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)
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
- 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
Here are My Slides
Now on to the Video…
Scott Weingart
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I like the subtle removal of the glasses. Great talk!
: )
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
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 south due to a lack of adequate preparation and equipment availability. I know it seems like overkill but I think it sends a powerful message to everyone in the room that we are mentally prepared to do a cric if needed. True story- I was working at a community ED when I was called up to the ICU to intubate. As I am preparing my equipment one of the nurses says “What’s the scalpel for” I said “That’s in case this airway goes south” HIs response “Why doesn’t everyone do this?” Good question! (And, of course- the airway was a… 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’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.
[…] Things Happen and the Airway chapter has multiple links out to Scott Weingart’s podcasts on Surgical Airways. Crucially, the links work across all versions too, so information and links should transition […]
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.
[…] This was a Pre-hospital case, an elderly patient who had been smoking with his home oxygen nearby. He had sustained severe facial burns. Although he was fully conscious on the HEMS team arriving, it was pretty evident that his airway would deteriorate rapidly and we were in the middle of rural England, with the nearest Major Trauma Centre 1hr away. It ended up being a difficult intubation eventually leading to a can not intubate, can not ventilate (CICV) situation. I had reflected a lot on this case and for the case debrief, had written some personal learning points. A few months previously, i had given a talk to paramedics and doctors on surgical airway. This was essentially an amalgamation of Scott Weingart’s SMACC talk (https://emcrit.org/podcasts/surgical-airway/) […]
[…] Cricothyroidotomy is the final common pathway for the cant intubabte cant oxygenate scenario. As I mentioned in an earlier post I am an advocate for open cricothyroidotomy because the evidence from the NAP4 report on over 3 million complications in airway management suggests that needle cricothyroidotomy fails 60% of the time. Scott Weingart gave a nice talk on the subject at SMACC Gold […]
[…] I won’t rehash them here, but instead point interested people towards EMcrit here and here respectively…. but what of the humble LMA in our airway […]
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 very moment. I performed the cric while the emergency-team continued the chest compressions (CPR-situation) – I´ve to tell you that it not only wasn´t a problem at all with the stitch-cutter – in my opinion there are some advantages using a stitch cutter.
The incission of the skin was no problem.
Because of the rounded blade it was very easy to do the stab-incission without getting to deep (under chestcompressions).
It also was very easy to widen up the stab-ibcission.
After anonymizing the pictures i can provide some.
Best regards Kostja Steiner
Anesthesiologist, Graz, Austria, Europe
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 the only “surgical knive” availeable in this very moment. I performed the cric while the emergency-team continued the chest compressions (CPR-situation) – Wat I want to tell you is, that it not only wasn´t a problem at all with the stitch-cutter – in my opinion there are actually some advantages using a stitch cutter. I have to state that this is a very personal opinion and I can only compare it to one cric i did with a regular scalpel but I think its worth mentioning. The incission of the skin was no problem. Because of the rounded blade it… Read more »
[…] To learn more about technique (and pretty much everything about the surgical airway), click here…EMCRIT SURGICAL AIRWAY […]
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 a trainee in Anesthesia!
-K
[…] https://emcrit.org/podcasts/surgical-airway/ […]
[…] It will come as no surprise to hear that Scott Weingart headlined the surgical cric station. He has become renowned for his podcasts and lectures on the topic, and gave a talk entitled “Cut to Cure” at the RCEM Scientific Conference, held in Manchester, UK late last year. You can see all of his resources and listen to the podcast on his website – EMCrit. […]
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.
[…] is embedded in a blog post full of resources that Scott Weingart, MD published at […]
[…] Scott Weingart’s EMCrit post on surgical airway […]
[…] EMCrit Podcast “Cut to Air: Emergency Surgical Airway” (Blog Post with Resources) […]
Surgical Airway, Cricothyrotomy, aka the Emergent Cric
[…]I just watched a woman go through a liposuction while AWAKE by a doctor in Indonesia on the suggestion of her BOYFRIEND. Women trying o![…]
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
[…] Surgical Airways by Scott Weingart (EMCrit.org) […]
[…] Surgical Airways by Scott Weingart (EMCrit.org) […]
[…] EM Crit – Cricothyrotomy […]
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