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)
Videos
- 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
- And here is the jet ventilation video:
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.
Additional New Information
More on EMCrit
- EMCrit 184 – Needle Cric (Again) and Transtracheal Jet Ventilation with Laura Duggan(Opens in a new browser tab)
- EMCrit 131 – Cricothyrotomy – Cut to Air: Emergency Surgical Airway(Opens in a new browser tab)
- EMCrit 62 – Needle vs. Knife II: Needle Thoracostomy (Decompression)?(Opens in a new browser tab)
- EMCrit – Wanted Dead or Alive, Your FONA Experiences(Opens in a new browser tab)
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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… Read more »
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… Read more »
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… Read more »
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… Read more »
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… Read more »
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… Read more »
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.
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!… Read more »
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.
My EMS service has adopted your trainer in our bougie assisted cric. Works great!
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… Read more »
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
Casey
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?
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.
for the readers, HUET is Helicopter Underwater Egress Training. Never heard about sterile cockpit before, fantastic rule.
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… Read more »
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… Read more »
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… Read more »
Jim,
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…
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… Read more »
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.
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?
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.
Hi Christopher
Thanks again for the info on the king vision laryngoscope
I ordered one yesterday and will let you know how it goes
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… Read more »
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.
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… Read more »
Hi Scott et al
I found this recent case report supporting the needle cannula cric technique during a hypoxic cardiac arrest post extubation
http://bja.oxfordjournals.org/content/107/4/642.extract
Check it out..it’s got some useful information.
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… Read more »
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!
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… Read more »
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!
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.
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… Read more »
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.
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… Read more »
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.
Were the videos pulled from the show notes? I’m not seeing any hyperlinks.
Thanks
Damon
videos are back
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… Read more »
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… Read more »
One option not discussed was using a 3.0 ETT adapter wedged into the hub of an IV cath or NDC needle hooked up to a bag-valve device w/ supplied O2 to provide positive pressure ventilation instead of apnoeic oxygenation. The 3.0 ETT adapter will fit in any size IV hub from a 10ga NDC needle to a 24ga IV catheter. I personally always thought I would do a tiered method of a quick needle crich with my 10ga NDC needle, connect to BVD using the adapter off of a 3.0 ETT while prepping for a definitive surgical crich. When the… Read more »