Hey guys- any opinions regarding preferences of cricothyrotomy kits? There are a number of them out there now, and I haven't tried them all. Thoughts? Thanks!
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Hey guys- any opinions regarding preferences of cricothyrotomy kits? There are a number of them out there now, and I haven't tried them all. Thoughts? Thanks!
Unless trained, and even still, performing a surgical cricothyrotomy is a highly invasive procedure. I highly doubt you will ever encounter the need to perform one, and if you did the amount of blood would disillusion all but the more experienced surgeons. I have seen a highly skilled and respected paramedic freeze after performing the initial incision, I'm not sure of your skill level, or doubting it, just food for thought.
I'm going to assume you're a Paramedic.
Surgical cric isn't allowed in my state, but the only kits I've ever trained with were the NARP ones. Apart from that, the scalpel from an OB kit and cutting the end off of an ET tube works...
I can't remember the name of the company, but I think it's the same one that markets the Home Appendectomy Kit and the Home Cholecystectomy Kit.
HahahaQuote:
Originally Posted by Hmac
*OP, I shot you a PM. It's now my understanding that this is within your scope, and I'd like to chat on the side and not clutter up the forum.
A small percentage of folks have a not inconsequential anterior jugular vein in addition to the more lateral internal & external jugular veins. This can make the procedure more complicated from a hemostasis point of view. OTOH - when you need one, there aren't a lot of alternatives.Quote:
Originally Posted by firefighter37
john
These things are best left to the professionals...not sure what your level of training is, but practicing one or two on a mannequin is from proper experience.
Another member informed me of his current licensing level, and it's within his scope.
The thing is...if a cricothyrotomy is even being contemplated for a particular patient, that patient is in deep shit. In that case, even a bad cricothyrotomy by someone only partially or poorly trained is better than no cricothyrotomy at all. If they get the cric, they might die, if the don't get it, they will die. Advanced airway management is IMHO the most important set of skills a Paramedic or emergency medicine doctor can learn. Nobody is going to be really good at it because the need for it represents about .5% of airway cases. The most experienced EMT-P may only see one or two crics in his lifetime, the average paramedic will never have to do a cric. Probably.Quote:
Originally Posted by Evel Baldgui
Dup............
Sorry guys, I guess I should have added some more qualifiers to the initial question. I can't drop a fly at 1,000 meters with a Barrett-but I do wear scrubs for a living.;) I'm in my lane here. Certainly cricothyrotomy is a high risk procedure with potential complications. I may be purchasing a bunch of kits and wanted specific recommendations since there have been several new products come to market over the last few years. Application is in-hospital (not field) use. Currently have the Melker and QuickTrach kits, but was seeking the group's expertise with any of the other kits that are out there. I figured that some of you may have developed preferences with various field kits and wanted to tap into that experience. Thanks, and have a good one!
Make your own kit. You probably have access to 5.5 ET tubes? Get a 5.0 or 5.5 (smallest cuffed tubes). Cut down to just above where the fill tube for the balloon/cuff (do not cut the little tube that fills the distal cuff/balloon) comes out the side of the ET tube shortening the tube, as you know you do not need the length for the oropharynx with a trach. Re-attach the adapter that receives the BVM or vent tube into the new shorter ET tube. Keep the tube with a surgical scalpal, some 2x2 and or 4x4 gauze, 18 ga needle, 10cc syringe and a trach hook in an appropriate sterile container or baggy. Perform procedure as you are trained and within your scope and protocols of course. Needle serves as a nice guide after marking the cricothyroid membrane and inserting into the space, scalpal used for vertical incision, using gauze to stabilize trachea midline and absorb blood. Having another set of hands is great. After incision, retain visual and control of the trachea with trach hook. Introduce the tube into the trachea until cuff is below insertion point and above carina. Inflate cuff as you would, confirm placement with auscultation of breath sounds, chest rise, ETCO2, bulb syringe etc. Secure in place as an impaled device with tape and or an ET tube holder if one fits the neck.Quote:
Originally Posted by tower59
* this is for research and educational purposes only. DO NOT ATTEMPT THIS OUTSIDE YOUR SCOPE OR AN APPROPRIATE FACILITY.
I receive hands on training for the cricothyrotomy once a year. Thankfully, other than performing the procedure many, many times on training models and observing a cadaver demonstration, I have not had to employ it in my practice in 20 years. From the point of view of a guy who may need to employ the technique but has never had to do it, I feel more than comfortable with the QuickTrach. I need it to be simple, since my personal stress levels are likely to be very high. Before I reach for that kit, a lot of things have failed to work. Airway management being a continuum my order of airway management is i.e., head tilt, chin lift, positive pressure bag valve mask with 100% O2, naso and oropharyngeal airways,LMA (laryngeal mask or a King airway), ET intubation and succinylcholine and then my QuickTrach. By then hopefully the paramedics have arrived and I won't have to do it. It seems that I have an easier situation than you as I perform mostly elective surgery under procedural sedation on ASA 1 or 2 with Mal I or II so landmarks are pretty straight forward. Not your typical thread on this board.
Our kits were home-brewed: a cut # 7 ETT, a trach hook, a 11 blade, and a Trousseau dilator (spreaders), taken to the local hospital to be steri-packed. Total cost, about $30. That was...1991. Now there are so many options, and of the manufactured kits, I like NARP.
I have done three. Two patients died. In every single case I about crapped myself.
When a crich is in the picture, even in-hospital, it is going to be a $hit-show. I don't do airway management regularly but I have done one. In this instance I used an #11 blade, a snap, and a Ciaglia Blue Rhino perc trach kit. This was what was on hand.
I would highly recommend having a trach hook, and this is a necessity if the pt's airway is not extremely anterior. You have to be prepared for, and be ready to work through, significant bleeding. Unless you are a highly experienced paramedic, ER MD, or surgeon it can be terrifying (I am the latter).
The kit I used was mechanistically similar to the H&H kit.
I've done a couple of crics over the years. They were always exciting, but certainly not excessively dramatic as they took place where the nurses attending were competent and the appropriate equipment was readily at hand - once in the ER and once in the OR. Both were attempted firearm suicides...one a 9mm pistol and the other a shotgun (THAT was a mess). OTOH, I've done at least a few needle cricothyrotomies with retrograde wire passage and other such convoluted airway manipulations. Our anesthesia people are very skilled. If they need me to secure an airway, that patient is indeed in deep yogurt. I'm sure it would be very exciting in a pre-hospital setting. Hopefully I'll never have to worry about that.
A self-inflicted shotgun to the face was one of mine. Bloody mess, no anatomy.Quote:
Originally Posted by Hmac
The possibility of having to do a cricothyrotomy in a field setting is virtually the only reason I carry a knife in my pocket and keep it sharp. Well...that and opening boxes from Amazon. That knife and maybe a couple of band-aids represent my version of an "IFAK".
There are several types of kits available- the traditional surgical approach (scalpel and a breathing tube), needle + Seldinger technique kits, and some newer kits (like the QuickTrach) that have a device that goes directly into the airway. The classic surgical approach is usually a bloody mess, and so one of the possible advantages of the percutaneous kits is purportedly less bleeding. I've never seen a study that was able to actually compare the bleeding rates between the devices in humans, though. (Kind of hard to get people to sign up to do that research!) That's one of the reasons I was hoping to hear from any folks with first hand experience with the new kits. Virtually all the research on this procedure and comparing kits is mannikin or non-living airway model.
This.Quote:
Originally Posted by TacMedic556
The only things I have to add are:
1/4 in cotton webbing or something to secure the tube. If you preattach it, make sure you practice like that because crap hanging off the tube can be distracting.
Optionally, small set of curved Kelly's in addition to the hook. Make sure there is a cover on the point of the hook.
I like a retractable safety scalpel for this type of kit, and when I practice, I always retract the blade, just like I practice safing my weapon.
Consider packing a flush instead of an empty syringe.
Vacuum sealers made for food work well for cric kits. Label it in big letters, make tear starting cuts with shears in several places, and mark the cuts with black sharpie. We lose IQ points rapidly under stress.
Edit to add: a couple of 4x4's are a good idea
Disclaimer: all of my cricothyrotomy practice has been on cadavers, animal models, and mannequins.
We have some needle cric kits that are pretty slick (stocked in each OR). I suspect the rate of successful perc trachs in the field (never mind open approach) is very, very low. The “best” trachs I’ve seen have been slash trachs by trauma surgeons where they just shove an ETT. As a CRNA, I hope to see more and more pre-hospital providers (military and civilian) using video scopes - that would save some lives.
Glidescopes all around here where I work, including PACU, ED, and all of the ambulances. Really takes the mystery (and chipped teeth) out of endotrachael intubation. Between needle crics and Glidescopes, if I ever get called to provide an airway, I know that we are in deep shit.Quote:
Originally Posted by mass-diver
Videolaryngoscopes have undoubtedly changed the whole landscape for difficult airway management, and they are good tools. They aren't perfect, however, with the notable limitations of: (1) ability to view the cords but unable to align a pathway to pass an endotracheal tube, and (2) inability to image due to blood or secretions. Also, it is simply not possible to intubate from above in some patients, such as in severe head/neck trauma or airway tumors, for example.
In my 911 service we now have both video scopes and needle crics. I’m skeptical about the uncuffed tube on the needle cric, but thrilled about the video scopes.