Transvenous Pacing - Decoding the Box

Let's say you're in a small shop at about 2 AM. You've got your feet up and you're reading the Sunday Funnies.  Suddenly, EMS comes rolling in with a patient with crushing chest pain.  Your EKG is done immediately, and while it does not show a STEMI, let's say it shows complete heart block with the rate somewhere in the upper 30's.

Your local interventionalist/EP is aware and is en route in his Maserati but it's going to be a good 20-30 minutes before he'll arrive.  You briefly consider transcutaneous pacing, but when you look back at your nice, cooperative, conscious patient and realize that deep down in your soul you're just not that cruel.  Dust off that kit, because it's time to float a pacer, people!

You might be thinking, "Transvenous pacing? Really? That made the cut?" We've chosen to highlight this procedure as it is, on paper, very straightforward, but IRL (as noted by several practitioners we've talked with) it can be filled with tons of confusing variables and details.  True, one could always hit the "EMERGENCY" button when in doubt but we're smart enough to understand this on a more sophisticated level.  Despite the haters out there, the evidence is clear that we can insert these just as efficiently and successfully as our colleagues up in the cath lab.

Before we put anything in your patient, let's do a FREEZE FRAME and look at your generator.  There's obviously a few commercially available products out there, but they all essentially have the same settings:

1.) Rate - How fast do you want them to go?  It depends, but generally you want them above their intrinsic rate, or if they're also getting paced transcutaneously, above that. I've heard experts recommend going about 20 beats higher.  80 bpm is usually a safe place to start.

2.) Output - How much current do you want them to get?  These usually run from 0.2 to 20 mA, and you'll want to start with it cranked all the way to 20 to ensure capture. You can adjust this later (and we'll address this again). The Medtronic generator depicted has two settings for output, labelled "A" for atrial and "V" for ventricular. Since we're only going to be tickling the right ventricle in this situation, leave the "A" output at 0 at all times.

3.) Sensitivity - How well do you want your generator to detect voltage? It's a bit nonintuitive: the lower you set it, the more sensitive it gets.  These go from 0.5 mV to 20 mV, so if you set it at 0.5 it will detect voltages down to that level.  If it detects a native depolarization at that voltage and it's equal or faster than the rate you program, your pacer will not fire.  Usually there's an asyncronous mode that just paces like a honey badger regardless of the intrinsic rhythm--and that's generally the setting you want to start on.

These things run on batteries, so also make sure they've been replaced recently.

Now hit the play button so we can insert this guy.  We won't go into detail about placing the initial line as this should be obvious, but just remember that you'll need a Cordis in either the right internal jugular or the left subclavian (it's a board question, people!).  Get sterile, but you will need a non-sterile colleague to help you when it's time to attach the generator to the cable--unlike most emergency medicine procedures, this will become a two man (or woman) job at this point). 

There are a number of different kinds of catheters you can use here but for the sake of time let's assume you have a flotation catheter.  They are placed under ECG guidance and generally are the most appropriate for our realm of practice (I mean do you really want to learn about Swan Ganz catheters???)

Thread in your catheter with the balloon down to about 10-12 cm.  DON'T FORGET THE SLEEVE! It's very easy to proceed and realize you've forgotten this step once it's too late.  Once it's on there it gives you a sterile mechanism to reposition the wire if need be. 

Now, hook this guy up!  You will need to have your trusty non-sterile assistant attach your line with adaptors to the connecting cable to the box (which, needless to say, goes in the VENTRICLE port).  The line marked "proximal" gets attached to the positive lead.  If you have an alligator clamp, the distal lead should be hooked up to lead V1 of your EKG machine.  This will put you into exploration mode.

Now tell your assistant, "BALLOON UP!" and float that sucker!  You'll need about 1.5 cc of air into the balloon, and move it downstream quickly.  You're looking for a STEMI pattern as the catheter tickles the very arrhythmogenic endocardium of the right ventricle. Ultrasonography will also enhance your experience as you can directly visualize your wire abutting the apex. Once you're there, deflate your balloon, close it off with the stopcock, and then lock your line with your sheath.

Plug the distal lead back into your box, because it's time to rock and roll.  Just like we stated earlier, get your rate at about 80, and then start with your output high.  Sensitivity can be asynchronous here. You will need to assess for capture both electrically (QRS complexes that follow the pacer spikes) and mechanically (palpable pulses that correspond to your pacing rhythm). Slowly titrate down your output until you lose capture.  It's generally accepted that your output should be about twice the threshold so you consistently get good capture.  

Always get a portable chest x-ray once your done to confirm placement, and to make sure you haven't caused any iatrogenic injury.  

Here's the legendary Dr. Al Sacchetti demonstrating how he sets up his transvenous pacers (I think this is tailored to nurses but it's still great):

Here's another video of him placing one in an actual patient:

Just as always, these writings and musings are for EDUCATIONAL PURPOSES ONLY.  Listening to me babble on in no way shape or form makes you the expert at floating these things.  Be smart.


Sources:

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 15.

Aguilera, P. A., Durham, B. A., & Riley, D. A. (2000). Emergency Transvenous Cardiac Pacing Placement Using Ultrasound Guidance. Annals of Emergency Medicine, 36(3), 224–227. doi:10.1067/mem.2000.108654

Birkhahn, R. H., Gaeta, T. J., Tloczkowski, J., Mundy, T., Sharma, M., Bove, J., & Briggs, W. M. (2004). Emergency medicine-trained physicians are proficient in the insertion of transvenous pacemakers. Annals of Emergency Medicine, 43(4), 469–474. doi:10.1016/S0196064403010540

Harrigan, R. A., Chan, T. C., Moonblatt, S., Vilke, G. M., & Ufberg, J. W. (2007). Temporary transvenous pacemaker placement in the Emergency Department. The Journal of Emergency Medicine, 32(1), 105–111. doi:10.1016/j.jemermed.2006.05.037

Al Sacchetti's YouTube Page

tamingthesru.com

Life In the Fast Lane.com

The Blind Internal Jugular Central Catheter

To today's young burgeoning emergency physicians, ultrasound guided internal jugular central catheters have more or less become standard of care.  And for good reason!  They are safe, and after a good amount of experience, quite easy to perform.

But what if you're practicing in those shops that don't have ultrasound? It's hard to imagine in this day and age but it's the truth in some places.  Let's say you're in said department, and a floridly septic patient rolls in.  You fluid resuscitate, but after several liters of fluid their blood pressure remains crappier than crappy.

What's your plan, doctor?  You can start that norepinephrine peripherally to buy you some time (bollocks to dopamine of course), but you're going to need central access.  Femoral lines are easily done blind, but you'll be unable to get CVP's, and the infection risk limits their lifespan.

Some of our colleagues who have been in the game more than a few years often quip, "In my day, we did all these blind, you know...."  Maybe we should take some advice from our wise forbearers and learn a thing or two.....

Clearly, your setup will be the same as it always is, with your kit that includes your local anesthetic, finder needle, wire, dilator, scalpel, suture, and catheter.  And it's still sterile as humanly possible, of course.  To make everyone's life easy, we'll just assume there is no reason you can't use the right IJ and describe the procedure as such.

Your best friend will be your sternocleidomastoid.  Know it like the back of your own sternocleidomastoid!  You can access the IJ either anteriorally, centrally, or posteriorally to this landmark.  To come at it anterior, find where the medial edge of the SCM meets the clavicle, and measure up 2-3 fingerbreaths.  Come in from 30-45 degrees and aim at the nipple.  Generally speaking, this approach carries the highest risk of arterial injury.

To come centrally, identify the triangle formed by the clavicle and the two heads of the SCM.  Your needle will enter at the apex of said triangle at an angle of 30 degrees, also aiming at the ipsilateral nipple.  

Finally, the posterior approach brings you higher up in the neck, decreasing the risk of carotid puncture of pneumothorax.  You'll need to come about halfway up the lateral edge of the SCM, and come in pretty steep at 45 degrees.  Instead of aiming at the nipple, you'll want to come in at the suprasternal notch.  Look out for the EJ on your way in!

The official New England Journal of Medicine video on IJ placement is largely ultrasound driven, but they do have some pretty impressive graphics regarding positioning in an ultrasonagraphically poor world.

Scott Weingart has a demonstration on the EMCrit blog:

This is just part of a fantastic piece on central lines that can be found here.  I highly suggest you check it out.

Just as always, these posts are meant for EDUCATIONAL PURPOSES ONLY.  Are you still only comfortable with doing these with a probe?  Maybe you should go practice on a model first.

Stay tuned--Procedures Club Videos are coming to a website near you!

jps

Sources:

Roberts and Hedges' Clinical Procedures in Emergency Medicine.  Chapter 22.

New England Journal of Medicine Videos in Clinical Medicine.

EMCrit.org

Life in the Fast Lane Website, Central Venous Catheters

Escharotomy

After our last post, a few viewers have suggested that we continue the trend of elevated compartment pressures and address a super duper rare yet potentially life saving procedure today.   So, escharotomy....here-a we go!

Let's say you have a patient brought in from a fire with full thickness burns to their torso.  You intubate, start hydrating per the Parkland Formula, and you (assuming you are not one) get your burn center on the horn.  Your respiratory tech suddenly notes that they are having an incredibly difficult time ventilating patient, and their peak pressures are shooting off the charts.  Your trauma surgeon is not readily available, but you need to do something now.  

It's time for escharotomy, as the full thickness burns are causing chest wall constriction.  Eschars can also cause peripheral arterial occlusion (not unlike compartment syndrome!), and tracheal compression as well. 

The pressure needs to be released in a fasciotomy-like release, and almost always this should be done in an operating room--if there's time.  The procedure itself really does creep outside of the scope of our practice, and really should only be done in absolutely dire circumstances, mainly airway compromise and severe limb ischemia.  

To prepare, you will mainly need some antiseptic prep and a scalpel.  It will be handy to have electrocautery (cutting diathermy for the skin and coagulative diathermy for bleeding) available as you may encounter some significant bleeding.

The incisions to the chest should start at the clavicles at the anterior axillary line and extend inferiorally, down to the subcutaneous fat.  You'll want to connect these lines with a transverse incision in the upper abdomen (the so-called "Roman Breast Plate"). If your pressures were significantly elevated you should see notable separation between the wound edges. If it's indicated, extremities can be incised in a similar manner along medial and lateral mid-axial longitudinal lines as depicted below.  You'll want to avoid any extensor or flexor creases.

If the burns are full thickness, the skin should be insensate but local anesthesia may be indicated if there's a question if it's partial thickness or not.  Overall optional as your patient is hopefully intubated and sedated at this point, and you may not have the time.

A very creative, MacGyver-esque simulation model can be seen here courtesy of Greater Sydney Area Helicopter Emergency Medical Service.

As always, these procedures are meant for medical professionals, and are for EDUCATIONAL PURPOSES ONLY.  All efforts should be made for this one to be done in a controlled, operative setting with trained sub-specialists, and not in your shop.

Sources:

Roberts and Hedges Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 38.

Life in the Fast Lane Blog - "Releasing the Roman Breastplate"

Compartment Pressure Measurement - "Stryker" It!

Let's say you have a middle aged otherwise healthy patient who, after throwing back a few cold brewskis, decides to "kick it" with a group of skateboarding youths.  We'll cut to the chase and state that it doesn't go well, he's now in your ED, and his left calf doesn't look too hot.  Maybe he's got a tibial fracture, maybe not.  Either way his leg is tense as can be, and despite getting an adequate dose of narcotics he is in E-X-Q-U-I-S-I-T-E pain.  You do an exam, and note a tense extremity with pain with passive stretch, some decreased sensation, but has a good distal pulse.

Just like Lloyd Bridges in Airplane, you should be shouting, "Stryker! Stryker! Stryker!"  Stryker needle that is (it's the most commonly used product, so we'll only refer to that one), to rule out compartment syndrome.

The condition can occur in any extremity, but the most common presentation you'll see is the one stated above.  It is an incredibly difficult diagnosis to make clinically, and it is a huge potential pitfall as correct identification can be delayed or even missed entirely.  An interesting cohort study from the Canadian Journal of Medicine noted that patients at a hospital in Montreal who underwent fasciotomies noted a concerning "median event-to-operation" duration of 9 hours for traumatic cases and a shocking 34 hours for nontraumatic cases.

We are always taught the classic 5 P's (pain/swelling, pallor, paresthesias, paralysis, pulselessness), but if you're noting these findings the cat is already out of the bag, and your patient will likely have permanent deficits as a result.  If it's early, you'll have to trust your gut and go check the pressure.

The set-up for this one is pretty simple, and everything you'll need should be in the pre-packaged kit.  It includes a side ported needle, a diaphragm chamber, a prefilled 3 cc syringe, and the main monitoring unit.  It is possible to jury rig a set-up to continuously transduce pressures like an arterial line, but it's beyond highly unlikely you would ever need to do this in the ED (more tailored for either the OR or a surgical ICU), so we will not cover that today.

Connect your needle to the diaphragm, and then screw in the syringe on the other side.  Load this assembly by pushing it into the monitoring unit, with the black side of the diaphragm down.  Snap the cover closed gently.  To calibrate, hold the entire unit up at a 45 degree angle, and flush it to get the air out.  Push the monitoring button to turn it on, then hold the monitor at the angle you're going to "Stryker at" and hold the zero button down.  You should see "00" appear.

Then you'll need to identify the appropriate site to target.  It all depends on where you think the affected compartment is.  For sake of discussion, and since it's the most common one, we'll focus on the anterior compartment of the calf.  Here, you'll identify the area where the proximal and mid thirds of the tibia meet, and then move 1 cm lateral to this.

You'll want to give them adequate local anesthesia at the site of injection, but you need to take care not too inject too deeply so that you get a falsely elevated reading. Once this is done and the area has been properly cleaned, insert your needle 1-3 cm into the compartment, and then, very, very slowly inject like an aliquot of saline (they state no more than 0.3 cc) and wait for the reading to appear.

If the pressure is greater than 30 mmHg, or within 30 mmHg of the diastolic blood pressure, your patient needs to be evaluated for a fasciotomy.

SoBroEm.com also features a nice step by step illustration here.

Here's another demonstration of the assembly and procedure from the Plastic Surgery Project:

If you haven't had a chance to check out the YouTube page of Dr. Nabil Ebraheim, go NOW.  He's a veteran orthopedist with some incredibly high yield videos.  Here's his clip on compartment syndrome (goes out of our scope but still a good watch):

As always, these writings are for medical professionals, and are for EDUCATIONAL PURPOSES ONLY. This is probably one of the least invasive procedures we've covered thus far, but that doesn't mean you should go running into a patient's room to needle their calf.

Sources:

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 54.

Messina et al.  A human cadaver fascial compartment pressure measurement model.  J Emerg Med. 2013 Oct;45(4):e127-31. 

Vaillaincourt C. et al.  Quantifying delays in the recognition and management of acute compartment syndrome.  CJEM. 2001 Jan;3(1):26-30.

Dr. Nabil Ebraheim's YouTube Page

Plastic Surgery Project YouTube Page

SoBroEm.com

Pericardiocentesis

So let's say you have a patient--maybe they have a history of malignancy or renal failure or lupus or whatever--and the patient's having some trouble. Let's say they're dyspneic and hypotensive, and round out the classic Beck's Triad with some muffled heart sounds and distended neck veins (although only 33% of patients actually have all three of this point of medical masturbation).  You astutely throw on your ultrasound on the chest, and you see something that looks like this:

                           

Let's throw out the typical Procedures Club stem of "you're at a community hospital and there's no specialist around" blah blah blah and cut to the chase.  You're doing a pericardiocentesis today!

But before you do any poking, let's review the basics for a spell.  The pericardium is made of two layers, the visceral and parietal pericardia, with the potential pericardial space between them.  Physiologically, there should be about 20ish cc's of fluid there for shock absorbancy and lubrication.

Generally speaking, once you've got about 200 cc of fluid acutely in there, you start to see some systolic dysfunction.  Chronically, the space can accommodate quite well due to elasticity of the structures, so you could theoretically see a huge effusion with no symptoms as it has been there a while.  Here's a demonstration of how you can fall off the curve, based on animal studies:

Some other things to note: first off, are they stable?  If so, you might have enough time to treat what's causing the tamponade as opposed to the tap--i.e. if they're end stage renal, get them to HD.  If they're not stable, consider fluid boluses and pressors to buy you some time.  You do want to avoid positive pressure ventilation in these cases, however, as this may cause hemodynamic collapse.

In terms of preparation, you'll more or less need the following: an 18 G spinal needle, a 10 cc syringe, ECG wires with alligator clips, a guidewire, a pigtail catheter, a dilator, a stopcock, local anesthesia, sterile drape and wipes, and your trusty bedside ultrasound.  If you're in a pinch, just grab the 18G and the syringe and go go go.

There are a few ways to approach the pericardium,  The standard approach is subxiphoid, with you standing on the patient's right. After prepping and injecting some local anesthesia, you'll need to identify the left xiphocostal angle, and slide down about 1 cm.  This will be your entry point, where you'll come in at about 30 degrees, aimed at the left shoulder.  As with any other tap, you'll slowly aspirate as you go in.  NEVER move the needle in a side to side fashion, as you may lacerate the underlying epicardium. Once you're in, try to get a good 60 cc out.   If you've opted to attach your ECG wire, you can see if you hit epicardium by watching the waveform.  If you start seeing ST elevations, back up and watch for them to resolve.  After that, wire it and place your pigtail for continued drainage in an ICU setting.

If you have a legit tamponade, even a small amount of aspiration will cause a significant improvement in your patient.  Remember, how they showed on Downton Abbey?  Dr. Clarkson did that blind, in ONE POKE?  That's how they did it back in the day.

If it's a hemorrhagic tamponade, the traditional teaching is that you can distinguish it from ventricular blood by looking for clot--pericardial blood shouldn't have any due to the fibrinolytic activity.  However, this isn't totally reliable as you may just be tapping a brisk bleed.  You'll definitely want to check a post procedure CXR to make sure you didn't put any air somewhere air isn't supposed to be.

If you're doing it blind, cadaveric studies have shown that subxiphoid is probably the safest way to go, although it is not without complications. Here's the (unauthorized?) ATLS version for your perusal:

 If you have an ultrasound, however, you'll want to try a different route.  Specifically, you'll take a parasternal long axis view to identify the tamponade.  Your needle will be in plane with the probe.  The best part about this one is that you can see the effusion decrease in size in real time.

Academic Life in Emergency Medicine has a featured a fantastic primer on these based on a paper published by Dr. Arun Nagdev from UCSF. If you want to look particularly slick with this one, you can identify the interior mammary artery with your probe and mark the skin so that you don't hit it with your approach.

I couldn't find a YouTube demonstration of this (which is a bummer as it appears to be awesome), but here is a subxiphoid approach from the Ultrasound Podcast page:

As always, these writings are for EDUCATIONAL PURPOSES ONLY.  Would you want a family member to unnecessarily have a needle shoved in their pericardium by some overzealous scrub because "he always wanted to do one?"  Be smart!  Talk soon.

jps

Sources:

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition.  Chapter 16.

Loukas, M., Walters, A., Boon, J. M., Welch, T. P., Meiring, J. H., & Abrahams, P. H. (2012). Pericardiocentesis: A clinical anatomy review. Clinical Anatomy, 25(7), 872–881. doi:10.1002/ca.22032

MPH, P. C. I. M., & MD, S. L. (2013). Techniques and Procedures. Journal of Emergency Medicine, 44(3), 661–662. doi:10.1016/j.jemermed.2012.06.019

MD, A. N., & MD, D. M. (2013). American Journal of Emergency Medicine. American Journal of Emergency Medicine, 31(9), 1424.e5–1424.e9. doi:10.1016/j.ajem.2013.05.021

Life in the Fast Lane Blog: http://lifeinthefastlane.com/ccc/pericardiocentesis/

Academic Life in Emergency Medicine Blog: http://www.aliem.com/ultrasound-guided-pericardiocentesis/

Ultrasound Podcast YouTube Page

Surgical Airway, Part Two: Pediatric Translaryngeal Ventilation

And we're back! In our last post, we discussed a number of approaches to the surgical airway, including the traditional "scalpel-hook-tube" method, the Seldinger technique, newer methods using bougies, and homemade/DIY/MacGyver approaches (a shout out to ALiEM's Dr. Andy Neill for sharing his study on emergently using Bic Pens!).  But what about kids?  That's truly a beast of its own, so today is dedicated to our precious we ones.

Clearly stating the obvious here: emergent pediatric airways are much less frequent than those in the adult world, and fortunately surgical airways in children are exceedingly rare.  But you always have to remember that you cannot do a traditional cric on a child. Their cricothyroid membranes are just too small to accommodate an endotracheal tube, and you have an incredible high likelihood of damaging local structures.  A paper we've referenced studied neonatal cadavers and found that in general their CTM's were about 2.8 mm tall, in comparison to the 2.0 ETT, which has an external diameter of 3.0 mm.

The exact cutoff age varies in the literature, anywhere from age five to age twelve.  Generally speaking, if there's a kid, put your scalpel down.  You could theoretically use this approach for adults as well, but they would require the jet ventilator--simply bagging them through the catheter won't generate adequate tidal volumes, and 15 L/min through the jet probably won't cut it either.

What you'll need is generally similar to the needle approach for kids: a 14 G angiocath with a 5 cc saline filled syringe (in a pinch, you can get this out of a central line kit), and some sort of adaptor for BVM (if that's your endpoint).

The big difference now is that you will need a jet ventilator--the system generally includes a hookup to high pressure wall O2 (generally at about 50 psi), tubing, an on-off valve/injector, a regulator, and a Luer lock to attach to your catheter (see below for images).  Is this easily located in your shop?  Best make sure that it is.

You'll start by identifying the laryngeal prominence, moving inferiorally to locate the CTM.  In neonates and smaller children this may be difficult as their laryngeal prominence is not developed.  In these instances, start low and move your finger up the tracheal rings until you've found the CTM.  After cleaning, aim your needle caudad at about 30-40 degrees.  Just like in our previous post, you'll want to aspirate to get air bubbles.  And it should aspirate easily--any resistance suggests you're still in soft tissue.  If your patient is awake (hopefully not), you can inject lidocaine via the syringe to suppress the cough reflex.

After that, just advance the catheter, and remove your needle.  If you're going to be using a bag, toss on your adaptor (usually a 3 mL syringe MacGyvered into a 7.0 ETT adaptor--seen below), and start squeezing.

One big downside to using the standard angiocath is that it can kink relatively easy.  An alternative, if you have it in your shop, is a nonkinking wire catheter, demonstrated here from the Walls text:

As for jet ventilating, you'll need to attach your apparatus and do some adjustments.  To avoid barotrauma, you'll need to reduce the inspiratory pressures to less than 20-30 psi.  This is where an expensive commercial device earns it weight in gold--you'll want a device that can reliably and easily do this quickly. You will want to set your flow rate at about 1 L/min per year of age, and then titrate up 1L/min based on how much chest wall movement you're seeing.  Your control will either be a handle or a button, with several variations depicted below:

Due to their small lung volumes, the jet is generally contraindicated in kids younger than five.  In these incidences, use the bag, ventilating carefully (but against a lot of resistance!) and with age appropriate equipment.

And now, here's your gratuitous Whit Fisher MacGyver video--this one features novel ways to jet ventilate when your equipment is not within grasp (along with some absolute ridiculousness):

As always, these writings on procedurology are for EDUCATIONAL PURPOSES ONLY.  Do your own research, keep calm/carry on, and always do the right thing.  You are the expert, and you are the one who will save a (young) life.

Thank you all for following!  And thanks again to emcurious.com!

jps


References:

Navsa, N. et al  (2005).  Dimensions of the neonatal cricothyroid membrane--how feasible is a surgical cricothyroidotomy?  Pediatric Anesthesia, 15:402-406.

Walls RM, ed. Manual of Emergency Airway Management, Section 2.

Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. 
Chapter 6.

Whit Fisher's YouTube Page

Surgical Airway, Part One: Cricothyrotomy

Hey there, super friends! So far, we've managed to settle down into a groove with this whole blog thing with some solid posts about tough, challenging, weirdo, what-the-heck style procedures.  Together, we've made our way through thoracotamies, Blakemores, and lateral canthotomies.  We're bigger men and women in white as a result.

So, I think we're ready to tackle the elephant in the room.  We're ready to battle Voldemort; we're willing to stop Johnny from "sweeping the leg";  we're going to confront the Emperor, and we will NOT turn to the dark side of the Force.  Our archnemesis is calling, and we're not afraid.

That's right guys, we're doing the cric today.

Most providers I've talked to can count the number of cric's they've had in their career on one hand, but they remember every single, bloody detail of theirs, and will continue to do so until the day they die.  And I'm not being glib there.  The cases that lead to crics are always insanely unique; so unique that writing about any of my examples will surely open the medicolegal Pandora's box from hell.  I'll abstain.

Remember your indications, mainly that you cannot oxygenate or ventilate.  If you can't get the tube, but you can successfully place something temporary like an LMA, step back for a second.  If there's an alternative, take it.

Anyway, just like many other things in medicine, there is more than one way to skin a cat.  We will talk of a few, but not all, of the methods here, starting with the most rudimentary.

1.) Traditional Cric.

The motto of this one is: keep it simple, stupid!  You need your knife, you need your hook, you need your dilator, and you need some sort of tube (either a nice trach or a sawed off 6.0 ETT).  That's it!

1.) Find the cricothyroid membrane.
2.) Cut skin vertically 2-3cm--get ready for some bleeding to screw up your view!
3.) Cut membrane horizontally.
4.) Get your hook in the superior aspect before you remove your scalpel.  Also get someone to hold traction on this!
5.) Get your dilator in laterally and rotate it down 90 degrees (the Trousseau's are kind of counter intuitive--squeezing opens them).
6.) Tube in, cuff up, start bagging.

In terms of incision the skin, there is a bit of discrepancy between our generally accepted way of doing these and what is done in the surgery world (i.e., vertically vs. horizontally).  I personally remember taking ATLS and having an older trauma surgeon laugh hysterically in my face when I demonstrated doing the initial incision vertically on a model.  Ignore the haters out there, this is how we do it and that's that.

Here's a very nice demonstration on a cadaver courtesy of the University of Maryland Department of Emergency Medicine:

2.) Seldinger Cric (aka "Melkering It").

I have never seen this one done but I love the sound of it.  For one, my fear of a horribly bloody surgical field is alleviated. However, this option requires a good, confident ability to locate the membrane--this might be a problem if there's significant trauma.

The kits are as simple as you'd want them to be, including your scalpel, wire, 6 mL syringe, 18 G needle w/catheter,  cuffed catheter, and dilator.

Identify your landmarks, and come at the cricothyroid membrane directed 45 degrees caudad.  You'll want to have your syringe loaded with a bit of saline so you can confirm entry into the trachea with air bubbles.  Thread your catheter, and the rest is just as you'd expect it--wire it, incise it, and then dilate it!  Your dilator slides into the catheter, and you'll want to grip them like so as you push them in:

After you've hubbed it, pull out the dilator and guidewire.  You should be good to go.  Here's an incredibly dated looking video from Cook Critical Care:

3.) Bougie Cric.

It's all the rage!  There's a lot of buzz about this one, and rightfully so--some initial data has shown that it is related to higher success rates and less risk of tracheal damage.  And it's quicker!

You need even less for this one.  Your kit will include a No. 20 scalpel, a bougie, a 6.0 ETT, and your finger (you could throw in a hook as well but it's not required).

The procedure: make a horizontal stab with the scalpel at the cricothyroid membrane (yes I realize what I said earlier).  Do it all the way through the skin and the membrane.  Bluntly dissect down with your finger, keeping it in there.  Load the bougie in under your finger.  Slide the tube in.  Bougie out.
Done!

Here's some demonstration images majestically taken by AP:

Here's a demonstration from Darren Braude via Scott Weingart's YouTube page:

4.) Crazy MacGyver Cric.

We're entering the world of the unknown on this one, but essentially you resort to this when you're patient is crashing and you essentially have to grab whatever is nearby. 

While I in no way shape or form recommend you try this, the ever brilliant Dr. Whit Fisher has an awesome technique for making a trach needle out of an IV spike (who would have known?):

Just threw it in for the sheer awesomeness of it all.

Pick your poison, but get it right.  Practice makes perfect, and the more times you can simulate a cric, the more comfortable you will be when your number comes up.  Academic Life in Emergency Medicine has a fantastic recipe to make a bleeding model for simulation here: http://www.aliem.com/simulation-trick-of-the-trade-bleeding-cricothyroidotomy-model/.

As always, these wannabe instruction manuals are made for EDUCATIONAL PURPOSES ONLY.  You already know darn well enough that a cric is the last-ditchiest of last-ditch procedures, so don't go getting heroic on us after this one.

Stay tuned!  Next up is the PEDIATRIC surgical airway.....

jps

Sources:

Robers and Hedges' Clinical Procedures in Emergency Medicine.

Makowski, A. L. (2013). A survey of graduating emergency medicine residents' experience with cricothyrotomy. The Western Journal of Emergency Medicine, 14(6), 654–661. doi:10.5811/westjem.2013.7.18183

Hill, C., Reardon, R., Joing, S., Falvey, D., & Miner, J. (2010). Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab. Academic Emergency Medicine, 17(6), 666–669. doi:10.1111/j.1553-2712.2010.00753.x

Nakstad, A. R., Bredmose, P. P., & Sandberg, M. R. (2013). Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 21(1), 1–1. doi:10.1186/1757-7241-21-59

University of Maryland Department of EM's YouTube Page

Procedurettes YouTube Page

Scott Weingart's YouTube Page

Airwaycam.com