This is the resource page for all things Crics (Cricothyroidotomy)
We spoke a ton about cricothyrotomy way back in episode 24; this is an update
Cricothyrotomy on an Actual Patient
Watch this video before going forward
Order a 3D Cric Model to Train on
Don't do anything else till you take Laura Duggan's free 3D plans and print out your own model
Best Case Series
Paix BR, Griggs WM. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel-finger-tube' method (PMID 22313556)
Review Article
Especially keen on the parts of this cricothyrotomy article that discuss the failures of non-surgical techniques
You probably would benefit from this Systematic Review of Cricothyrotomy as well
Understand the Surgically Inevitable Airway (thanks, Rich)
In appropriate circumstances (prophylactic cricothyroidotomy) has numerous advantages, not least the potential to secure and check the ‘rescue airway' in a calm and unhurried manner, without hypoxia, before an emergency arises
— NAP4 Study (Page 112, bottom left)
Anatomy
- Watch Andy Neill's incredible Surgical Airway Anatomy video so you know where to go
- and see Richard's Slides here
- Want to find the membrane by ultrasound? [cite source='pubmed']25991744[/cite]
- Or use Rich Levitan's Laryngeal Handshake
We Suck at Finding the Membrane
(Acad Emerg Med 2915;22:908)
The EMCrit Method is from the Notch Upwards
The method of cricothyroid membrane location that I have taught in the EMCrit classes has now been validated as superior in an RCT. Always go from the notch up rather than from the top down. [10.1213/ANE.0000000000005744]
Use a Checklist so you are Ready!
CricCON2
Here was the original CricCON Wee
ANZCA report on transition from supraglottic to infraglottic airway (they ref CricCON2)
Which Trach Should you use?
- This one
- Or, less preferably, a 6 or 6.5 ETT (confirm your bougie fits well before you ever do an actual cric)
Needle Cric
I don't recommend this method, but some just will never feel comfortable cutting the neck
- Needle Vs. Knife, Part I
- and More from Minh
- The amazing Andy Heard has a slightly different method he recommends for anaesthetists, who may be less comfortable wielding a knife
Some Evidence I Like
- Best review demonstrating the lack of goodness inherent in needle techniques (BJA 2015;114(3):357)
My Current Cric Method
and
See it on a Real Patient
see this post for full attribution and explanation
Other Cricothyrotomy Lecture Videos
- Andrew Heard’s Videos
- For historic interest only: The Standard Old-School Surgical Technique
Ultrasound Guidance
- Anesthesia & Analgesia 2018, Volume 127 (6), p 1377–1382. Practice of Ultrasound-Guided Palpation of Neck Landmarks Improves Accuracy of External Palpation of the Cricothyroid Membrane
-
Anesthesiology December 2018, Volume 129 (6), p 1132–1139
- Inverted V
- 10.1111/anae.14485
Build a Cric Trainer
Watch the EMCrit Cric Trainer Podcast
- From Chris Bond
- Then use Laura's 3-d Model as the basis
Manikins seem better than porcine1
Why Scalpel and Twist Method Fails
Failure of the leaving the scalpel in and twist method
How to Run a 1 Hour Cric Course (It only took 8 years of trying to get it right)
EMCrit 248 – How to Teach Surgical Airways – you knows, Crics: The One-Hour Cricothyrotomy Course
Here are My Slides
My Cric Show with Dennis Kim
Additional Refs
- 20 year experience of prehospital cric
- Anesthesiologists to temporary surgeons paper
- Updated Cric Model
Additional New Information
More on EMCrit
Additional Resources
- Riggsy on Mental Scripts for the Practice of Crics
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Now on to the Video…
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 383 – The Ultrasound Hierarchy of Needs in Cardiac Arrest with Mike Prats - September 6, 2024
- EMCrit RACC Lit Review – September 2024 - September 3, 2024
- EMCrit 382 – A Deep Dive on Vasopressin: Timing, Push Dose Vaso and the Vasopressin Load Test - August 23, 2024
Do you still use a tracheostomy tube if available? I’ve only used ET tubes for crics, mainly due to availability and also being more flexible. I once tried to replace a regular trach over a bougie and found the rigidity made it difficult. On the other hand it can be challenging to secure an ETT in a cric and they easily migrate into the mainstem. Has anyone tried using a soft silicone trach tube over a bougie?
6-0 portex works beautifully and the ability to secure is much better than ETT
I recorded a real life surgical airway from the TV show Inside Combat Rescue (NATGEO). I use that video on my classes.
If you want me to send you the video email me to Sebastian@mayanz.cl
May you simply share this video ? Via Yutube or whatever. That’s probably a high value material for teaching
Scott, Great episode- it’s great that we are embracing the fact that performing a surgical airway isn’t a failure and sometimes it should be the primary technique. You mentioned in the updated CriCon that you only mark the neck and have the cric kit at bedside for the anticipated “risky” airways. Why not mark the neck and have the cric kit within arm’s reach for all airways? I started routinely marking the neck on every airway and I have gotten feedback from the other docs and nursing staff that they like this approach. They have seen too many airways go… Read more »
Steve,
got no problem with that–but if you feel the neck, have the kit in the room, and announce the end of the airway plan is cric, that seems enough for most situations. if you want to mark everyone, i say go for it.
Hi Scott,
Thanks for a fantastic talk. I completely agree that just by picking up a laryngoscope you are commiting to a cric if need be.
Speaking as someone who’s never done one in anger, is the longitudinal incision necessary? If you can feel the anatomy, why cant you just do the transverse incision to save time and cut down on bleeding (even though as you say, the bleeding it’s self is no big problem). What problem would i create for myself by doing this?
Thanks,
Stuart
Anesthesia/ICU resident, Stockholm, Sweden
we generally advocate to train for how you fight. this seems like a perfectly rational idea now (and it is), however when you have to actually do this you will fall back to how you trained. you should train just one way and do it continuously. hence the lack of an option to diverge based on anatomy.
Great talk, Scott. We use at fast stepwise approach to locate the cricothyroid membrane by US egen we are in CRICON yellow.
http://www.anesthesiologynews.com/download/Ultrasound_ANGAM2013_WM.pdf
We feel this ads substantially to Safety during airway management.
like it! the ultrasound podcast guys did a whole series on this
Scott- awesome talk. Amazing how it doesn’t matter how many times I have heard you speak about a topic, always seem to pick up on new subtle things. Wondering if you have ever personally incorporated u/s into your cric, or at least used it for your cric planning/marking in the morbidly obese pt..?
yes, for awake intubations i scope out the neck with ultrasound first
I like the subtle removal of the glasses. Great talk!
: )
I’m going to ask what may be a very silly question. Once the cric is completed, and the patient recovers from their illness. Does the membrane grow back? Do they do fine without it? Does it require surgical repair by ENT later on.
they do just fine without repair–as it is not done, same for trachs. Not sure how much of the membrane heals if any–can just tell you the skin is closed and it heals well.
Nice podcast.
Andy Neill’s video link here is dead. It has moved to a new link.
Thanks
thanks so much!
Hi Scott. Fantastic as always! For how long do you think is safe to leave the cric before converting it to a tracheostomy?
the idea that it has to come out right away has been debunked by the recent ENT literature. Prob. a few days is fine. Depends on whether you have a long unstable ETT sitcking out of the hole.
You can use a stitch-cutter! I just did a cric´ today. But I have to tell you that I´m not an expert on this because it only was my second “real life cric”. Without discussing the case there are two things i want to point out: 1) You can use a stitch-cutter to do a crick. If you want to stop reading at this point this was the most important part. 2) The roundes shape of the blade was very useful! I used a stitch-cutter this time because in the situation it was the only “surgical knive” availeable in the… Read more »
You can use a stitch-cutter! I just did a cric´ today. At this point I have to tell you that I´m not an expert on this because it only was my second “real life cric”. Without discussing the case there are two things i want to point out: 1) You can use a stitch-cutter to do a crick – it works really well. If you want to stop reading at this point this was the most important part. 2) The roundes shape of the blade was very useful! I used a stitch-cutter this time because in the situation it was… Read more »
Simply awesome videos and talk, and very slick! Two quick questions from a Canadian Anesthesia resident: 1) How big is the risk of cutting yourself on bone when sticking your finger into the cricothyroid membrane? I’ve heard some say that a Trousseau dilator should be used instead and to avoid inserting the finger into the hole because of this risk. 2) What is the chance of a Cric leading to voice problems in the future? Ie. damaging the muscles controlling the vocal cords? Thanks a ton and thanks for all your amazing work, it is hugely valuable for me as… Read more »
Great post. Thank you.
The one thing that I have not seen on any of the videos or heard described is how to secure an endotracheal tube that is used for a cric. Could you please comment on your best practice for this?
circumferential taping is the only way–it is not a good way. it is why i prefer trach tubes. i would try to get these tubes changed out to an ETT from above as soon as possible. I’ll post on how to get that done soon.
Hello Scott!
I attended the SMACC airway pre course in Berlin. Thank you for a very educational course. Now to my question. You had a 3D printed model for the surgical airway and stated that the model would be posted here on your site. I can´t find it. When will it be posted?
Best regards
Jonas Westman
I could not find the video. I did see a live performance video and the slides… it said Video does not exist
Esta muy bueno!! Excelente video
Hi Scott, there is an even better 3D model for practicing cricothyrotomy described in this publication in the European Journal of Anesthesiology:https://pubmed.ncbi.nlm.nih.gov/34617924/The model can be downloaded freely. The cricothyroid “hole” in Laura Duggan’s model is quite big, which can lead to false security when praticing with her model. Best regards, Nils.
Laura’s model is taken from an actual male trachea and the “hole” is perfectly commensurate with the male crics I have performed. Her original model did have the space between the hyoid and thyroid, but we chose to eliminate to keep the models more durable–I can argue for the benefits of both directions. I very much like the idea of having a trachea by making the distal end a tube connector.