BCE 71 Cricothyrotomy and the Value of Simulation Training

In anticipation of EM Cases Episode 110 Airway Pitfalls Live from EMU 2018 with Scott Weingart, we have Dr. Shira Brown tell her Best Case Ever of a pediatric trauma patient who required a cricothyrotomy. She explains how, despite working in a non-trauma center with limited resources, her team was well prepared because of the robust simulation program specifically designed for practicing emergency physicians that she had developed in her region. We also discuss the advantages and disadvantages of the scalpel-Bougie vs scalpel-finger-Bougie cricothyrotomy techniques and to maintain an optimistic attitude in seemingly futile cases... Podcast Production and Sound Design by Anton Helman, May 2018 Surgical cricothyrotomy is indicated in "can’t intubate, can’t oxygenate scenarios". This typically occurs after 3 failed DL and/or VL attempts followed by a failure to oxygenate adequately using a supraglottic device. The procedure itself is not difficult. What is difficult (if you don't prepare adequately) is the mental leap required to start doing the procedure. This psychological barrier can be overcome more easily if you prepare as outlined below. The Difficult Airway Society guidelines recommend the scalpel-bougie technique. Elements required to maximize your chances of a successful cricothyrotomy Phase 1: Before you start your ED shift * Familiarize yourself with a standardized challenging airway cart containing simple Bougie-assisted cric kit (Bougie, #10 scalpel, 6.0mm ETT - see image). * Establish a cohesive "difficult airway" program in your hospital based on current guidelines adapted to your specific environment. * Two step simulation training: low fidelity deliberate practice with simulation model (see examples SOCMOB video below and at ALiEM), followed by case-based simulation to augment psychological skills in a stressful situation. * Post a standardized algorithm on the wall of your ED resuscitation room. Phase 2: Before you perform the cric * Mark the cricothyroid membrane with an indelible marker before any intubation attempt in anticipated challenging airway scenarios. This provides you and your team confidence in starting the procedure if it becomes necessary. Consider POCUS to aid in locating the cricothyroid membrane. * Verbalize a failed airway plan and assign roles to your team. * Clearly announce a "can't intubate, can't ventilate" situation. Phase 3: The Bougie-assisted cricothyrotomy technique * Extend the patient's neck (unless c-spine precautions). * Use a "laryngeal handshake" to stabilize the larynx. * Use the "scalpel-finger-scalpel-finger" technique (see below) * Railroad the 6.0mm ETT over the Bougie * Attach BVM, check tube placement and confirm end tidal CO2 Simplified Bougie-assisted Cric kit Build your own bleeding cric simulation model at ALiEM Scalpel-Finger-Scalpel-Finger Bougie Assisted Cricothyrotomy After extending the patient's neck and stablizing the larnx with a "larnygeal handshake"... * If the cricothyroid membrane was identified prior to airway management, make a 3cm vertical incision with a #10 scalpel that crosses the cricothyroid membane. If you did not identify the cricothyroid membrane in advance of airway management make a lar...