Prehospital Surgical Airways
As we have figured out by now, all our training and all of our efforts are useless without quickly, often aggressively, establishing and maintaining, complete airway control on all ill/injured patients with inadequate respiration . 99.9% of the time, airway control can be accomplished with basic or advanced airway maneuvers. But, its that one in a thousand patient, where the traditional means of acquiring an adequate airway fails, quickly creating a true life and death situation for the patient. Emergency prehospital surgical airways although rare, may be necessary at some point in your career, in order to save a life. Remember, if some sort of airway access can't be established when it is needed, proper respiration/ventilation won't take place, period. The patient is very quickly running out of time, before brain damage and tissue death begins (<4 minutes).
What do we do when all normal options to gain an adequate airway fail?
When the normal airway procedures; basic and advanced fail, a surgical airway may be required; ultimately preventing the patient's death. A surgical airway is one of the rarest and most invasive procedures performed in the prehospital environment. It requires special training and medical control orders, to attempt either surgical airway technique. An emergency surgical airway can be obtained in the prehospital environment by 1 of 2 methods:
- Needle cricothyrotomy
- Surgical cricothyrotomy
Of these 2 advanced methods, needle cricothyrotomy provides the simplest, fastest, and safest access.
A needle cricothyrotomy is a last ditch, very temporary procedure used in an effort to save a life, when all other means of accessing the airway have been exhausted. It is useful when the airway is completely obstructed as a result of:
- Edema of the glottis
- Complete upper airway obstruction
- Fractured larynx
- Severe oropharyngeal trauma/bleeding
- Airway deformity from trauma
A needle cricothyrotomy is used to provide air at high pressure oxygenation to the lungs. This is accomplished by cannulation of the trachea, below the area of the glottis. The procedure will deliver a large volume of oxygen (50 psi) through a small port at high pressure to the lungs. But, this procedure is temporary, at best! Rapid, safe transport is imperative for a positive outcome.
- A 12 or 14 gauge over the needle catheter with a 10 mL syringe attached
- Alcohol or Povidone-iodine swabs
- Adhesive medical tape or appropriate ties
- Pressure regulating valve and a pressure gauge attached to a high pressure (30-60 psi) oxygen supply
Note: Most oxygen regulators can provide 50 psi at 15 lpm oxygen flow
- High pressure tubing connecting the high pressure regulator valve to a hand controlled release valve
Note: A 5 foot tubing set is recommended
- A release valve connected by tubing to the catheter
Note: This may be accomplished using a "Y" or "T" connector, a 3-way stopcock attached to the high pressure tubing, or by cutting a hole in the tubing to provide a "whistle- stop" effect
Needle Cricothyrotomy Technique
- Make sure your patient is supine and in neutral alignment; if spinal injury is suspected, inline stabilization may be provided as in the procedure for tracheal/nasal intubation.
- Stabilize the larynx using the thumb and middle finger of your gloved hand. With the other hand, palpate the small depression below the thyroid cartilage (adam's apple). Slide the index finger down to Identify the anatomical structures of the neck.
- Cleanse the area thoroughly with alcohol and/or povidone-iodine.
- Insert the catheter of the syringe downward through the midline of the membrane at a 45 to 60 degree angle toward the patient's carina. Apply a little back pressure on the plunger of the syringe during the insertion. The entrance of air into the syringe indicates that you have successfully entered the trachea.
- Advance the catheter over the needle (again toward the carina) and remove the needle and syringe. Be very careful not to remove or damage the catheter while conducting the procedure.
- Hold the hub of the catheter to avoid dislodging it during ventilations. Remove the end of the oxygen tubing from the hub of the cannula and connect it to the oxygen regulator. A release valve should be added so that when it is closed, oxygen under pressure is forced into the trachea. The pressure is adjusted to a level that will allow adequate lung expansion.
- The patient's chest must be watched closely for proper rise and fall. The release valve will have to be opened in order to allow exhalation. The correct ratio of inflation to deflation depends on whether an upper airway obstruction is present.
- If the exhalation isn't adequate, the medic can add another catheter following the same procedure as above, beside the first catheter. It's job is to allow the trapped air out.
Note: For an open airway, the inspiratory to expiratory ratio of 1 to 4 seconds is adequate. Ratios of 1 to 8 seconds are needed in order to prevent barotrauma (injuries caused by excessive pressures [pneumothorax] when upper airway obstruction is present).
Needle Cricothyrotomy Advantages:
- It is the least invasive emergency airway surgical procedure
- It can be completed quickly and easily by properly trained paramedics
- When performed properly it is inexpensive, and effective for a short period of time
- Very minimal spinal manipulation is needed
- Gives the patient a chance when all other means have failed
Needle Cricothyrotomy Disadvantages:
- It is invasive and temporary
- Constant stabilization and monitoring are required
- Jet ventilation is required
- The airway isn't protected by the procedure
- Procedure doesn't allow for the proper disposal of carbon dioxide
- Is only effective for < 30 minutes
- High pressure during ventilation may cause pneumothorax
- Hemorrhage may occur at the injection site
- The thyroid and esophagus can be perforated if inserted to far
- Direct secretion suctioning is impossible
- Subcutaneous emphysema may occur
Removal the needle cric should only be considered after proper orotracheal/nasal intubation, cricothyrotomy, or a tracheostomy has been performed.
A cricothyrotomy is a true surgical procedure, so cleanliness is imperative. It allows the rapid access to the lower airway, when all other means of gaining a patent airway have failed and your patient will die if an intervention isn't rapidly accomplished. It is quicker, easier to perform in the prehospital setting, and doesn't cause spinal column manipulation. Of course, this is a last ditch effort to save the patients life and should never be attempted if the patients airway can be controlled by a less invasive means (orotracheal, nasotracheal intubation). Very few situations will require this procedure but nonetheless, we must always be prepared as if it were going to happen everyday!
- Severe facial/nasal trauma that prevents intubation by usual means
- Massive midface fracture
- Possible spinal injury preventing normal respiration
- Anaphylaxis after complete airway occlusion
- Chemical inhalation injuries causing massive edema
Note: Cricothyrotomy as with needle cric, requires special training and authorization from MCP, before attempting the procedure.
Commercially prepared cricothyrotomy kits are available through a number of manufacturers but, if a kit isn't available when it is needed, the following equipment must be on hand:
- Scalpel blade
- Size 6 or 7 ET tube or tracheostomy tube (if ET tube is used a size 6 is preferred for an average adult)
- Antiseptic solution
- Oxygen source
- Suction device
- BVM device
- Identify the anatomical structures of the neck, especially the cricothyroid membrane.
- Clean the identified area with alcohol and/or other antiseptic solutions
- Make a 2 cm (3/4 inch) horizontal incision with the clean scalpel, at the level of the cricothyroid membrane. Some MCP's may recommend a vertical incision in place of the horizontal incision.
- Open the incision once you've entered the open space of the trachea, with the clean as possible scalpel handle. Rotating the handle blade 90 degrees will open the incision enough to accommodate the required 6/7 ET tube.
- After the tube has been inserted a few centimeters to prevent mainstem intubation, the cuff should be inflated and the tube secured after the placement has been confirmed (use traditional means of assuring proper tube placement).
- Provide ventilations with BVM and high flow oxygen. Determine the adequacy of ventilations by bilateral auscultation and observing proper chest rise/fall.
- Prolonged procedure time without ventilation
- Major hemorrhage
- Aspiration during the procedure
- Easily misplaced during movement
- Perforation of the esophagus
- Injury to the vocal cords
- Laceration of the carotid/jugular blood vessels
- Subcutaneous emphysema
- Inability to identify landmarks on some patients
- Underlying anatomical abnormalities (tumor, subglottic stenosis)
- Tracheal transection
- Acute laryngeal disease caused by trauma or infection
- Small children under 10 years old should only receive needle cric
- No attempts should be made to remove a tube after insertion in the prehospital setting
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