Todd Fraser on 30-09-2012
The subject of emergency surgical airway technique is one of the favourite topic of emergency, critical care, anaesthetic and pre-hospital bloggers these days. So why shouldn't Crit-IQ join in? Here's your chance to describe what you do.
There are a number techniques described. Its one of the most feared procedures in clinical medicine, and with good reason - the outcomes from these events are often not good. Many of us have had, and will have, no experience with it in practice, so almost no one can claim to be proficient in any of these methods.
This topic comes up this week because of the release of a head to head comparison of a percutaneous method versus knife-to-skin in a simulated enviroment. The results of the study suggest that a surgical method improves times to secure access and was favoured by the 30 practitioners studied.
Of all the methods described, the one that sits most comfortably with me is the knife-dilators-bougie method. This appears to have the support of the literature, and in my hands in a similated environment, it feels easiest. The equipment required is readily available and familiar, so when the heat is on, is more likely to be familiar.
So what do you do?
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My approach is horizontal incision, trachy dilators run along southern edge of blade, open vertically, size 6 tube between the tips. Tube needs to be well lubed. I've used this only once pre-hospital and it went as smoothly as I could have hoped. Hope never to have to do it again.
I guess it depends on what you're comfortable with. The technique for perc trachy is not too dissimilar, and in parts of the world like Australasia we're a bit more accustomed to this - that might explain the results in the paper you referred to.
How would you secure an airway in a patient who is a grade 3 airway and is now intubated and ventilated on ICU following aspiration pneumonitis and ARDS. She is recovering well. Because of the anticipated extended stay on ICU a surgical tracheostomy is performed (considering she is a difficult airway). Tracheostomy dislodges a few days later and she develops severe subcutaneous emphysema and severe hypoxia. The tracheostomy track is no longer usable because the anatomy is distorted from the severe subcut emphysema. Bear in mind we now have lost our definitive airway and intubating her is impossible.
Okay, I'll be the sucker.
You literally have seconds.
Sounds like an awful experience (I'm assuming this is a true story).
A blocked tracheostomy, doesn't mean the upper part is always blocked, I would always try to thread a epidural catheter and try if there is any scope for Retrograde intubation.
Are you saying you'd feed the epidural catheter up the tract? I think the initial question was what you would do if the trachy dislodged. If its a new trachy, the tract is likely difficult to follow, and the emphysema would make it worse.
Best way by far is single cut with scalpel across membrane, insert dilator forcep, bougie and size 6 trach tube. NAP4 tells us needle jet insuff doesn't work in 60%, but surgical airway works 100%
I don't know, I still think my preferred option would be a needle cricothyroidotomy - its more familiar (Seldinger perc trachy) so feels more comfortable in a crisis, and if you can jet ventilate someone, you might be able to tube them from the top with a bit more time, saves them potential complications.
Not that I've ever had to do it for real, mind you...