The video footage is attributed to Dr Peter Rhee a trauma surgeon in USA.
There are some excellent learning points to take out of this footage.
- Whenever you see the intubator squinting, that is not a good sign. It means they are having trouble visualising landmarks. Offer to help improve view with simple techniques like jaw thrust, pulling the lip or corner of mouth , external laryngeal manipulation, removal of cricoid pressure if it was applied.
- Notice the vertical incision. Very clever as it produces the least amount of bleeding and allows the operator to extend the incision quickly if not in right location.
- What, no scalpel bougie cric technique, you cry! More like Scalpel Finger technique but be careful with the blade as you see it comes very close to cutting the finger of the operator.
- You need something to replace your finger and here they use a Kelly Clamp . A bougie is fine but does not dilate the wound as much as a clamp/forceps
- Notice the use of the tracheal hook. very handy to open the wound further and pull the thyroid cartilage out of the way. You can make your own with a 21 g needle bent into hook shape and attached to a syringe ( Luer lock secure connection!)
Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds 
Reblogged this on Sim and Choppers and commented:
Great post by airway expert Minh Le Cong. Thanks for sharing! Nice follow up to some of the training the Auckland Rescue Helicopter did this week with cricothyroidotomy.
Really uncomfortable watching that finger and scalpel! Messy, high pressure situation, so ripe for errors. Good to hear some solid guidance in the backgroud.
Some more points I noticed on the intubation attempt:
1) The stylet was not ideally shaped
2) The intubator blocked his line-of-site while inserting the tube
3) He also gripped the tube quite low, limiting his dexterity
Assuming he really did see the cords, perhaps addressing these issues would have allowed him to successfully pass the tube. It’s a messy airway and there’s a lot we can’t see in the clip so I don’t want to sound too critical, but I also want folks to recognize these errors so they can avoid them in their own practice.
what is not shown is that there were two intubators. You only see the second intubator’s attempt.
I suspect it was going to be impossible orotracheal even with optimisation techniques. The best thing shown here is that the decision was made to proceed quickly to surgical airway when two intubators had failed. And I think you can hear the oxygen saturations are called out at 90% during the cric. So they had not let it progress to a critically hypoxic state before starting the surgical airway. Yes it looks messy but they did a good job in rescuing a failed intubation .
I believe the patient made a good recovery from his injuries.
Thanks Minh, there’s always a lot more going on than a quick clip like this can show. As you said, the biggest mistake someone can make is failing to perform the cric in a timely manner (or at all). Kudos to these providers for sharing this experience with all of us.
I’m personally still trying to perform the “perfect” resus, and I suspect that’s what keeps us all glued to FOAMed, It’ll never happen, but every day we get just a bit better and learn a little more.
A bougie would have been an ideal first/second pass device and bilateral suction available may have helped a lot.
I too was pretty impressed by their quick decision to cut. I’ve had the pleasure of attending some lectures by Dr. Rhee and he is definitely on the forefront of trauma resus.
Very instructive. Thanks to Dr. Rhee and the original posters to YouTube, and to Minh for allowing us all to see it! Applause to the team for decisive action and strong resus leadership, leading to a successful cric in what seems to have been a CICO situation. It appears this is from 2001, from the pre-bougie era. We know a lot in 2013 that we didn’t know in 2001. A bougie sure would’ve been helpful, both with DL and with cric.
Totally agree with Vince: a straight-to-cuff tube shape a la Levitan would’ve improved DL chance of success. In 2013, we’d obviously be doing nasal apneic oxygenation as well, giving the intubator more time. Failing that and a bougie, we’d probably next be moving to an SGA, ideally one through which we later could achieve definitive endotracheal intubation. I suspect an SGA may likely have been able to oxygenate and ventilate this patient. In 2001, the team may have not had an SGA available.
This serves as an excellent reminder that in an actual emergency cric, the finding of the CTM is completely tactile. You will not be able to see it.
Love the vertical cut, and the use of the trach hook, but not the interspersed use of the finger in between those steps. I prefer to cut to air, and while the tip of the scalpel is still in the trachea, slide the metal of the trach hook alongside the blade into the trachea, turn the trach hook 90 degrees, and then and only then remove the scalpel and lift the trachea up out of the bloody hole with the trach hook. Bougie next, then dilation. In 2013, we ought to have waveform capnography ready to go immediately upon tube placement.
Note that no one was using BMV on the patient during the cric procedure (at least as far as I can tell). Even in what I’ve determined is a CICO situation, I’d still be doing maximal technique bagging during the cric (two-person, two-hands on the mask, two NP trumpets, an OP airway, and a PEEP valve) to try to eke out a little bit of oxygenation and ventilation to give the cric operator and the patient more time before cardiac arrest.
Thanks again for this awesome educational opportunity– a chance for us to mentally rehearse and visualize ourselves in the same situation… it will make us better the next time we encounter this.
Great share, thank you.
A proper cricothyroidotomy is not a messy procedure. There is only three layers of skin that is thin and tight and below is the membrane going into the trachea. You can palpate the depression as it is a grove directly below the Adam’s apple and between the thyroid cartilage which are the two most prominent areas of the neck anteriorly. Most like using a 14 gauge needle or an 1/8th inch vertical cut then a 90 degree turn to widen the area for a tube. A fast procedure yields almost no blood at all or shouldn’t have any.