Surgical Airways

Report
Amy Gutman MD
EMS Medical Director
[email protected] / www.teaems.com

Surgical airway indications

Airway anatomy review

QuickTrach© policy &
procedures


Utilizing a surgical airway
“assumes” provider followed the
Difficult Airway Pathway &
“Cannot Intubate, Cannot
Ventilate”
QuickTrach© is a rapid, safe &
reliable surgical airway device


Prehospital emergency
cricothyroidotomy rare
As with all rarely performed
skills, after initial training,
regular re-training required


Creation of an opening in
space between thyroid
cartilage anterior-inferior
border & cricoid cartilage
anterior-superior border to
access the subglottic airway
Allows endotracheal tube
placement when airway
control not possible by other
methods

Can’t Intubate, Can Ventilate
• 2 unsuccessful advanced airway
attempts (ETI, supraglottic)
• BVM maintains O2 sat >90%

Can’t Intubate, Can’t Ventilate
• 2 unsuccessful intubation
attempts (ETI, supraglottic)
• Cannot maintain O2 sat >90%
with BVM
ETI / NTI
Alternatives:
Biluminal
LMA
Combitube
Lighted Stylette
Unsuccessful
Successful
Cricothyrotomy
Or
Retrograde
Successful
Post Airway
Management
•
•
•
•
L
E
M
O
N
Look Externally
Evaluate 3-3-2
Mallampati
Obstruction
Neck Mobility
•
•
•
•
•
M
O
A
N
S
Mask Seal
Obese
Aged > 55yo
No Teeth
Snores / Stiff

Three Basic Steps:
• Insert, Inflate, Secure




Sterile sets pre-assembled for
immediate use
Needle tip reduces bleeding risk
Stopper prevents needle from being
inserted too deep reducing risk of
tracheal perforation
Neck-tape allows fast fixation
• Infants (1.5mm)
• Children (2mm)
• Adults (4mm)
• Uncuffed
• Larger Children
& Adults (4mm)
• Cuffed

1.5mm infant
• <3 yo



2mm pediatric
• <100 lbs
4mm size adult
• >100 lbs
Kits look similar except
for length



Massive trauma to larynx or
cricoid cartilage
Damage to affected structures
make it impossible to perform
procedure properly
Alternative or less invasive
maneuver allows ventilation

Hemorrhage

Esophageal perforation

Tracheal perforation

Tracheoesophageal fistula

Infection / Abcess

Subcutaneous air

Place patient supine with neck
slightly extended
• In-line stabilization if cervical
trauma suspected


Locate cricothyroid membrane
midline between thyroid
cartilage (Adam’s apple) &
cricoid cartilage
Prep overlying skin

Palpate thyroid & cricoid
cartilage for orientation
• A: Cricoid Cartilage
• B: Cricothyroid Membrane
• C: Incision Site
• D: Thyroid Cartilage

Puncture cricothyroid membrane at
90° angle

Confirm needle entry into trachea
by aspirating air


Change hand angle to 60°; slide
catheter sheath forward to stopper
hub level
Advance plastic cannula as you
remove needle & syringe
• If cuffed, then inflate with 2-3cc

Begin ventilation when needle &
syringe removed
http://www.youtube.com/watch?feature=player_de
tailpage&v=waHwm7QQ17M

Ventilate patient, observing for
chest rise & fall

Auscultate for BL breath sounds
• If absent, ETT may be in neck
subcutaneous fascia or esophagus
• Remove & attempt to re-insert



Secure device
Continuous evaluation &
documentation of oxygen
saturation, ETCO2, vitals
Notify ED of Priority 1 patient



Maine Department of EMS. “Advanced Airway
Training”. 2010
S Hopkins RN. “Equipment Review”. Condell Medical
Center EMS System. 2008
CPT A Proulx, MPAS, PA-C. “Airway Management in the
Combat Casualty”. 2011

Emergency Medicine: A Comprehensive Study Guide,
Tintinalli, 6th ed, Mcgraw-Hill, 2004

www.myrusch.com

Ron Walls Difficult Airway Management Text (2011)

Difficult Airway Site (www.theairwaysite.com)




Well-documented success in
prehospital, military & other
emergency settings
3 Basic Steps ~ Insert, Inflate,
Secure
Reduced time to advanced
airway placement in critical
patients who cannot be
ventilated
Rapid, safe & effective method
of providing a definitive
airway

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