a definitive airway” scenario is much more common in my experience – for me this is also a scalpel-bougie scenario – I have not trained with the dedicated airway kits and have gone with the one technique for all occasions.

    Thanks for the Shout out
    Casey @ Broome Docs

    • Minh Le cong says

      Thanks Casey
      It would seem equal that in the cannot intubate but can ventilate how you do the surgical airway does not matter. A needle approach with, seldinger technique like the Melker kit is valid and supported by the literature.
      If you don’t have such a kit, then sure scalpel bougie technique. If you don’t have a bougie then standard open surgical cric technique.
      But Casey, even you recently described a case of a 10yo child with bacterial tracheitis. Do you really think scalpel bougie would work in a child and psychologically are you prepared that is your fall back technique across all age groups?

    • says

      Casey, I saw the post as soon as it was written; great stuff! I would be appreciative if you would send Dr. Heard the link to this page so if he gets a chance he can listen and possibly comment.

  4. says

    Hi Scott

    Thanks for the cric podcast with minh.

    I am yet to have to do or see a cric in 6 years or so of training (the uk is unusually reticent about using this; I have been in situations were i think it should have been used but persistent intubation attempts were used instead…) but I think after reading and thinking about this procedure I’m fairly convinced a scalpel technique is the way to go.

    Though to be fair I do teach anatomy for a living at the moment and am perhaps more confident with a scaple than most!

    The tendency to choose or favour a needle technique seems to be a perceived (and I emphasis perceived) confidence that needle technique are easier and more dependable.

    The two points that I appreciated most were
    – awareness that this is a bloody procedure
    – the ability to be able to do this blindfolded and by palpation is key.

    • says

      The point I would add to those two is to practice a few hundred times. This seems daunting until you realize that the trainer made up from some vent tubing and two rolls of tape is fairly realistic and allows you to practice 20-30 times in 10 minutes. See the cric video on this site to see the trainer. From my perspective there are only two difficult things about this procedure: getting the gumption to move to it and then being able to do it blind.

  5. Minh Le Cong says

    thanks Andy

    Your observation that on several occasions you have personally witnessed the situation where doctors refuse to proceed to surgical airway and persist with intubation supports my assertion that having a stepwise graded approach is better from a psychological viewpoint. Psychologically it is more acceptable to proceed if we believe we are taking limited risks at each step with an escalating level of risk rather than just rolling the dice and taking the biggest level of risk right at the beginning. THis huge risk level perceived by the doctor is enough in many cases as you have stated to prevent them proceeding. I don’t see anything wrong in having a graded approach if it means docs are more likely to proceed to DO SOMETHING ELSE. If you just teach them that all they need to do is make that decision and do scalpel bougie, and many docs choose not to proceed in reality, you must come to the conclusion there are real flaws in that strategy that you must be prepared for.

    The other way to address this psychological barrier is training and of course I support this wholeheartedly. Blind folded training is a brilliant idea and is akin to what we do in HUET ( Helicopter underwater escape training) where eventually you have to demonstrate a blind folded egress from an upside down underwater position. Scott and CAsey, you have seen and performed surgical airways successfully and witnessed at least one failure of needle cric. I have audited one failure of scalpel bougie and seen and done several needle crics that were effective in rescuing the situation prior to a more definitive approach through the neck. Saliently no one has argued the point over paediatric airway cases and in one of the cases a colleague of mine performed a needle cric on a kid with epligottitis with failed intubation, it clearly rescued the situation enough for a second intubation attempt to be successful, avoiding the need for a formal surgical airway.

    Indeed in the crashing hypoxic patient, the two techniques have unique advantages and disadvantages in that setting. YOu simply cannot argue one over another given that. But in the 5yo kid crashing after a failed intubation for tracheitis/epiglottitis, I challenge anyone to argue that scalpel bougie is superior or even the standard of care over needle cric/trachie. Andy I don’t know how many 5yo cadavers you practice and teach anatomy on but suspect its rare.

  6. says

    Hey Andy
    My comment – see my donkey analogy at the Broome Docs link above

    For kids – tough, very rare outside of rare syndromes. Needle cric is probably the bet here as the flOws and volumes are more achievable.
    My2 cents. Casey

    • Minh Le cong says

      Ok thanks Casey
      You concede then needle cric is superior as it covers all age groups?
      Or you concede that both techniques are valid depending upon the patient?
      In other words non inferiority of needle vs knife?
      Which means you have changed your opinion?

  7. Anthony Lewis says

    As soon as I heard Scott’s training technique of blindfolding the operator whilst performing a scalpel bougie technique, I thought of HUET (as discussed by Minh).

    It is fascinating that in certain situations, the removal one of our primary senses may improve our ability to perform a critical intervention.

    This is also akin to the ‘sterile cockpit’ phenomena whereby pilots ask for quiet during take-off and landing.

  8. says

    Minh, I’m on your side. Needle cric is a temporary oxygenating procedure, with no more things that can go wrong than scalpel and bougie, especially in a situation where the operator’s arenal gland output probably excedes that of the patient. Once performed, the point is to not sit back and enjoy the success, but to move on and secure a definitive airway from the top or by opening the tract along a guidewire placed through the 14G.

    With the use of ultrasound, rather than marking the site, have you tried real-time scanning to guide the needle down on to the cricothyroid membrane?

    Again, as you have stated in the above replies, it does not have to be a mutually exclusive skill, as having options gives greater latitude to deal with particularly tricky cases. you just need to be (appropriately) confident in your abilities.

    Finally, I really like the blindfold training. I’ve used and seen this used in a number of procedural skills training, including having to run a MET (Medical Emergency Team) scenario as a blindfolded team leader. It really reinforces the tactile nature of many of the procedures that we do and gets you paying attention to feedback.

  9. Minh Le Cong says

    thanks Mathew
    No I have not tried real time scanning to guide needle cric. I am also unaware of any published studies examining this. Quite frankly in the CICV/CICO situation I would not do it as it is just another factor to think about and get wrong. Its real role is in the impalpable neck patient who you have time to do some airway assessment and mark where the trachea is and the cricothyroid membrane. Dr Heard advocates in these cases if you have the time, to insert a cannula through the cricothyroid membrane prior to your intubation attempt, just in case things go astray. We are nothing but somewhat superstitious sometimes in emergency medicine ( who believes in full moon night shift chaos?) and I believe by marking the surgical airway sites on the neck using USS prior to a predicted difficult airway tube then it wards off the evil spirits.

  10. James DuCanto, M.D. says

    Thanks for this discussion. I am an anesthesiologist, and Seth and I did the sheep/fiberoptic sytlet study together. Several additions from experience, fact, and shear opinion.
    1. Jet ventilators cost $250 USD and use either the wall oxygen or can be adapted to O2 tanks, and allow the user to set the driving pressure precisely (I use 20-26 psi when I do elective jet vent cases with the Hunsaker Mon-Jet ventilation catheter from Xomed-Medtronic). Everyone concerned about this technique should buy one of these, read the manual that comes with the device, and have it on their cart for when it is needed. Use this company and device: http://www.progressivemed.com/estylez_item.aspx?item=16580

    Forget using the BVM adapted to the catheter–it’s too hard and too inefficient, and ultimately, you don’t know what you are doing because you can’t set the pressure and have no idea what your flow rates are.

    2. I have clinically used needle cric ONCE in my career. CICV with one of my colleagues. Using the above mentioned Jet Vent device, I placed an 18 gauge IV, hooked up and ventilated. This technique stabilized the patient, Sats came up into the 80’s and low 90’s, and gave my colleague TIME to get the patient orally intubated with a fiber scope. Minh’s technique gives you TIME to do something else. Maybe you can intubate the patient after all.

    3. Anesthesiologists deal with elective cases the greater majority of the time—all of your cases are emergencies. We try not to leave marks on people if we can help it. I used an 18 gauge iv cannula to great effect in my clinical case (N=1). It can and does work if you use the proper equipment for the job, i.e., a formal jet vent. I’ve been to NYC, and the price of eating out is greater than the cost of this jet ventilator. No one has any excuse to not acquire these devices, even if you never use them.

    4. Formal cric with an optical stylet will grow in this decade, as the cost will come down and availability of these systems will increase. You’ll all end up with one of these devices by 2020, I guarantee it. Then, you’ll rediscover the paper that Seth and I wrote. The primary use of these devices is to use alongside your DL or Video Laryngoscopes, so if you fail at airway management with all this stuff, you can intubate through the Air-Q supraglottic airway, or if that fails, you can cric with it.

    5. If you haven’t incorporated the Air-Q SGA into your kit (now with an esophageal blocking balloon for you nervous EM guys), you are practicing 10 years in the past. That’s my opinion and conviction.
    Here is JEMS Video link. I have used this device clinically, and it’s awesome.

    Pdf on the product:

    That’s all I am going to say. I know several of you through the extended community, including Jose, with whom we are members of SAM. Good luck, your jobs are harder than mine, and I really do respect that (except I have to work with surgeons and nurses that surf Facebook looking for hookups during surgical cases).

    Jim DuCanto, Milwaukee Wisconsin.
    Yes, our rate of alcoholism is twice the national average.

    • says


      Great comments!
      (Folks, Jim is going to be on the podcast soon)
      I think I would feel better about needle cric if folks did have the formal jet ventilators. Just for the record, nobody here has advocated the BVM/adapter approach, which just doesn’t work.

      Seth’s video of fiberosptic-stylet aided cricothyrotomy is on the site.

      An interview with Dan Cook, inventor of the AirQ ILA, is here as well. It is my preferred SGA and seemingly Jim’s as well.

      I’ll also have an EMCrit Short with Seth Manoach on catheter selection issues if you are going to do a needle cric.

      Stay tuned…

  11. Minh Le Cong says

    thanks Jim and Scott

    For the record, my retrieval service in Queensland (Royal Flying Doctor Service, Australia) carries the following in our difficult airway pack : Levitan FPS optical stylet ( the inventor came and taught us !), Fastrach ILMA, ENK oxygen flow modulator kit and needle cric, Melker cuffed seldinger cric kit.

    I think the fibre optic stylet assisted cric is a great idea. Prob even better than scalpel bougie.Problem is not everyone has a Levitan stylet . They are not cheap, albeit cheaper than all the current video assisted laryngoscopy systems!
    About formal jet ventilators, I think this misses the point of apnoeic oxygenation. The term itself gives you the false impression your goal should be to achieve adequate ventilation via a needle cric. This is not the case. Put simply all you need is oxygen and flow rate of >200ml/sec. An oxygen cylinder and flow valve meter running at 15l/Min is all you need…then O2 tubing and the needle/catheter.

    As for the AirQ..I have researched this device as never used one. It looks pretty cool and is a much better conduit to fibre optic intubation than the other SGAs. IN retrieval medicine we don’t usually carry fibre optic flexible scopes, although I have heard of a couple of cases where this was done to good effect. I have used the Fastrach ILMA a lot in prehospital/retrieval medicine and find this a reliable SGA for blind intubation. I cite a couple of recent papers comparing it to the AirQ below to support my experience. The French SMUR prehospital services report similar positive experiences as well.

    ultimately though I find a reductionist philosophy to emergency airway management is best..relying upon one piece of gear will be your enemy in dark times

    A colleague of mine in RFDS Western Australia was faced with one of the worse airway scenarios imaginable : a complete tracheal transection/disruption from the patient being swung around at high speed by their shirt neck collar caught on a rotating seeder machine. There was no way any of the current fancy airway toys , needle cric, scalpel bougie, optical stylet, bronchoscope would help in this case. IN the end it took steely determination and a scalpel to locate the torn ends of trachea and stick a ETT down the distal end. Patient made a full recovery. A couple of retrieval colleagues I know carry their surgical airway kit in their wallet : a scalpel blade. Like Bruce Lee said ” Adapt to your opponent”

    • says

      King Systems (who produce the King Airway family, LT-D/LTS-D) has their King Vision video laryngoscope which appears to debut around USD 900 and USD 25 per blade. I was fortunate enough to try them in Dr. Levitan’s airway lab and am working to get these integrated into my system. Their price/performance point is excellent.

      • Minh Le cong says

        Thanks Christopher
        That’s an incredible price and given the current exchange rate even cheaper for me to buy and try!
        What did Levitan think of it?

        • says

          I don’t recall if Dr. Levitan spoke on it specifically besides an intro to its use (and its price). However, I personally found it far better than the AirTraq and C-Mac. Perhaps most attractive was the ability to switch between channeled and a normal blade. The screen on it is gorgeous as well. I would recommend getting a demo to play with and see if it impresses you as it has me.

          • Minh Le Cong says

            Hi Christopher
            Thanks again for the info on the king vision laryngoscope
            I ordered one yesterday and will let you know how it goes

  12. James DuCanto, M.D. says

    Thanks for the discussion and feedback,, I had to think about what you’ve said a little before responding.

    1. The Levitan is a portable endoscope in and of itself with more versatility than most realize. I have counted 5 ways to intubate with the device:
    1) Alongside DL/VL
    2) Alone (on its own) in sedated or dying patients
    3) Through the LMA Classic or the Air-Q
    4) Cric (Mannequin, Sheep I have done)
    5) Retrograde (Mannequin only to date)

    2. Intubating through the Air-Q with the Levitan takes practice and a specific stylet shape to make it happen–you may want to wait for the lower cost version to come out late this year or next year, rather than bend your Levitan, but I have already bent my Levitan into a specific shape to do this. This technique (Optical stylet through Air-Q or LMA Classic) is my go-to rescue technique in my practice. It is actually easier than flexible bronchoscopy, because the ETT leads the scope (in the case of the Levitan), so there is no hang up during tube passage, which happens quite often during flexible bronchoscopy, unless you know all the tricks.

    3. You are spot on about the jet ventilation—-it is not ventilation if the airway is completely obstructed, it’s only oxygenation. Using the formal equipment is probably still smart, but I understand where you are coming from, and understand that you don’t want to carry a colossal amount of equipment around with you—but the formal emergency rooms of this country should “put their ducks in a row” and use the right equipment, with the understanding that the use of this device is for insufflating oxygen in the amounts you suggested while the airway is completely obstructed.

    4. I have about 800-1,000 videos demonstrating the intubation technique of the Levitan (or close cousin optical stylets) in the operating room. How about I send one to Scott for posting on this site? The laryngoscopes of the future will be modified supraglottic airways—they will serve as tracheal tube introducers, in the way that vascular introducers are used to placed PA catheters or pacing electrodes.

    5. You have everything you need right now, but the Air-Q is worth another look, and most certainly, a trial in your hands, if you can manage it. You will need the Levitan bent to at least 40 degrees distally to achieve visually guided intubation with it. Best to practice on a mannequin first, of course.

    Thanks again! Jim

  13. says

    We use a bonfil rather than the levitan, but the use is pretty much the same. We bent it to the ideal shape for use with the AirQs. This was petrifying to do, but once done it is now an incredibly versatile device as Jim points out above.

    I’ll be posting 2 of Jim’s incredible videos tonight.

    • Minh Le cong says

      Thanks James and Scott

      You can bend the Levitan but I did not think you could bend the Bonfils..wow what a gamble you took! I attended a lecture Carin Hagberg gave at the ANZCA AIRWAY SIG meeting earlier this year where she presented these techniques of using SGAs as conduits or bridges to intubation and extubation. I think it’s a brilliant idea to train with and perfect. The crux is that it does require a reasonable amount of training, especially if you are using fibreoptics as well. I have practiced with the Levitan through the classic and pro seal LMA as well as the iGel device. The Air Q looks to be the money if you are choosing this technique but I must caution that it is not a technique readily adaptable to emergency airway management. These techniques and devices sometimes lull docs into thinking they can manage any airway using them. I know of German prehospital services staffed by Anaesthetists who take the Bonfils on retrieval and use that. There is an article in EMJ recently about using the CMAC video laryngoscopy system on HEMS missions. I would suggest that in emergency airway management keeping things simple, like traditional DL, SGA and then or even first, a surgical airway approach is tactically more effective than trying to maintain complex skills in multiple techniques. Sometimes the best restaurant meal is a simple well prepared menu rather than the smorgasbord!

  14. says

    Leon, a 4th year surgical resident writes:

    I just successfully (and easily) did a crash cric on a patient with anaphylaxis (huge tongue) which anesthesia couldn’t incubate/ventilate using the methods I learned from Scott Weingarts website (and have practiced and thought about a lot too) last night on the medicine ward.

    I was called overhead to assist.

    I’m a surgeon.

    What this technique does not require is having advanced surgical skills. It simply requires making the decision to do it and knowing the technique which Weingart describes in his video.

    It works. And let me tell you…. It worked so much better than I ever could have anticipated.

    This patient would have died with the needle method. In fact, this patient would have died with her body habitus had i tried doing a quick elective style surgical approach.

    Regarding needle….Equipment not around, very fat neck, no jet ventilator, and she was so hypercarbic that she needed some drastic ventilation to lower her CO2 which a needle won’t do.

    Thank you Scott! This save was just as much a function of your podcast as it was my knife!

  15. Minh Le Cong says

    Merry Christmas Leon and Scott! To bestow the gift of a life saving cric to a critical patient, all through the mentorship of social media and emcrit.org. Jolly good show, chaps! Needle vs knife, it does not matter as long as you decide to act. the delay in acting is what is detrimental. if this podcast, blog discussion and Scotts videos has enabled Leon to sAve one life, what a great way to end the year! Happy new year guys!

  16. says

    As a gift for the new year, I get this email from PM of Canada:

    I want to offer a heartfelt THANK YOU for the education you gave me and others on bougie aided cric. I listened and watched last year, taught my group last year with the model you showed…… and saved a life today. As I cut into the neck your voice was in my head saying:”Don’t worry about the blood, do it blind”. I crapped my pants but saved a life after both myself and an anesthetist failed at RSI 3+ times and desats started. I owe you!

  17. Minh Le Cong says

    online airway management training. No OR needed! Only streaming videos and podcasts, bits of cheap plastic tubing and tape. No fancy expensive video laryngoscopes or awake topicalised techniques. And voila, two lives saved! Now the next challenge Scott is to use Emcrit.org to teach anaesthetists to pick up the knife after failed RSI 3 + times…instead of the faecally incontinent EM physician who channelled the spirit of Emcrit.org to guide his/her hand to do what needed to be done. ” dont worry about the blood, do it blind”, almost biblical words of power!

  18. Aly says

    The preferred oxygenation technique taught at Royal Perth Hospital is not a 3 way tap device- it is a T-piece device which they have designed and studied. The 3 way tap device can be dangerous since it does not permit expiration when connected to oxygen at 15l/min.

    • Minh Le Cong says

      Hi Aly
      You are absolutely correct for the completely obstructed airway scenario. Expiration of gas is a real issue with this technique regardless of what setup you use. Barotrauma is always a real risk and you have to be aware of the amount of gas you are delivering. My service carries the ENK flow modulator kit from Cook and this is a bit safer with one study showing it had less excessive pressure issues than the manujet. The manujet does not allow any feedback to the user to allow a determination if excessive pressure is being delivered. Studies in animals using complete airway occlusion using devices like the Manujet have always been invariably fatal

      The 3 way tap setup allows some feedback to the user as excessive pressure builds up. IN the partially occluded airway scenario ( which is more common), I believe the pressure issues are less of a concern but one must remain vigilant . The paediatric T Piece used at RPH is ideal if you can source one. Sometimes you can’t even find a 3 way tap. In those situations I believe holding the oxygen tubing onto the cannula hub is the way to go. You hold it on and take it off, allowing at least a 1 : 8 ratio. The goal is rescue oxygenation.

      The EMAC course run by the ANZCA college offers up the 3 way tap connector as one of the recommended methods for transtracheal oxygenation using a needle cannula

      this is another study on the 3 way tap setup vs manujet , concluding its useful for oxygenation but not ventilation

      Fascinating older study in dogs on transtracheal oxygenation using a 14G catheter

      I wrote an a article for Emcrit about this with more articles to reference

      thanks for bringing up the safety issue.

      • says

        Well, as usual, Minh replied more quickly and comprehensively than I could. I want to echo the difference between upper airway obstruction cases vs. difficult airway with open cords. In the latter, the 3 way stopcock is fine. In the former, Minh’s method of holding and removing the bare tubing is the best way to go.

        The true ideal and what I will do a blog post on shortly is using the ventilator.

        Minh’s video and post will be up next week.

  19. Darrel says

    Amazing discussion!! I work as an advanced care paramedic (ACP or ALS) in Vancouver (targeted system) and have had the unfortunate opportunity to perform an emergency surgical airway only once. We have the Melker Emergency Cricothyrotomy kits, I was trained to use the needle jet injection and melker but we are encouraged to use the melker kits by our medical director.

    My call was for a young male who drove into a rock wall, vehicle burst into flames, severe burns to upper body and head/face. I pulled up as the patient was being pulled out of his burning vehicle by the fire crew. I could tell while sitting in my ambulance at 10 feet away that he needed a surgical airway, there was no doubt. Swollen face, tongue protruding out of mouth, indrawing of the intercostals, and it was christmas morning (-2 C) so you could see your own breath and it was obvious he had no air movement. He was conscious and alert (GCS 15) and panicking, I was able to communicate with him. I grabbed the melker kit, instructed the patient I was going to cut a hole in his throat to help him breath and he nodded (like do it now dam it). I was working with basic life support paramedics and they can’t draw up our medications so no time for sedation or pain control. I cut through his edematous neck (lots of tissue) with a vertical incision to the point were I could finally landmark anatomy for the procedure. I never anticipated asking a patient to stop swallowing (thyroid cartilage moves up and down every time he swallows) so I can cut through the cricothyroid membrane. I did not use the needle and wire provided as I felt it was too cumbersome and needed access immediately. I cut laterally through the membrane and stuck my finger in the hole, he instantly began to breath while coughing blood all over me… yes, lots of blood but necessary. Inserted the tube and removed the trocar, then had time to empty my morphine pouch and give plenty of versed.

    I would use this technique again, however seeing the bougie assisted method this will be my procedure of choice. It is amazing, so simple and basic equipment that we have in every kit.

    The patient survived the accident, 3rd degree burns to face, head, neck and chest (about 40%) with some 4th degree burns to his head. Burn/plastics team have never seen this type and extent of facial burns alive in their unit. Usually asphyxiate before arrival… along with airway burns and cyanide poisoning.

    To Christopher, that King Vision video laryngoscope looks very nice. It would be a great tool for prehospital use, especially in trauma patients with suspected neck injuries. I will send some info off to our medical director. Also check out the McGRATH MAC video laryngoscope, also cheap and similar to the King. We are trialling the McGRATH MAC in our airevac program, so much smaller than our Glide Scope Ranger and a fraction the cost. Tricky to get used to when first learning (kinda like a video game) but a life saver. I have not used the McGRATH MAC yet while flying but will post my experience when I do.

    • says

      I’ve used the McGrath as well, but found it got schmutz on the lens more readily than the King Vision did. Otherwise I very much enjoy the McGrath’s form factor.

  20. Damon Tedford says

    Were the videos pulled from the show notes? I’m not seeing any hyperlinks.



  21. SamG says

    Hey guys,
    I have a question for Minh- (btw love your involvement with the site and your nice touch with ever-interesting and helpful comments and input)

    My question is regarding the concept that needle cric is essentially a form of apneic oxygenation, as ventilation is essentially nil, and the goal is to buy time with rescue oxygenation: You and Scott discussed this briefly in the podcast, as Scott brought up the point that in pts with bad shunt physiology, apenic oxygenation w/needle cric prob won’t be too effective just as acknowledged with high flow via nasal cannula. Apneic oxygenation has only over the last few years (thanks mainly to Scott and Rich Levitan) really gotten to be what I would call standard of care now. I’m assuming that in the present day can’t intubate/can’t oxygenate scenario, that all these pts have been undergoing O2 high flow via nasal cannula throughout the resuscitation. Do you think then that in the majority of cases, in the present day can’t intubate/can’t oxygenate scenario (when nasal O2 high flow nasal cannula has been present throughout) apneic oxygenation has already proven to be a fail? It seems that in the absence of any obstructive process from the nares to the cric, maybe these people are already declaring themselves to have shunt physiology- what is your experience with needle cric in the O2 high flow nasal cannula era?

    Thanks so much in advance for your time and thoughts..

    • minh le cong says

      thanks Sam
      I have yet to do a needle cric since adopting the NODESAT technique of nasal cannula during RSI.
      My opinion is that the needle cric is a way of bypassing the problem supraglottically.
      its not the be all or end all and certainly can fail but it is quicker to do and certainly I know of at least 4 cases where it rescued the situation.
      I think if NODESAT is on and you fail to tube duringRSI. and it develops into CICV situation, then you do whatever you can to bypass the problem. needle, knife whatever! get oxygen in by bypassing the problem.
      we had one case where a junior doc used the needle cric to rescue the CICV and then kept it going all the way to OR whereENT. did the formal surgical airway.
      would NODESAT had prevented the need for needle cric? maybe
      but I would not say right now, seeing what I have seen, that if NODESAT is failing , then needle cric is useless.


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