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Cricothyrotomy

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Heard’s CICO algorithm

heard-cico-algo (Anaesthesia 2009;64:601)

Cricothyrotomy (Surgical)

  1. Stand at pt’s right (if you are right hand dominant, otherwise reverse all sides)
  2. Left hand holds thyroid cartilage with index finger touching membrane.
  3. Make a vertical incision from thyroid cartilage to above jugular notch.
  4. Make horizontal stab incision through cricothyroid membrane
  5. Drop trach hook into incision with pointy hook facing towards the ceiling
  6. Then turn the hook to grasp thyroid cartilage and hand it to an assistant
  7. Put in trousseau dilator with blades at caudad/cephalad positions.
  8. Dilate the airway.
  9. Put tube between blades of the trousseau with the tube lumen facing towards the patient’s left.
  10. Rotate the trousseau with the tube so that the lumen faces the patient’s feet.

The trach kit supplied at most hospitals is good… in case you accidentally cut off the patients head and have to sew it back on. Otherwise you are probably better off taking out the scalpel, trousseau, and trach hook and repackaging them. Minimum training for successful cric should include mannequin practice for 5 attempts or until the procedure can be performed in less than 40 seconds or less (Anesthesiology 98(2):349, Feb 2003) Homemade Cric trainer (Anaesthesia 2004;59:1012) and a recent addition to the model (Anaesthesia, 2009, 64, pages 687–697) Article showing wire cric is incredibly slow (Anaesth Anal 2010;110(4):1083) and (Anaesth 2006;61:565) Bougie-guided cric is faster than standard (ACADEMIC EMERGENCY MEDICINE 2010; 17:666–669) Battlefield Cric was difficult and often unsuccessful (J Spec Op Med 2012;12(1):17) Surface landmarks lie, at least in this study (Anaesthesia 2010;65:889)

Cricothyrotomy (Needle)

Can use nasal canula c 02 on 15 lpm as jet insufflator. Put one prong in catheter and the other as valve aim flow perpendiculat to cannula to effect venturi effect–bench research (Anaest 2009;64:1353)   wall flow was better than bvm, no sig. difference between a 13G and 16G catheter (AMERICAN JOURNAL OF EMERGENCY MEDICINE Volume 22, Number 4 July 2004)   Or attach 3-0 ET tube adapter to 14 g angiocath for needle cric FOR PEDS ONLY Or 3ml syringe barrel with 7-0 ET adapter (Am J Emerg Med 2004;22:37) Or larger syringe barrel with ET tube inserted and cuff inflated Article using anesthesia circuit with PEEP of 35-40 (Br J Anaesth 2011 Oct;107(4):642-3) Catheter or cath with 3-way stopcock is prob. inadequate for exhalation unless 13 seconds between breaths (Anaesthesia 2009;64:1353 and Pediatric Anesth 2009;19:452)   Resuscitation Volume 72, Issue 1 , January 2007, Pages 164-166 Manual specifically states the oxygen source must be high pressure (capable of a driving pressure of 50 psi). A wall oxygen flowmeter provides a maximum flow of 15 L/min at a pressure of up to 400 kPa (58 psi) dependant on the resistance to flow. that connects directly

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to the piped oxygen supply at 400 kPa (58 psi) and provides sufficient flow for effective ventilation.Hospital wards have wall-mounted oxygen flowmeters or oxygen cylinders, from which the maximum driving pressure is 400 kPa (58 psi). Failure to connect the equipment described in Figure 1 to an appropriate oxygen source may waste valuable time following emergency needle cricothyroidotomy. We propose the following clarification to the information provided in the ALS Student Manual: “When performing emergency needle cricothyroidotomy the cannula should be connected to either the wall oxygen flowmeter directly to a jet ventilator or to an oxygen cylinder and not to the common gas outlet of an anaesthetic machine.”   Wall O2 flowmeters have enough pressure, but only if you turn them up way beyond 15 lpm (Anesth Anal 2010;110:94) Extrapolated to the clinical situation, these data suggest that low-pressure devices will not deliver adequate MVs via a cannula cricothroidotomy and should no longer be advocated.Purpose-made devices should be available in all areas where anaesthesia is administered or airway interventions are performed. (Br J Anaesth 2009; 103: 891–5)

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Are Prolonged Crics Really a Problem?

Probably not (American Journal of Otolaryngology, Vo121, No 3 (May-June), 2000: pp 195-201) and British Journal of Oral and Maxillofacial Surgery 51 (2013) 779–782

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Levitan’s Cric Key

Validation study (Ann Emerg Med 2014;63:1)

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