Cite this post as:
Scott Weingart, MD FCCM. EMCrit Wee – Bougie Prepass and CricCon for Difficult Airway. EMCrit Blog. Published on July 4, 2012. Accessed on January 20th 2025. Available at [https://emcrit.org/emcrit/bougie-prepass-and-criccon/ ].
Financial Disclosures:
The course director, Dr. Scott D. Weingart MD FCCM, reports no relevant financial relationships with ineligible companies. This episode’s speaker(s) report no relevant financial relationships with ineligible companies unless listed above.
CME Review
Original Release: July 4, 2012
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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I agree Scott. If you dont subscribe to EMRAP audio, do so NOW! The airway corner monthly instalment with Darren Braude is always GOLD! This months episode is a real case discussion of a CICV situation, mainly due to extreme hypoxia. An initial intubation attempt with VL actually got a look at the cords but the tube could not be passed due to rapid desaturation. I have commented on EMRAP already but one strategy for these forced to act RSI situations..I know Scott you do not like the term as it means a degree of loss of control..but in these… Read more »
CricCon is predicated on the double set-up, so I absolutely agree. Can’t rehash the whole needle cric debate except to say that CricCon 3 would work just fine as the time to place and confirm the 18g angio, and CricCon 2 would have you passing the wire and making the scalpel cut.
Thank you for highlighting this interesting and educational case Scott. I agree with Minh on the placing a 18g cannula with Melker kit ready pre RSI. I have utilised this technique successfully in a case of angioedema previously. My one concern pertains to the utilisation of extra help. I just want to highlight the difference between competence and expertise in certain rarely performed task (surgical cric being a good example). All emergency and critical care physicians should be competent and willing to undertake such challenging awake intubations with extreme physiology and proceed to surgical cric if necessary. In certain resource… Read more »
Peter, your comments are well taken. I am always v. reluctant to latch on to specialties, especially in the States where things are a bit more difficult to parse. Based on NAP4, our EM folks are doing far more of the emergent airways than their EM counterparts in Great Britain. I would take your sentiment to its heart, which is to bring the most experienced folks immediately available to bear. I would gladly step aside for an experienced ENT attending/consultant for the cric, but at the same time I am sure I have performed more emergent crics than any of… Read more »
a couple of weeks ago, a Spanish EM doc tweeted about a case he managed of a critically hypoxic OD patient who they were unable to preoxygenate using usual means for RSI. He remembered the needle cric oxygenation technique we had debated on EmCrit and inserted a 16G cannula via .CTM and oxygenated the patient up to 100 % by just holding the oxygen tubing to the cannula hub, intermittently at a ratio of 1:8 ..then did a successful RSI ETI. It works and Peter I am sure can attest to this as well as I can. Scott though is… Read more »
I agree completely on the ‘never equate job title to relevant experience’. The case of angioedema I mentioned the surgeon I question I called was very confused as to what help he could offer given he had never done a surgical airway! Moral of the story the most experienced person for the job should be present in challenging scenarios. As for the needle vs surgical cric argument I sit on the fence. I do a lot of awake needle crics for flexible AFOI to anaesthetise the larynx. IF time allows pre-induction and you are skilled in the technique then a… Read more »
Sorry published too early!
In CICV and CICO scenarios the surgical cric is probably the technique of choice and my preference. The NAP4 highlights the success rates of the surgical airway and superiority over the needle cric in stressful environments. But there is no right answer for all clinicians, you can only put forward the evidence and hope individuals extrapolate it to their practice in a way they feel comfortable with.
Kindest regards,
Peter
Lovely debate with no right answer! I must confess my use of needle crics its restricted to a very select patient group and a surgical cric would be my technique of choice for the majority of difficult and stressful cases.
On the topic of operators for surgical airways in the States, I read this interesting paper recently on a decade of practice in Boston trauma centres. Does this break down reflect practice in your centre Scott?
http://www.ncbi.nlm.nih.gov/pubmed/22205011/?
very few crics occur at our shop outside of trauma. For trauma we splite procedures by day between surgery and EM. Crics probably split about 60% surg and 40% EM. We have quite a few EM attendings that will step up and cut if necessary, but would much prefer to have the surgery trauma chief perform the procedure if he or she is already present.
While listening to this podcast, I couldn’t help but to think back to an article I had read the previous evening. The article was about a group that is working on a way to infuse oxygen in a liquid solution directly into ones vein. If this pans out it could certainly make situations like the one Darren was faced with much easier and safer to manage.
The article is below.
http://www.sciencedaily.com/releases/2012/06/120627142512.htm
Yep, can’t wait to see if this stuff pans out
What an amazing case and a great discussion. I love the CriCon levels- it makes you aware of the fact that even what seems like a “routine” or “easy” airway may need a cric. I for one will be doing a better job of predefining the cric anatomy before I start an RSI- we should be doing it on all our patients. As far as the patient discussed on EM:RAP- a tough case with no easy answers and the treating team did their absolute best. However, I am sure that they put this out there for discussion, dissection, and debate.… Read more »
Steve–I think it is a suggestion that must be thrown into the mix. Darren and I both lecture about the awake cric and you can argue this may be another way this case could have gone. I don’t think a paralyzed cric would be my first choice; I’d probably give at least one try at intubation from above, then proceed to cric. I will put one more idea out there that I did not want to mention in the show, b/c unless you have done them and have the right equipment, they can be a clusterfuck, but I think I… Read more »
Scott, if you are going to take the trouble to cannulate the trachea via the CTM, you might as well pass the wire and do a seldinger cric if you got a Melker or similar seldinger Cric kit.
can’t say I agree. Awake retrograde gets you a patient intubated from above and just a needle-hole through the membrane without losing anything if you fail. Melker cric is much more invasive and then pt still needs to be intubated from above or trached.
disagree. the gear to do awake retrograde intubation is even harder to find in any department let alone in an assembled kit. you need a wire then something to pass over the wire to cannulate the trachea..from an oral route. an airway exchange catheter or bougie with a lumen might work over the wire. Not all ED bougies I have seen have a lumen. but all that is a lot of screwing around in a time critical situation when the patient needs oxygen. If needle in trachea, then give oxygen via it and let the oral intubator have another look… Read more »
Phenomenal case discussion, Scott! I will give bougie prepass a shot; I dig the concept, as I hate having to look up once I’ve locked eyes on cords. Regarding the discussion of going straight-to-cric; my take is that rarely, it can be a reasonable answer, if you look at a patient and say to yourself, “there’s no possible way I can ever intubate that guy from above.” (Think Pierre Robin syndrome with angioedema and simultaneous posterior epistaxis.) That wasn’t this patient. I like the concept behind CricCon: a defined stepwise progression of readiness. But I wonder, half seriously, if equating… Read more »
nuke war comment is fair, we got similar comments re: SimWars.
ignore the detractors. CricCon is brilliant concept. genius in fact. The terminology is not what engenders the fear. Its the traditional notion that it is a procedure of failure. Its our very attitudes as airway teachers that promulgate the fear. Braude’s attending colleague in the EMRAP case articulated her own prejudice about cric which underscores the origin of the fear, Folks, Scott receives regular emails from docs around the world , thanking him for demystifying and reducing the fear around surgical airways and indeed for helping save lives with his surgical airway training concepts and tips. So whatever concepts in… Read more »
Great advice and discussion as usual. You enrich my practice so much i get teary eyed .
I have marked the cric for a long time. I do it horizontally along the cric membrane. Never had to use it since ive done this tho (altho have done 6-7 crics before). do you think it would be better to mark from thyroid cart vertically? or wouldnt my horizontal mark be better?
don
I make two cuts so I mark the vertical. If you are a 1 cut guy, make it a horizontal mark. Or go by the pt’s anatomy. Horizontal if you can feel the membrane; vertical otherwise.
I am vertical cut guy. Horizontal is fine if you can feel the anatomy. First time you get a case where you cant feel anything, like Andy. Buck’s fractured larynx case we discuss on the latest PHARM podcast, you will regret having never trained the vertical incision. If you get a tracheal transection as some mates of mine had a few years ago, the horizontal cut will get you no where .I saw photos of their vertical cut from floor of mouth to sternal notch and they did find the distal transected trachea n the mediastinum, Guy made a full… Read more »
Scott, where are the pics for the swivel adapter set up?
don
Take a look here
Minh- Your objections are exactly why I put retrograde only in comments and not in the main show. If you are going to even consider the technique, you need a few things: Either a commercial kit or a bougie with a lumen and a LONG wire. Just as you imply, ET over a wire is a joke familiarity with the equipment and technique before trying it on a pt a spontaneously breathing patient Retrograde has gotten a bad rap b/c people think it is a failed airway technique. It is always a flail for that. It is an awake intubation… Read more »
Many times during intubations, easy or not, anterior neck manipulation is required. It would be difficult for the airway operator to fully “attempt” the tube placement without this maneuver. Obviously at level 3/2, this would be difficult and may contaminate the sterile field. Ways around this could include a sterile glove on the right hand of the intubator. This would allow for either manual manipulation and/or “hand holding” with the cric person until the cords are seen. At this point, the cric person could hold cord position and the sterile field would not be lost, just in case. Comments
it’s a great point; i’ll tell you what my bosses told me when they were training me to do OR trachs–if we think this is a sterile procedure, we are crazy. The betadine makes us feel better, not the pt.
Friends! Interresting discussion! As a second-year resident in anaesthesiology/intensive care-medicine (same residency in Sweden) I have only been in this kind of dramatic situation one time. I performed an open cric with scalpell, and was struck by how difficult it was to get the tube in the airway (BMI 57…). A bougie saved the pt (and my) life after a few pretracheal placements of the tube. Now, when I have the attention of all the airway-management-silverbacks, I would like to hear your thoughts in a matter: You are discussing the use of a 18 G needle placed in the membrane… Read more »
Dear Scott et al., Thanks for another great post and interesting discussion. I recently had similar (although less challenging) patient with terrible ARDS who was refractory to preoxygenation. I did an awake intubation with ketamine and a glidescope. High-flow nasal cannula was used throughout the procedure so that the patient kept on breathing highly oxygenated gas and maintaining her lung recruitment. The patient did desaturate during the procedure but her saturation plateaued in the low 80s and stayed there (without plummeting to zero). I think an awake intubation strategy plus high-flow nasal cannula oxygenation is a good approach to patients… Read more »
Josh, you are dealing with shunt at that point. You are correct that the pt shouldn’t plummet and intubation doesn’t need to cease. You might want to consider placing a bronch port onto a facemask and doing the awake on CPAP.
big fan of this Cricon idea. Simple question re jargon – you mentioned you marked up the cric site with an “industrial sharpie”. What is this? You suggested to see your ACEP lecture but I’m not sure which lecture this is or where it is located.
thanks for assistance
I love these markers. And they stay sterile patient to patient according to this study.
ah a marker, cool