S4C31 - Surgical Airway Management

Question 1

Children <10

Answer 1

-do needle cricothyroidotomy

• 12-14g catheter over a needle
• temporizes until tracheostomy can be done

Question 2

Emergency tracheostomy

Answer 2

• indicated if the trachea become detached from the larynx
• increased risk of bleeding and thyroid gland injury
• should be performed by a surgeon

Question 3

Surgical cricothyroidotomy: equipment

Answer 3

• # 10 scalpel
• 6mm ETT or tracheostomy tube (preferred)
• tape
• ribbon, sutures
• BVM

Question 4

Surgical Cricothyroidotomy: Procedure

Answer 4

• stand on pts right side (if right handed)
• pt is supine and neck is straight, prep skin
• locate cricothyroid membrane
• place index finger at sternal notch and palpate up until first rigid structure is felt (cricoid ring)
• roll finger one breadth up to locate the hoolow b/w the cricoid and thyroid cartilages –> this is the cricothyroid membrane
• cricothyroid membrane is about 1/3 of distance from manubrium to chin (changes with habitus)
• hold trachea with thumb and middle finger of L hand
• make vertical inciscion with scalpel, midline b/w the two cartilages
• then with scalpel horizontal, perforate the cricothyroid membrane, blade should go in 1/2 of it’s length
• place blunt end of scalpel into incision and widen opening (may also use a kelly clamp)
• place ETT or tracheostomy tube in place
• secure tube
• complications (occur 15% of the time):
• bleeding:may injure the thyroid ima artery (runs in the midline), if cut, then ligate
• misplacement of tube into the mediastinum, usually occurs in obese pts
• injury to neck structures - laceration of trachea, esophagus, recurrent laryngeal nerve
• pneumothorax (usually from barotrauma)

Question 5

Needle cricothyroidotomy: Equipment

Answer 5

• 14 or 12 gauge sheathed needle catheter
• 3ml syringe
• adapter from the end of a 7mm ETT
• wall oxygen at 15L/min connected by tubing with a Y connector

Question 6

Needle cric

Answer 6

• adults can be oxygenated for only 15-20mins with a needle cric therefore a definitive airway needs to be planned –> surgical cric, ET intubation, tracheostomy
• procedure:
• stand on pts Right side if right handed
• locate the cricothyroid membrane
• attache a 3cc syringe to 12/14g catheter
• introduce catheter into the subcutaneous tissue at a 90 degree angle to the skin
  
  • aspirate gently while advancing the catheter over the needle
  • when air is aspirated change angle to 45 degrees and advance catheter over the needle into the larynx
• withdraw plunger from syringe and attach plunderless 3cc syring barrel to catheter in the neck
• attach the adapter (From the 7mm ETT) to teh open end of the 3cc syringe or place a 7mm ETT into th empty syringe barrel and inflate the balloon
• attach O2 source

Question 7

Needle cric

Answer 7

-complications: bleeding, perforation of esophagus/trachea/larynx, subcu emphysema