Missouri EMS Central Region

December 2011 WebinarThe Surgical Airway

Jeffrey Coughenour, MD, FACS

Assistant Professor of SurgeryMedical Director, Missouri EMS Central Region

Purpose

• Monthly educational opportunity for providers within the Central Region

• Focus– Performance improvement, actual case review– Literature review– Discuss practice management guidelines

Objectives• Basic review of airway

interventions• Indications for surgical airway• Review standard

cricothyroidotomy and trachestomy

• Introduce the “3-Step Cricothyroidotomy”

Drug-Assisted Intubation

• Controversial topic• Improve intubation success—Outcomes? • Large systems with short transport times or small

systems with inadequate call volume: No

County of San Diego

Health and Human Services Agency

Emergency Medical Services

The Use of Neuromuscular Blocking Agents and Advanced Sedation by Field EMT-Paramedics for More Effective Airway Management in Adult Trauma Patients with Glasgow Coma Score of 8 or Less

Presented to the California EMS Commission, August 28, 2002

A meta-analysis of pre-hospital airway control techniques: orotracheal and nasotracheal intubation success rates

Hubble MW, Brown L, Richards ME Prehosp Emerg Care 2010 Jul-Sep; 14(3):377-401

• Systematic literature review reporting success rates for pre-hospital intubation

• 117 studies OETI, 23 regarding NTI; 57,132 patients• Non-RSI/Non-DAI: 86.3%• OETI for non-cardiac arrest patients: 69.8%• DFI: 86.8%• RSI: 96.7%• Historical trend: 0.49% decline in success per year

Prehospital intubations and mortality: a level 1 trauma center perspective

Cobas MA, Manning R, Vandiotti K Anesth Analg 2009 Aug; 109(2):489-93

• Ryder Trauma Center, incidence of failed intubations and correlation with mortality, risk factors

• 1,320 interventions upon arrival to the TC• 203 had airway intervention in the field (15%)• Combitube (28), LMA (6), cricothyroidotomy (4)• 31% incidence of failed PHI• No difference in mortality

Absolute Indications

• Respiratory insufficiency• GCS ≤ 8 or deteriorating exam• Maxillofacial trauma or neck injury with soft

tissue swelling• Persistent or uncompensated shock

Relative Indications

• Agitation (harm to self or others, inability to facilitate evaluation or safely transport)

• Compensated shock• Potential respiratory compromise• High-risk for deterioration during transport

Airway E&M

• LOOK, LISTEN, and FEEL• C-spine immobilization• Oxygen via facemask• Jaw thrust, chin lift, OPA/NPA, suction• BVM• Endotracheal intubation• Surgical airway

Surgical Airway Selection

• Inability to establish airway with standard means

• If patient in extremis, don’t delay!• Examples:– Airway compromise with ETT already in place– Complex maxillofacial or neck injury– Anatomy

Cricothyroidotomy

• Procedure of choice in emergent situation– Membrane is subcutaneous– Anatomy usually easily identifiable– Procedure fairly easy to perform

• Literature to substantiate high incidence of subglottic stenosis lacking

Cricothyroidotomy in Peds

• Avoid in children < 12 years of age• Dependence on cricoid ring and softer, less

developed cartilage raises risk of stenosis• Needle cricothyroidotomy preferred– Assumes advanced methods to achieve

endotracheal intubation soon available (bronchoscopy)

Cricothyroidotomy

• Equipment– Scalpel (prefer #11 blade)– Appropriate sized endotracheal tube (6.0-7.0)– Finger– Large, chaotic crowd– Brown pants

Landmarks

Cricothyroidotomy

• Procedure– Chlorhexidine prep,

local anesthetic a luxury

– Vertical midline incision over cricothyroid membrane

– Palpate to confirm appropriate landmarks

Cricothyroidotomy

Cricothyroidotomy

• Procedure– Transverse incision

through membrane– Insert finger into the

airway– Advance 6.0 ETT– Secure with suture

after placement confirmed

Cricothyroidotomy

• Pitfalls– Failure to act– Retrograde tube advancement– You’re stupid (or scared stupid…)

• No urgency to convert to formal tracheostomy• Use standard methods to assure correct tube

placement

Cricothyroidotomy

• Commercial kits are available

• Familiarize yourself with service’s equipment

• Knife, finger, tube method most reproducible

Tracheostomy

• Indications– Prolonged mechanical ventilation or inability to protect

the airway– Injury or persistent PE finding that make airway high-risk if

recurrent respiratory failure/failed extubation

• Contraindications– High ventilation/oxygenation requirements

• PEEP > 15 or FiO2 > 60%

– Severe TBI with unresolved intracranial hypertension

Tracheostomy

• Percutaneous dilational techniques well established in the ICU

• Seldinger wire-guided insertion of cuffed tracheostomy tube

• No solid literature to solve debate of superior technique

Tracheostomy

• Appropriate care to protect cervical spine• Adequate sedation, analgesia, NMB• Dedicate someone to control the existing ETT• Equipment for re-intubation ready and

accesable

Tracheostomy

• Vertical midline incision between cricoid cartilage and sternal notch

• Blunt dissection of subcutaneous tissue down to pretracheal fascia

Tracheostomy

• Ideal insertion site between 2nd and 3rd tracheal rings

• Must be able to palpate endotracheal tube

• Failure to identify tube can lead to malposition, inadvertent extubation

Potential Complications

• Dilation of pre-tracheal space• Incorrect tube position• Extubation during procedure• Bleeding– Anterior jugular veins– Thyroid isthmus

Bronchoscopy with PDT

• Adjunct to PDT at some centers

• Consider in special situations– Cervical spine injury or

fixation device– Morbid obesity– Factors predictive of

difficult re-intubation

Early Tracheostomy

• Timing variable• No survival benefit• Lower ICU LOS and ventilator days in TBI• Lower incidence of pneumonia

Practice Management Guidelines for Timing of Tracheostomy, Eastern Association for the Surgery of Trauma, 2006 www.east.org

Three-Step Cricothyroidotomy• We hypothesize that an elastic bougie used as a

guide for proper placement of a definitive surgical airway will utilize fewer steps in less time, while decreasing complications and increasing rates of successful placement.

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Methods• METI® ECS® trainer– Common trainer used throughout the country– Feedback mechanisms were not utilized – Removable skins over the trachea

Methods:Participants• 12 flight crew members• Each with previous advanced airway training• Performed traditional method per service

protocol first• Then they performed the 3-Step Method

Methods:Analysis• Techniques were video recorded • Time to completion– Hand on the airway to cuff inflation

• Number of hand repositions– ie. Regrasping the trachea– ie. Palpations through the wound

• Successful placement– Tube in the airway with the cuff inflated

• Complications

Three-Step CricothyroidotomyStep 1: Incision

Three-Step CricothyroidotomyStep 2: Bougie insertion

Three-Step CricothyroidotomyStep 3: ET tube over bougie

Conclusion• Three-Step Cricothyroidotomy was shown to

require fewer total hand movements, took less time to complete, resulted in more correctly-placed airways, and fewer complications compared to traditional cricothyroidotomy.

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January 2012 Webinar

Trauma Systems

Questions ?

www.muhealth.org/acutecaresurgery