Surgical cricothyrotomy - Queensland Ambulance Service

Clinical Practice Procedures:
Airway management/Surgical cricothyrotomy
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Date
April, 2016
Purpose
To ensure a consistent procedural approach to Surgical cricothyrotomy.
Scope
Author
Applies to all QAS clinical staff.
Clinical Quality & Patient Safety Unit, QAS
Review date
April, 2018
URL
https://ambulance.qld.gov.au/clinical.html
This work is licensed under the Creative Commons
Attribution-NonCommercial-NoDerivatives 4.0
International License. To view a copy of this license,
visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Surgical cricothyrotomy
April, 2016
All clinicians conducting rapid sequence intubations (RSIs) must be skilled in failed airway techniques. Cricothyrotomy is a definitive rescue technique
for the failed airway if time (i.e. preservation of oxygenation) does not allow
for other approaches or if they fail.[1] In addition, mental preparations to
perform a surgical airway should be undertaken each time RSI is considered.
Indications
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The QAS has adopted an open cricothyroid technique in adults as numerous studies have shown higher success rates in novice operators compared to ‘over the wire’ techniques.[2]
• Can’t Intubate, Can’t Ventilate situation and oxygen saturations less than 70%
• Primary airway attempt if laryngoscopy not feasible (e.g. massive facial trauma)
Contraindications
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Equipment required for surgical airway
• Child < 12 years of age
• Open tracheal injury
• Cardiac arrest
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Complications
• High likelihood of blood obscuring the
surgical field, this is a tactile rather than visual procedure
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Figure 3.16
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Procedure – Surgical cricothyrotomy
1. Maintain ventilation with bag valve mask or supraglottic airway as best as possible.
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2. Prepare the neck with antiseptic solution.
3. With the non-dominant (ND) hand, identify the laryngeal landmarks
(thyroid cartilage, cricoid cartilage and the cricothyroid membrane.)
If the laryngeal landmarks are not identifiable (e.g. secondary to soft tissue swelling, burns or obesity):
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- Make a longitudinal, midline incision at least 6 cm in length through skin and the
subcutaneous tissue.
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Approximately
6cm longitudinal
incision
- Using fingers, separate strap muscles and identify the laryngeal landmarks
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Procedure – Surgical cricothyrotomy
4. Once laryngeal
landmarks are
identified, stabilise
the structures with
the ND middle finger
and thumb, ensuring
the ND index finger
is on the
cricothyroid
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5. Lift the ND index finger. Using a scalpel, make a transverse, 1 cm deep ‘stab-like
incision’ through the cricothyroid
membrane.
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7. Switch hands so
that the ND hand
now stabilises the scalpel.
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6. Twist the scalpel 90° so that the
blade is pointed to the feet.
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Procedure – Surgical cricothyrotomy
8. Move the blade
laterally a few
millimetres to
achieve a slightly
widened opening
for the insertion of the intubating
catheter.
10. Rotate and align
intubating catheter
to allow insertion
along the line of the trachea.
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9. With the intubating catheter pointing away from the head and parallel to the floor, insert the tip along the flat of the
blade as a guide
into the trachea.
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Procedure – Surgical cricothyrotomy
11. Railroad a lubricated
size 6.0 mm ETT
(remove 15 mm
connector to aid
passage over bougie).
Continually rotate ETT
to facilitate placement.
If the ETT is unable to
be advanced, insert
the Trousseau dilator
into the incision,
directing the blades on the longitudinal
axis.
13. Whilst holding the
ETT carefully remove the intubating catheter.
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14. Using a syringe,
inflate the ETT cuff
with the minimum amount of air
required to provide
an effective seal.
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12. Insert the 6.0 mm ETT until the skin is between the 2 black ETT intubation markers.
15. Remove syringe from the ETT to effect the closing of the one-way
valve, ensure pilot balloon
remains inflated.
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Procedure – Surgical cricothyrotomy
16. Connect resuscitation bag
and commence ventilation.
e
Additional information
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17. Confirm correct tracheal
placement by observing an appropriate continuous EtCO2 waveform (minimum of 6 ventilations of moderate tidal volume required for confirmation).
• The potential for scalpel injury during this procedure is HIGH. All precautions that serve to minimise risk to the clinician and patient are to be applied.
• The QAS supplies the High Acuity Response Unit with a Melker Emergency Cricothyrotomy Catheter Set that contains all non-standard QAS equipment necessary to complete a surgical cricothyrotomy, specifically:
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18. Administer post intubation sedation as required (titrated aliquots of morphine/fentanyl and midazolam).
- tracheal hook
- trousseau dilator
- sterile gauze.
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19. Assess and adjust ETT cuff pressure as required.
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