So I had no plans to discuss this topic and I still feel it will be net negative. However, it came up on a recent EM:RAP piece and I therefore felt that I should address it.
Well, I got my butt dragged here, so let's get into it…
Patient Selection
Retrograde intubation is an older technique for patients who are still breathing (awake in the Resus world, sedated in the anesthesia world). I have seen in the past that elective cases may done with an induced patient–THIS IS NOT APPLICABLE TO RESUS!
Site of the Puncture
In a study on fresh cadavers, the incidence of damage to the vocal cords was 8% from needle cricothyrotomy [, , , . Retrograde intubation using the subcricoid region (Correspondence). British Journal of Anaesthesia 1992; 69: 542–5] at cricothyroid and 0% at sub-cricoid. Also a much higher rate of success subcricoid
Needle Choice
Should we be using a micropuncture set?
Otherwise the angiocath in a central line set
Can use bare needle, but potentially more risk of injury
Puncture Angle
90 or angled?
Anesth
Make a nick on skin
Wire
J-Tip
Stiffer
Double the size of ( ETT (35 mm with connector for 8-0) and (distance from mouth to cricothyroid ~18cm)), so at least 100 cm is what we are looking for
Angio wires are ideal (10.1097/HN9.0000000000000016) 140 cm such as the Amplatz Stiff Lineup J tip 145 cm
Looking in the Mouth
McGills and video laryngoscope are ideal
May also pop out of the nose
Throw on a Hemostat
to keep the wire from migrating
Intubation Using Wire Only
Throw a bougie down the tube
[, . Guided blind oral intubation. Anaesthesia 1980; 35: 921 and IP Latto, RS Vaughan, eds. Management of difficult intubation; Difficulties in tracheal intubation. London: W B Saunders Company Ltd, 1997]
Tautness of Wire
Without an anterograde guide, the wire must be held taut enough to keep the ETT on target, but nit so tightly that it will rip tissue at the neck. This is sometimes a difficult balance, hence why anterograde guide is so key.
Intubation Using Anterograde Guide
Specialized Cook Set
or
Airway Exchange Catheter (83 cm length, 14 F or 19 F)
Intubation Using a Bronch Scope
Careful of inner channel
Pulling Out Wire
I like pulling out through the neck if I have used an anterograde guide
Complications
- Subcutaneous Emphysema
- Torn membranes
- Vocal Cord Damage
Oxygen
Hi-Flo NC real or Fake
Review Article
Anaesthesia – 2009 – Dhara – Retrograde tracheal intubation
Additional New Information
- This video is brutal and just another example of why retrograde probably should not be done without specialized equipment
- A video using the Cook Retrograde Set
You Need an EMCrit Membership to see this content. Login here if you already have one.
Now on to the Podcast
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit Wee (392.5) – Naughty or Nice? Bad Behavior in Healthcare with Liz Crowe, PhD - January 15, 2025
- EMCrit 392 – All Things Defibrillation with Sheldon Cheskes - January 10, 2025
- EMCrit 391 – Pericardiocentesis and Tamponade Temporization - December 27, 2024
A little off topic, but on the issue of the GI bleeding airway case mentioned, has anyone tried the SALAD technique where a large bore ETT is blindly placed (likely into the esophagus), cuff inflated and through the use of a meconium aspirator (with the thumb activator hole taped over) converted to suction diverting away all the blood, allowing then with the use of a second suction unit, to clear out the contaminants and proceeding with the intubation as normal? It’s been my plan if faced with that scenario (prehospital, paramedic), but I haven’t had a chance test it other… Read more »
yes, that is what i responded to the EMRAP with in my recording to them. The mec asp and suction is not even needed, just aim it at your buddy and let it spont drain.
very nice good articail.Mepco Bill Online Check Downloads
I agree with your sentiments here for the most part. I think there is still a role for this, but like changing religion, pursuing medicine as a career, or the impossible turn after aircraft engine failure, it is something that should always be discouraged and left only to be done by those very certain they are the exceptions. I’ve done one in a patient who could be bagged but not intubated, and was severely coagulopathic so there was little enthusiasm for open cricothyrotomy. I had an Amplatz wire and tube exchanger available so decided to give it a shot (and… Read more »
Before listening to the episode- my 2 cents is that retrograde intubation should largely be relegated to the trash heap- but if you are going to do it, you need to do it in the right patient and not spend so much time doing it that you cause harm when you should have just done the cric and called it a day. You can’t be what Rich Levitan calls “stuck on stupid” and keep trying to make it work when it’s not working.
Back in the day, in anesthesia training, we could practice this on patients coming in for elective laryngectomy for cancer. There was nothing difficult about their airways and it could be done under full general anesthesia. Since the entire larynx was being surgically resected, there was little concern for injury to cords. We are retrograde kits.