Removal of Needle Crich from Protocal

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Permalink Reply by David Mac on November 5, 2009 at 5:58pm

Yep totally agree, total waste of time, if your going to cric, surgical is the best way to go... as for the toys... too expensive... Try this, one pig approx 150lbs= $75 to $100 dollars, Ketamine and other assorted drugs to keep him sedated... you can cric him, decompress him, evicerate him, wound him how you want, will last all day if your skills are up to scratch, work as a individual or a team, then finally you can do a live vivasection... point out the various organs like the heart still beating etcetera (Oh don't forget keep bagging during this portion LOL)
Cheers,

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Permalink Reply by dr-exmedic on November 5, 2009 at 7:29pm

How far are you out from the hospital? And are you using BVM or jet ventilators? Because I agree, the BVM technique is indeed worthless.

If you have jet ventilator equipment and the specially-designed needles, needle cric will get you to the hospital, though the pt is probably going to die anyway. Our system practices yearly on needle-cric manikins and (occasionally) pig plucks (which is basically the entire airway). We use curved needles designed specifically for the purpose (which for whatever reason I can't find online) that don't have quite the problems Mike described. They are also somewhat cheaper to keep around than a lot of the other kits--let's face it, getting to the point of needing a cric is pretty rare in the field.

I've done a single needle cric in the field. It was no problem (although when I aspirated the syringe to confirm placement and got blood, I was briefly worried--then pulled a little more and got air) and ventilation was easy with the jet ventilator. It was quite a sight to watch the pt's lungs expand after they cracked her chest in the ED. She ultimately ended up dying, as most of these pts will.

Frankly, I don't know that having anything available is going to help anybody. Certainly not something that requires a bit of training and anatomical knowledge like surgical cric (unless, of course, you're in one of the high-performing model systems we all like to talk about).

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Permalink Reply by Skip Kirkwood on November 5, 2009 at 10:42pm

Hopefully this procedure, which seems to be of only slight benefit, will be replaced in your protocols with an honest-to-God surgical airway that CAN ventilate and oxygenate a patient.

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Permalink Reply by Skip Kirkwood on November 5, 2009 at 10:42pm

Hopefully this procedure, which seems to be of only slight benefit, will be replaced in your protocols with an honest-to-God surgical airway that CAN ventilate and oxygenate a patient.

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Permalink Reply by Adam Tomko on November 5, 2009 at 11:59pm

frm your mouth to my medical directors ears...

Skip Kirkwood said:

Hopefully this procedure, which seems to be of only slight benefit, will be replaced in your protocols with an honest-to-God surgical airway that CAN ventilate and oxygenate a patient.

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Permalink Reply by David Mac on November 6, 2009 at 10:25am

Hey Mike,
Regarding the surgical cric, having done over 11 in Iraq here's my advice,
1. Before making you incision have all the tools necessary
2. Make incision vertical... muy important...LOL
3. Use a 14 gauge hook... easy to make... bend the tip about a quarter of an inch at an angle of approx 45%,
4. Once you have made the incision leave the blade in, slide the hook alongside, pulling the hook to the left or right, this gives you the opening you need to insert the et tube,
5. I use a 6.5 or 7.5... now this is the important part.... while a partner holds the opening you take you et tube and bend the crap out of the distal end, damn things are stiff as hell... so yah need to really bend it so it slides in.. a little lube helps..
6. Placement, usually down to the first black line..... inflate, aucsilate left and right, you should get a good bilateral sounds, (Unless they are also suffering from blast injuries, pneumo's ect) if absent in one side, just deflate cuff pull back half an inch, re-inflate and again aucsilate... generally I sew it in place as I'm usually far from the near combat support hospital..

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Permalink Reply by dr-exmedic on November 6, 2009 at 1:26pm

Mike said:

Thanks, I will see if I can try with the "hook."

I just glanced at your original post an noticed you mentioned bluntly dissecting the cricothyroid membrane. Why on earth would you do that when you have a scalpel in your hand?

In the hospital you may have one of the actual tracheal hooks (I believe our cric kits have them, and I've used them on cadavers), which would do the same thing. There's also using hemostats to hold the incision open. You can also try the ATLS trick of inserting the scalpel handle into the membrane and twisting, but I watched a surgeon try that on a rather large pt using a disposable scalpel and the scalpel just bent--no opening for the tube that way.

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Permalink Reply by blair4630 on November 6, 2009 at 5:37pm

We have Nu-Trake kits. A previous service had another kit, don't remember the name. They will definetely move some air, and prevent hypercarbia, unlike a 14 ga jimmy rigged with a 15mm adapter and BVM.

I usually only get to practice when I take PHTLS, although I try to take that and other major courses every year, and when I'm at the skill stations I like to do the skill over and over, not just once.

So, I probably get to do the procedure with the kit I use 5-10 times a year, not great, but for something I may only do once or twice ever, no terrible I think.

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Permalink Reply by dr-exmedic on November 6, 2009 at 10:18pm

Mike said:

(I know you can also appreciate the perils of a student questioning the technique of the old school, master of the universe, surgery professor)

<<deadpan>>I have no idea what you're talking about.<</deadpan>>

The flimsy green plastic handled ones? I think those are junk.

Totally. But they are what we've got, and for the other 99% of things we use them for, they're adequate. Only you fancy OR types get the pretty metal handles with removable blades. :)

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Permalink Reply by Chance Gearheart on November 7, 2009 at 3:39am

I think, personally, we need to make video laryngoscopes mandated equipment on all intubation-capable prehospital care teams. It makes things SO MUCH easier, expecially in very difficult or non-traditional intubation settings, such as seated patients or suspended patients.

dr-exmedic said:

Mike said:

(I know you can also appreciate the perils of a student questioning the technique of the old school, master of the universe, surgery professor)

<<deadpan>>I have no idea what you're talking about.<</deadpan>>

The flimsy green plastic handled ones? I think those are junk.

Totally. But they are what we've got, and for the other 99% of things we use them for, they're adequate. Only you fancy OR types get the pretty metal handles with removable blades. :)

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Permalink Reply by dr-exmedic on November 8, 2009 at 10:00am

Chance Gearheart said:

I think, personally, we need to make video laryngoscopes mandated equipment on all intubation-capable prehospital care teams. It makes things SO MUCH easier, expecially in very difficult or non-traditional intubation settings, such as seated patients or suspended patients.

Yes! I got to use a Glidescope for the first time the other day and it was wonderful! It doesn't make up for people being poorly trained but it's a wonderful, wonderful adjunct for those people with thick necks and huge tongues and small mouth openings (didn't even try DL on that pt).

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Permalink Reply by Tom Sasso on November 9, 2009 at 11:03am

I've used the Needle Cric with Peds attachment/BVM a number of times... always seemed useless, just not enough air moving in (and none out). I had the chance to use a needle cric with a Jet Vent once, but the cath. we carry for it's use sheared as I attempted to insert it... I went to a surgical cric.
As for the surgical cric., I do IV's and Intubations all the time, both are relitively easy skills, but to be honest i think a surgical cric is easier than both. The pyscological factor may be more difficult, making a cut and the pressure etc... but the skill itself, unlike an IV and Intubation were you can "miss" if not right on, once the cut is made, there is your whole. I teach TCCC in a "live tissue lab" and know the carious techniques for insertion of the tube, but I've never had to use them. I just make the cut, insert my finger to create the diamiter needed for the tube, and put the tube in like in like a peg in a whole. Faster and easier then IV's or Intubations. Not something I want to do unless absolutely needed, not a pretty version of the technique (I'm not a surgeron, i'm doing this only if they are to die RIGHT NOW otherwise) but never had anything but praise form trauma surgeaons.
So I agree, No, don't like the needle cric, ma well have it's place somewhere, but I haven't seen it successfully yet, and the Surg cric is doable and useful when you really need it.
Just my .005 cents.

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