Today on the podcast, we discuss a little philosophy of crics, then go to an interview with Rich Levitan on a case of central airway obstruction that he saw.

Scalpel vs. Scalpel

Never Trust a Cric Dreamer or a Cric Ace

Never use the Chef Knife Scalpel Technique!

Rich's Airway Case

This is the email I received…

Airway enthusiast friends,

0330…working solo at critical access hospital (ED crew is me, 2 nurses)…50 year old woman with stridor, drooling, pulse ox 60%, heart rate 165, BP 90….history of weight loss for months, trouble swallowing, now unable to take any liquids and trouble breathing  for ~1-2 days.  High flow helped oxygenate for a few minutes but she would cycle down to severe desaturations and become semi-conscious. 

The woman had had an outpatient CXR a week earlier showing a mass…but she was not immediately referred for CT.  She had been having trouble getting a primary care appointment for months. Husband  right up front tells me he's angry, and they don't trust doctors. Asked me why his wife didn't get the CT scan sooner, even though he told her provider she was having trouble swallowing with weight loss.  A nurse practitioner had told her it was just GERD.

I told the patient and her husband, “I am going to knock you out with medicine and cut a hole in your airway to keep you from choking”….she nodded “yes”, and her husband said “Please!”.  He was in the room watching as I did it.

I gave a dose of Ketamine and cut her neck as my primary approach…didn't think she could lay flat.  There was way too much secretions, drool, and agitation to scope, and zero time. Any manipulations sent her into a coughing/choking episode with worse desaturations.

It was one of those “walk the talk” moments…I'm an airway enthusiast [“expert”–is a term I avoid]. No one cares—just get it done, or she's dead.  #10 blade, finger, 6-0 tube. Took under ten seconds.

I couldn't get her scanned…her airway was too unstable to allow it.  I spoke to a thoracic surgeon 90 minutes away who realized, as I did, that a lesion in the  esophagus was probably compressing from behind…and it might be too far down to bypass with a tube….and that it's acting like a flutter valve.  Basically she needed a stent or ECMO.  Best ventilation achieved was with bagging a decent volume–2 hands–but only 6-7 breaths a minute–she needed a lot of time to exhale–still we had to disconnect and suction every ten or twenty minutes when pulse ox would drop to 70's and lower.

Took four hours from arrival to finally get helicopter transfer out; she made it to the receiving center with continuing see-sawing episodes of hypoxia, but got a Y stent placed in the trachea at the carina.  Esophageal tumor is at the level of the carina compromising distal trachea and the proximal segments of both bronchi. May have TE fistula. It's a wonder she lived. Pics attached.

Definitely a case for discussion at my next airway course.

Central Airway Obstruction

• Central Airway Obstruction

Rich's Stuff

• Control-Cric
• USB Bougie
• Cric-Alot
• Practical Airway Course

Additional New Information

More on EMCrit

• EMCrit 248 – How to Teach Surgical Airways–you knows, Crics: The One-Hour Cricothyrotomy Course
• https://emcrit.org/cric
• EMCrit 231 – How to Practice Cricothyroidotomy (Cric)

Additional Resources

• Author
• Recent Posts

Scott Weingart, MD FCCM

Editor-in-Chief, at EMCrit.org

An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).

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