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Hella from Denmark wrote 06-24-2013 07:10:22 pm
My preference is surgical - vertical incision, blunt dissection, horizontal cut through the membrane, insert trachea dilator forceps and then direct insertion of the tube.

This is easy for operator and easy for assistants, and is quick.

Todd Fraser from Australia wrote 06-25-2013 03:48:20 am
I've added the vodcast to YouTube - http://youtu.be/-50MKbBh5dw. Check it out and let me know what you think

Doc Martin from Australia wrote 06-26-2013 09:46:18 am
I've only done one, but have witnessed 2 others. I used a horizontal incision, all in one, but it was in a reasonably thin person. After reflection on these 3 cases, I'd do the same, but if the patient was fat, would do a vertical incision through skin - landmarks are more identifiable after this so can find membrane easier, then do horizontal incision through membrane.

Not sure I'd worry about the bougie - seems an unnecessary step

Rfdsdoc from Australia wrote 06-27-2013 07:46:25 am
thanks Todd for video of surgical airway ! also thanks for the comments , folks!

One point to raise on the needle cric technique and rescue oxygenation via it. The 3 way tap technique is useful but it takes reasonable force to stick the tap into standard O2 tubing.
I ran a simulation session once with a timed challenge to perform a needle cric and use a 3 way tap setup to oxygenate. None of the 14 participants could do it within 3 minute limit set!

So either practice that technique a LOT! or preassemble the tap and tubing!

And for the doubters, the needle cric and oxygenation does work! We did it on a kid with epiglottitis with failed ETI/LMA and it saved em till backup arrived and second ETI attempt successful

Also an intern emailed me who did the technique shown on my blogsite in a CICV situation from a laryngeal tumour admitted for surgery next day. Guy went from hypoxic full arrest to ROSC and flailing around within 40 seconds of needle oxygenation. no time to find 3 way tap in that case! Intern used 14G , syringe and just O2 tubing..held it onto end of cannula intermittently at 15 L/min. worked a treat and guy alive today!

Thats actually how we did it in that epiglottitis case for first time and discovered it worked really well.

Now about open surgical cric..the bougie addition is interesting..its quite trendy right now. And it works no doubt but we have had a few cases whereby it created a false passage in the neck soft tissues. The key seems to be in confirming tracheal access reliably.

Paix and Griggs EMA article on their 24 case prehosp series advocates finger confirmation and this works really well!

the key I think is in making a decent cut to expose the anatomy and thats where the vertical incision is King. In fact its the only approach I have seen that has saved a life in a complete traumatic tracheal transection case during a retrieval. Having said that the bougie was useful in that case to intubate the torn distal trachea!