Cite this post as:
Scott Weingart, MD FCCM. Guest Post: More from Minh Le Cong on Needle Cricothyrotomy. EMCrit Blog. Published on February 17, 2012. Accessed on January 17th 2025. Available at [https://emcrit.org/emcrit/more-needle-cricothyrotomy/ ].
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: February 17, 2012
Date of Most Recent Review: Jul 1, 2024
Termination Date: Jul 1, 2027
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Would you change the I:E ratio or flow rate if you were using this during a pedi cric?
Hi Chris. Yes I would. APLS teaches 1L/min/year of age. thats a reasonable rule of thumb. but it really depends overall on what you think you are dealing with. with suspected complete upper airway obstruction, you have to be very careful. the work of Black et al using low flow TRIO in an animal model was compelling. 2L/min rescue oxygenated from critical hypoxia within 30 sec of initiation. in paediatric resuscitation the research is very scant to guide us but overall in an emergency for kids, 2L/min would be reasonable as a starter if you are unsure. You can look… Read more »
Excellent, thank you! Does guidance exist for the choice in catheter size in peds? Also, would switching to a bevel down approach perhaps be warranted (per the recent literature in switching to this method for IJ cannulation) to reduce the possibility of posterior wall damage?
Hi Chris. I am unaware of any research published about using a bevel down approach to reduce injury to posterior tracheal wall. This is of course a recognised complication of the needle cric technique. if the neck skin is tough, it is easy to use excessive force and injurethe posterior tracheal wall. if need be to minimise the risk, making a small skin nick with a blade prior to needle insertion may help. it depends though how critical the situation is. if its a rescue oxygenation situation then it does not matter. if its a situation where you can oxygenate… Read more »
Thank you for an interesting follow-up to the Needle vs. knife-podcast, Minh. As a nurse anesthetist I agree on your recommendations for needle cricothyrotomy as the primary rescue airway in a CI/CV situation. I also agree that in most situations, without any personal experience though, you would probably also get passive expiration through a partially obstructed airway, even in situations where ventilationattempts with BVM/SADs fail, and the airway seems totally obstructed. The main problem is then the really totally obstructed airway, and the risk for barotrauma. About a month ago I became aware of a jetventilation-device called Ventrain, which uses… Read more »
thanks Lars that looks quite novel. I had read about the design of the Ventrain but never seen one used. It seems to address the main problems of emergency needle cricothyrotomy based oxygenation using high flow systems, typically at 15L/min for adults…expiration and build up of excessive pressure, in particular with the near completely obstructed airway. In my experience the manual holding of the oxygen tubing to the catheter hub and taking it off is practical and effective in the emergency setting. A colleague and I had one successful case of a child with epiglottitis,rescued with this technique after failed… Read more »
Lars, I wanted to add that in my view you cant always rely upon one technique in the CICO situation. There will be cases when needle cric will have a high failure rate if not impossible. if you transect your trachea, the needle will fail always. colleagues of mine had to deal with a real case of this in WA.
Thank you for your comments, Minh! This post was very interesting, and the Needle vs Knife-podcast really was a eye-opener for me to the fact that the needle technique has such a low successrate, according to some of the studies mentioned. The use of the tubing directly on the needle was new to me too, simple and easy! I’ve never heard about the “low-flow” option either, many good points! Hopefully, I will never have to deal with such a situation where TTJV is impossible. As a nurse anesthetist, without “the license to use a scalpel”, needle is my last chance.… Read more »
18 G or bigger is the way to go. Adult and kids. The Black et al study of low flow rescue oxygenation used a 15 G catheter. honestly , use something big whatever you got.
the caveat about initial insp time with this technique is reversing the lung collapse during apnoea. In the scenario of a failed intubation and a period of apneoa, there will be collapsed lung to overcome initially. Providing an initial longer period of inspiration wiht the needle cric may be optimal but not proven yet. Certainly a low flow rate seems to be enough to provide rescue oxygenatioon in the animal model.
Lars & Minh, Regarding the ventrain: I think this device has many advantages and is probably the best commercial option I have seen thus far. That being said, any of these devices scare me b/c of the cognitive dependence they encourage. If you train with a ventrain and then it is missing, there is a barrier to saving the patient while someone is looking for a replacement. Minh’s concept of oxygen tubing held (not attached) to the cath hub is the CLEANEST technique I have come across. It has changed my teaching entirely. In cric situations, needle or surgical, I… Read more »
Let me share with you a frustrating, somewhat humorous anecdote from a retrieval I did 2 days ago. We were flying a ventilated patient. OUr drug and airway packs are kept stored in slide out drawers in the aircraft. Well one of the drawers containing our airway pack decided to get stuck and refused to open. This pack has all the laryngoscopes, bougies, stylets and ETTs! I thought what do I do now if we get a cuff leak and I need to exchange the ETT?? Yes Scott’s right. We should not rely upon certain pieces of gear to always… Read more »
Hi Minh, I work in a small provincial hospital in Gisborne, New Zealand (on the East Coast of the North Island). One of my colleagues was recently called to a respiratory arrest in the surgical ward. A middle-aged man with a throat malignancy had been admitted for an elective tracheostomy the following day. Unfortunately he developed a complete airway obstruction, had a respiratory arrest and lost consciousness soon after admission. Due to problems locating the ‘Difficut Airway Trolley’ my colleague did exactly what you recommended in your video i.e. inserted a 14G angiocath through the cricothyroid membrane and connected it… Read more »
Hi Tom
Is it possible to invite your colleague to do an interview with me via Skype on his case ? You can contact me via my email, mlecong@rfdsqld.com.au
It would be great to record the details to share to colleagues who might find themselves in exactly in the same situation one dark night shift!
Imagine one dark night you are working late in the hospital, when a patient is admitted for tracheostomy the next day due to a laryngeal tumour. imagine you are called to this patient who has developed worsening airway obstruction and he suffers a respiratory arrest and goes blue in front of you. Imagine you have no useful airway equipment nearby….what do you do? Start CPR? get a knife from the dinner trolley? Try a digital oral intubation? This is what you do. You run to the IV trolley and grab a 14G needle cannula. You run back and insert this… Read more »
It had to be done, so I did it is the line of the year!
Tom, thanks for the great feedback. You have made this dreary week so much brighter for me! God speed and all my prayers to you all in your next resuscitation. I dont believe in dificult airway trolleys any more based on similar bitter experiences. I think the best difficult airway gear is what you can carry in your pockets and the thing between your ears. If it cant fit in my pockets I am suspiscious that when badness visits, it will not help me…but then again I have pretty big pockets. Airway kung fu, folks. Bruce would have been proud… Read more »
Tom fantastic work! Minh-best line of the year, “the most important equipment to manage a difficult airway is carried between your ears.” love it!
Must read post (and comments!) on emergency airway management and needle cric – it changed my thinking http://t.co/JSHtqXkd
It had to be done, so I did it is the line of the year! See Minh’s story in the comments of this post: http://t.co/4uxkrUVt
I just saw this post today- reminded me of many experiments I did (with fake lungs/trachs, etc) while I worked for a prehospital service where needle cric was an important option in our protocols for inability to ventilate noninvasively. I spent a lot of time sitting on the floor making many many variations of improvised devices. The three-way stopcock method Minh shows in his video was one of the iterations but I decided I would be uncomfortable with it in the field primarily because it tended to allow huge pressure build-up in the lungs if there was obstruction (or even… Read more »
The best paper on this issue is
– Anaesthesia 2009;64:1353
Shows inadequate exhalation with stopcock or catheter in general
and the similar study
– Pediatric Anesth 2009;19:452