EMCrit Wee – A Cric Case with Rob Bryant


The Case:

Rob got permission to share:


30 year old male with past history of SCC of the tongue at age 14 who presented with cough, and dyspnea with concerns for recurrent pneumonia. He was still on antibiotics and steroids after a recent hospitalization for pneumonia.

His cancer recovery was hampered by osteo-radio-necrosis of his jaw, and he was left with a scarred larynx, baseline trismus with incisor to incisor distance of <2cm, and some thickening of the anterior neck tissues. He had a G-tube for feeding.

He had normal room air sats, no stridor, productive cough and no fever. Chest Xray was normal, and he was considered safe to go home and follow up with his pulmonologist the next day. The family was nervous about going home so he was observed overnight in the ED.

A very specific discussion was has with the patient regarding the challenges emergent management of his airway would represent:

“I love to manage airways, but your airway scares me, and I would never want to be the one to intubate you”

“If you have an airway emergency on the floor, it would take longer for someone to cric you than if you had an airway emergency at home, and had to present via ems and have a surgical airway performed in the ED”

He was discharged from the ED the next morning with some racemic Epi to try at home.



He represented 4 days later in respiratory distress with 36 hours of ‘anxiety’ symptoms that had not been helped by escalating doses of benzodiazepines.

No fever, no cough, very hoarse voice at home.


HR 140, BP 160/110, RR 29. Sats 86% RA, 98% 15L NRB

ETCO2 84.


Altered, sweaty, moving minimal air, and non verbal with significant stridor.

Initial interventions:

Racemic epi nebs,

125mg solumedrol iv

Glycopyrollate 0.2 mg iv.

Lido 4% neb.


VBG: pH 7.17, pCO2 104.


Anesthesia was called for Awake FiberOptic Intubation (AFOI) if a trial of BiPAP failed. Due to concerns that NIV could worsen his laryngeal irritation, or that giving Ketamine to help him tolerate the BiPAP could cause laryngospasm (est 1:200 risk) BiPAP was not started until anesthesia was present and ready to perform AFOI.


Anesthesia presented promptly and agreed with AFOI plan after BiPAP.

Beside table was set up with 4×4’s with betadine, trach (6.0mm), pocket bougie, and #10 blade scalpel, and gloves. Lido 1% w epi was prepared.

Pt kept at 20 degrees HOB elevation, NC at 15L, then BiPAP at 15/5 was started with no decrease in his work of breathing.


3 AFOI attempts were made, with each attempt aborted once sats hit 90%, the patient was hard to bag due to laryngeal stenosis, but with assisted spontaneous ventilations additional attempts were considered appropriate.

The neck was palpated, and prepped prior to first AFOI, and injected w lido w epi after 2nd AFOI.

3rd AFOI was with glidescope assist. Glidescope could barely fit into the mouth, and there were no obviously recongnizable laryngeal structures.

During 3rd AFOI cricothyroid membrane was punctured with 27g needle on the Lidocaine with epi syringe and air was aspirated to confirm location.

The patient received 1mg per kg Ketamine iv prior to incision for cricothyrotomy.

With sats of 92%, a midline 3cm incision made, then horizontal incision 1.5cm through the cricothyroid membrane. There was a small spray of blood and air, and audible air movement was present in the wound.

A Bomimed Pocket bougie was placed with some digital guidance, and advanced into the trachea. No tracheal rings were obviously palpable, and I did not forcefully check for bougie holdup.

A 6.0 mm external diameter Shiley trach was railroaded over the bougie, with some hangup at the skin level, it was then advanced with firm pressure into the trachea.

Oxygen saturations were 68% at time of Shiley passage, 25-30 seconds after procedure start time. Airway confirmation was with ETCO2 detected immediately, good breath sounds and chest rise, and rising oxygen saturations.

Post intubation analgosedation was with fentanyl bolus and drip, and propofol.


Holy Sh-t, Right!!!

Update: See this amazing story posted on G+ Community as well

Now, on to the Wee…



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  1. Taylor Zhou says

    What was the difficulty with the AFOI attempts? Could not see laryngeal inlet? Could not pass vocal cords? Would a transtracheal catheter have provided more oxygenation and time for FOI attempt?

    • says

      Anesth. could not see laryngeal inlet. I couldn’t see anything recognizable on the glidescope screen on the 3rd look. There was a total of an est. 8 min of FOI attempt, there was no request for another look from anesth. after 3rd look when I said we should proceed to cric.

  2. says

    It is almost a year since Scott helped me with the Difficult Airway course for Critical Care physicians since then I have done 5 surgical airways. We are preparing to have another course and refresher, it is amazing how many individuals who believe are experts on the airway have not done surgical airways or even practiced how to do this.

  3. says

    Great case, I guarantee your case takes anyone who has had to perform an emergent cric right back there. My last one was an inhalation burn case, and I promptly needed to head out to ambulance bay for a moment of recovery.

    I think we need to get together an EM surgical airway registry. They are rare but we do them. Depending on the anesthesiologist, they are often less prepared mentally and practically for this scenario than we are.

    I had a question. Was there any discussion of an attempt that did not involve AFOI off the bat? Maybe RSI, maybe Ketamine and a look with VL? I sometimes feel in a case that is headed for a surgical airway no matter what, anesthesia often “hedges” with AFOI, when we know that RSI will give you the best chance and best view first time out. My general experience with FOI is that it is poor sometimes for distorted anatomy, because of the limited field of view. if you can’t identify landmarks your lost… On the other hand VL with a smaller blade often gives a better global view and opportunity to orient yourself. Thanks again for sharing.

    • says

      He had extremely poor mouth opening, I was surprised that the glidescope was able to fit. In a do-over I would consider trying a right paraglossal look with a miller blade. Most of my mental energy was spent on prepping for the surgical airway, and AFOI was the only realistic option I considered from above. I am glad we did not paralyze him given the difficult time we had bagging him while spontaneously breathing.

      • says

        Rob I think you made the right call. Anatomy appeared far too difficult to risk paralyzing — that’s the second most important decision we make in airway management (first is the decision to intubate, of course)

    • says

      No we did not call ENT, he was profoundly unwell, and I did not think we had time to wait for ENT to perform the procedure in the OR. He was looking sicker (increasing HR, decreasing responsiveness) in the 20 minutes we spent getting everything set up before the AFOI attempt.

  4. says

    Amazing case, thanks for sharing & great discussion!

    This case highlights one of the drawbacks in “calling for help” — sometimes the cavalry arrives without their horses.

    In your case, it was just the breakaway bite block. But I have been involved in a number of cases the backup arrives with just a Mac 3 and a big syringe of propofol, despite going through some of the specifics of the case and specifically requesting advanced equipment (eg FOI).

  5. Ryan J. says

    I would like to comment that as a trained assistant to Rob Bryant, I had the Ketamine in hand and had asked for a Cric Con. Since, there has been a lot of training in our department; via conferences and “trauma optimization” this had a good outcome for the patient. Rob failed to comment on, how shaky his hand was and how he could have benefitted from some stabilization.


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