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Flying physician Cynthia M. Griffin shared the lessons of emergency cricothyrotomy performed in a pre-hospital environment
New Orleans — Most oxygenation/ventilation difficulties can be solved with basic or advanced techniques. Although it is rare in pre-hospital settings, in some cases, traditional practices may not be suitable to provide enough breathing to sustain life. When treating patients with severe head, neck, or facial injuries or diseases, needle or surgical cricothyrotomy may be the last resort to obtain a clear airway.
Cynthia M. Griffin, DO, NRP, a flight physician from Med Flight at the University of Wisconsin in Madison, Wisconsin and a St. Agnes emergency physician from Fond du Lac, Wisconsin, presented a conference called "Charlie Fox Cric and Common Pitfalls" Surgical airway during EMS Expo 2019".
Find more information from educational conferences, product announcements and updates at the Expo site
Here are some of Griffin’s most memorable quotes about the lessons she learned while facing a challenging surgical cricothyrotomy in a pre-hospital setting:
"The important thing is to remember to cut low."
"We no longer say that this is a failed airway. Now, this is an inevitable surgical airway."
Griffin shared a case and pointed out: "I hope you will succeed when you do this." The following case study inspired her to help others learn more about unexpected complications during prehospital cricothyrotomy and how Modify the practice of ensuring difficult airways. Some information has been changed to protect the identity and privacy of patients.
Griffin introduced the following case studies encountered while serving as a flying doctor:
After the flight team arrived at the scene, the oral report was as follows:
The initial and secondary vital signs are as follows:
The preliminary assessment revealed the following:
Griffin explained that an additional evaluation of the airway revealed dry blood on the face, bright red blood in the mouth/nostrils, and distorted anatomy. Griffin's initial observations revealed submandibular deformities, broken tongues, and large amounts of blood in the airways.
Breathing is prolonged, the number of slow/deep breaths is reduced, and the chest does not rise during oxygenation. The capnogram shows occasional waveforms. Griffin suggested that a sudden drop in the capnogram could mean a leak in the system, a partial disconnection, a partial airway obstruction, or a tracheal intubation in the hypopharynx.
The blood circulation is touched by the beating pulse and warm skin. Establish IV/IO to provide liquid.
The disability assessment rated the patient as GCS 2T, with no exercise purpose, unresponsiveness, bilateral raccoon eyes, and bilateral pupils 6 mm unresponsive.
After some troubleshooting, Griffin noticed that the error was caused by a wrong paragraph. As the gunfire separates the muscles that hold the trachea in place, the anatomical structure of the neck moves laterally. The neck injury is extensive, causing the tube to be initially placed over the triangular cartilage of the cricothyroid membrane, which is more like a supraglottic airway.
The following are some important gains from this case.
1. Keep calm. You got this!
Lauria et al. (2017) found that psychological preparation is essential to reduce the pressure of medical service providers during the resuscitation of critically ill or injured patients [1]. Griffin sees box breathing as a technique, and she uses self-encouragement and preparation to deal with the key calls mentioned above. It looks like this:
Griffin explained that the two main issues affecting the success of the anterior neck passage are operator pressure and anatomical distortion. Generally speaking, Hubble et al. (2010) A meta-analysis of the pre-hospital airway control technology of the alternate airway device found that the success rate of surgical cricothyrotomy was 90.5%, while the success rate of needle cricothyrotomy in emergency medical services 65%. Therefore, this study supports the use of surgical cricothyroidectomy rather than needle cricothyroidectomy in the field.
The definition of cricothyrotomy is the surgical operation to place a hole in the cricothyroid membrane and insert a cuffed tube into the trachea to provide ventilation. The key landmarks in anatomy help the doctor to place the incision correctly to insert the cannula. If the anatomy is distorted due to injury or edema, locating the correct landmark can be challenging.
Bair and Chima (2015) studied three techniques and success rates when locating the cricothyroid membrane (CTM) through general palpation (62%), four fingers (46%) and neck creases (50%) [2] . Recent research conducted by Altun et al. (2019) and Siddiqua et al. (2018) It is recommended to use advanced ultrasound technology to improve the success rate of difficult airway CTM localization [3-4]. Drew, Khan, and McCaul (2019) found that inserting an i-gel supraglottic airway device helps to locate CTM in female patients with an accuracy of 66% [5].
Care should be taken to avoid serious complications of carotid arteries, veins and muscles.
3. Complications of intubation and inability to ventilate
In a pre-hospital setting, intubation and inability to ventilate are often challenging. Griffin described a variety of complications that may occur during prehospital surgery cricothyrotomy:
4. Simulation is the key to help learn how to avoid some complications and adapt to challenges
Griffin suggests that the more bloody and realistic the training, the more successful you will be in the field. The following are some of the key points she raised while training as a prehospital surgical cricothyrotomy team:
Study anatomy and educate yourself
Master BLS skills (such as BVM, safety, equipment, personal protective equipment (PPE), etc.)
The patient is unresponsive in the prone position and awake in the side position
Ready for primary and secondary suction
Choose the right size probe (pediatric or adult)
New pants from ALS supplier
Review the anatomy, prepare for complications, and do more training
Review the case with your OMD
High-fidelity simulation: distractions, wet gloves, bloody airways, multiple tools
The patient is unresponsive in the prone position and awake in the side position
Ready for primary and secondary suction
Choose the right size probe (child or adult)
New pants from ALS supplier
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Dr. Nicole M. Volpi, NREMT, has extensive experience in emergency medical services, law enforcement, military/civil disaster response and disaster management research. She currently works full-time in the Westwego Emergency Medical Services Department and is a volunteer in the VIGOR Program of the New Orleans Emergency Medical Services Department. She is one of the Southeast Region Regional Coordinators designated by the Louisiana Department of Health for District 1 EMS, responsible for responding to various emergencies where local/state authorities require/request emergency medical services.
She holds a PhD in Public Safety/Emergency Management from Capella University and a Master's in Criminal Justice/Enforcement Management from Loyola University in New Orleans.
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