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Removal of Needle Crich from Protocal
The system that I work in is currently looking to remove Needle crich from its protocal base..
Removal of Needle Cricothydroidotomy
One published case series is often used to describe the efficacy of this procedure, with no immediate fatalities reported
as a result of this procedure (Patel RG. Percutaneous transtracheal jet ventilation. Chest 1999;116:1689–94. -
http://www.mdconsult.com/das/article/body/159240626-
8/jorg=journal&source=MI&sp=11141198&sid=886415344/N/161055/1.html?issn=0012-3692 )
But this series included
the use of transtracheal jet ventilation. Low pressure ventilation (i.e. BVM) was initially described in 1909 by Meltzer
(Meltzer SJ, Auer J: Continuous respiration without respiratory movement. J Exp Med 1909; 11:622.) but reported the
success of this procedure in anesthetized dogs for whom the technique allowed for 30 minute survival when the dogs
were neither hypoxic nor hypercarbic at the time of the procedure.
The FDNY performed a review of all adult and pediatric patients on whom this procedure was performed. Every
patient who was pulseless at the time of the procedure remained pulseless upon ED arrival. Every patient with intact
perfusion at the time of procedure progressed to cardiopulmonary arrest prior to ED arrival. No patient in either group
survived. We therefore recommend its removal.
I can appreciate the fact that Needle cric does not work very well... However, It is just my oppinion that it should be replace with some other emergency airway choice (preferably surgical crich or a device like NUTREACH)..
what are your thoughts out there...
Removal of Needle Cricothydroidotomy
One published case series is often used to describe the efficacy of this procedure, with no immediate fatalities reported
as a result of this procedure (Patel RG. Percutaneous transtracheal jet ventilation. Chest 1999;116:1689–94. -
http://www.mdconsult.com/das/article/body/159240626-
8/jorg=journal&source=MI&sp=11141198&sid=886415344/N/161055/1.html?issn=0012-3692 )
But this series included
the use of transtracheal jet ventilation. Low pressure ventilation (i.e. BVM) was initially described in 1909 by Meltzer
(Meltzer SJ, Auer J: Continuous respiration without respiratory movement. J Exp Med 1909; 11:622.) but reported the
success of this procedure in anesthetized dogs for whom the technique allowed for 30 minute survival when the dogs
were neither hypoxic nor hypercarbic at the time of the procedure.
The FDNY performed a review of all adult and pediatric patients on whom this procedure was performed. Every
patient who was pulseless at the time of the procedure remained pulseless upon ED arrival. Every patient with intact
perfusion at the time of procedure progressed to cardiopulmonary arrest prior to ED arrival. No patient in either group
survived. We therefore recommend its removal.
I can appreciate the fact that Needle cric does not work very well... However, It is just my oppinion that it should be replace with some other emergency airway choice (preferably surgical crich or a device like NUTREACH)..
what are your thoughts out there...
Replies to This Discussion
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Permalink Reply by Robert Sullivan on -
We use the Pertrach. I used it once on a gunshot wound to the face while my partner read me the directions. He was not-quite-dead-yet when we got to him and was when we got to the hospital. We had good breath sounds and capnogrophy waveform, though.
I think you need to have a surgical airway protocol for things like airway burns, anaphylaxis, facial trauma, or choking. We see these so seldom that it would be hard to study, but could make a difference.
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Permalink Reply by Anthony Gorman on -
Well, the data is there. it has 100% mortality rate (deterioration) in people who were alive, and people who were in arrest remained in arest.
The surgical cric was presented to the commitee and shot down by most of the doctors. It does require skills practice and maintenance. Yes, surgical cric it is an effective airway, however NYC is not as progressive as everyone thinks they are. As far as replacing it with a device, NYC REMAC will not endorse or specify a device. So to tell every ambulance agency in the region you have to by product X is unreasonable.
The RESCUE Medics (FDNY) and ESU Medics (NYPD) have a sub set of protocols that still allow needle cric (they actually use the Rusch quick-trach). It is removed from the field level guys because you are 10 minutes from any given hospital and the way the protocols are written, if you have an unmanageable airway you divert to the closest 911 destination.
I would like to see the Surgical Cric. I have material from our other regions that I have submitted to commitee and spoken with the head of OMA ad Training for FDNY (WHO IS ALSO AND ADVOCATE FOR IT). However when you get the group of doctors together they don't trust medic with Lasix let aone a surgical cric.
Again NYC is not as progressive as people think. We are WAY behind the national curve.
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Permalink Reply by Robert Sullivan on
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Aren't there a few high rise apartment buildings in NYC? A lot of patients would be without an airway for more than 10 minutes. I found much greener EMS pastures outside of New York State where you're allowed to think more.
Anthony Gorman said:Well, the data is there. it has 100% mortality rate (deterioration) in people who were alive, and people who were in arrest remained in arest.
The surgical cric was presented to the commitee and shot down by most of the doctors. It does require skills practice and maintenance. Yes, surgical cric it is an effective airway, however NYC is not as progressive as everyone thinks they are. As far as replacing it with a device, NYC REMAC will not endorse or specify a device. So to tell every ambulance agency in the region you have to by product X is unreasonable.
The RESCUE Medics (FDNY) and ESU Medics (NYPD) have a sub set of protocols that still allow needle cric (they actually use the Rusch quick-trach). It is removed from the field level guys because you are 10 minutes from any given hospital and the way the protocols are written, if you have an unmanageable airway you divert to the closest 911 destination.
I would like to see the Surgical Cric. I have material from our other regions that I have submitted to commitee and spoken with the head of OMA ad Training for FDNY (WHO IS ALSO AND ADVOCATE FOR IT). However when you get the group of doctors together they don't trust medic with Lasix let aone a surgical cric.
Again NYC is not as progressive as people think. We are WAY behind the national curve.
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Permalink Reply by Anthony Gorman on
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Yep, agreed. Way more progressive protocols outside of this NYC bubble. The elevator is not part of the transport "loaded miles" There is a section of documentation that you can mark extend for elevators, security, traffic etc.
Robert Sullivan said:Aren't there a few high rise apartment buildings in NYC? A lot of patients would be without an airway for more than 10 minutes. I found much greener EMS pastures outside of New York State where you're allowed to think more.
Anthony Gorman said:Well, the data is there. it has 100% mortality rate (deterioration) in people who were alive, and people who were in arrest remained in arest.
The surgical cric was presented to the commitee and shot down by most of the doctors. It does require skills practice and maintenance. Yes, surgical cric it is an effective airway, however NYC is not as progressive as everyone thinks they are. As far as replacing it with a device, NYC REMAC will not endorse or specify a device. So to tell every ambulance agency in the region you have to by product X is unreasonable.
The RESCUE Medics (FDNY) and ESU Medics (NYPD) have a sub set of protocols that still allow needle cric (they actually use the Rusch quick-trach). It is removed from the field level guys because you are 10 minutes from any given hospital and the way the protocols are written, if you have an unmanageable airway you divert to the closest 911 destination.
I would like to see the Surgical Cric. I have material from our other regions that I have submitted to commitee and spoken with the head of OMA ad Training for FDNY (WHO IS ALSO AND ADVOCATE FOR IT). However when you get the group of doctors together they don't trust medic with Lasix let aone a surgical cric.
Again NYC is not as progressive as people think. We are WAY behind the national curve.
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Permalink Reply by Duncan Hitchcock on -
If the patient's condition is such that requires making a hole in their lower airway to attempt resuscitation or stabilization the hole must be big enough to do adequately ventilate the patient.
I offer the following test: take a 12G or 14G cathlon; remove the needle and dispose of appropriately; sit back in a recliner; pinch your nose; now breathe thru the cathlon. How long can you tolerate breathing like this? Remember, you're healthy, non-traumatized and in no acute distress. Repeat test with a vendor quick trac kit of your choice (The breathing thru the canula part.....geeze). Now try it with a #7 or 7.5 ET tube (length of tube shortened as would normal for a surgical airway).
See above statement.
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Permalink Reply by Anthony Gorman on
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@Mr. Hitchcock. Excellent point. When we teach needle cric in the Paramedic Classes, one of the things I do is, as soon as the cric is established I have the student breath through a coffee stirrer for the duration of the scenario. I think it addesses the affective domain pretty well. Makes them realize the difficulty in adequate oxygenation and end organ tissue perfusion when they can't even catch thier breath.
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Permalink Reply by blair4630 on -
To Mr. Hitchcock and Mr. Gorman....I agree completely, and have thought about this myself. At my former service, where I was the supply officer, one of the projects on my list was trach kits. Funny you put it like that, I was going to do exactly that with the board members, have them breathe through a 14 ga and ask them how they like it. I never got the chance, as I've moved on to another service.
At the new service, we have the nu-trach, which has the introducer needle, then expanders that are 4.5, 6, and 7 mm (i think, if not, that's close), so while not technically being a surgical airway because of not using a ET tube and creating a scalpel opening in the crichothyroid membrane, they create a nearly equal sized airway, allowing for easy ventilation and also, just as importantly, exhalation of CO2.
If you're not going to do surgical crichs, you HAVE to use the kits (they're all similar).....using the needle from the I.V. kit just doesn't cut it.
Side note, and I've brought it up in other threads, but while we're talking about what NOT to use your I.V. angios for....chest decompressions.....you need to get something 2.5 to 4" per current studies and recommendations. We use 3" 12 ga angios that are in there own little kit with cut off glove fingers, preps, and 1/2" tape.
The point is, if your service is saving a buck by telling you to use your 14 ga from the I.V. pouch for crichothyrotomy and thoracotomy, it will behoove you and your pt.'s to point out the errors of their ways.
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Permalink Reply by Skip Kirkwood on -
Is this a money issue, an evidence of benefit issue, a frequency of use issue, or a proficiency issue?
If it's a money issue, get over it! You can't ventilate somebody through an IV catheter, for the reasons described above. Dumb idea - always was, always will be. Buy devices with adequate lumens that can be quickly inserted.
If it's an evidence of benefit issue, I haven't seen a prospective study saying so. You only use this on way bad hurt patients, so "controlling" is an issue, but the fact that they all wound up dead from different causes doesn't persuade me - they didn't die because of the airway, they died in spite of it.
If it's a frequency of use issue, get over it. Taking something out of a protocol because it is rarely used would be like taking the guns away from patrol cops because they rarely use them. When you need your pistol, you need it very badly.
If it's a proficiency issue, find a way to maintain proficiency! It's called training, and specifically critical skills drills. What are they thinking, anyway?
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Permalink Reply by Brian Dunnigan on -
Skip Kirkwood said:Is this a money issue, an evidence of benefit issue, a frequency of use issue, or a proficiency issue?
If it's a money issue, get over it! You can't ventilate somebody through an IV catheter, for the reasons described above. Dumb idea - always was, always will be. Buy devices with adequate lumens that can be quickly inserted.
If it's an evidence of benefit issue, I haven't seen a prospective study saying so. You only use this on way bad hurt patients, so "controlling" is an issue, but the fact that they all wound up dead from different causes doesn't persuade me - they didn't die because of the airway, they died in spite of it.
If it's a frequency of use issue, get over it. Taking something out of a protocol because it is rarely used would be like taking the guns away from patrol cops because they rarely use them. When you need your pistol, you need it very badly.
If it's a proficiency issue, find a way to maintain proficiency! It's called training, and specifically critical skills drills. What are they thinking, anyway?
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Permalink Reply by Brian Dunnigan on
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http://www.narescue.com/Video-Downloads-C236.aspx If you follow the link to narescue.com and then go to video downloads you will see a great film a surgical crics. Hope you all enjoy the film and the website has some good info on other video presentations. I don't work for them so I just found them a year ago and I think they have some great tools.
Also the videoscopes are good for intubation but if you have a fractured larynx they are useless. The surg cric. is your only alternative.
Have fun ...............Don't cut to deep and verticle cuts as suggested earlier are the best approach. Unless the patient has a huge fatpad surg. crics are not terribly difficult unless your from a state that does not allow them to be performed.
A good question is would you do one if it was not allowed in your protocols if you knew you could save your patient.This is open for discusion. And say you have no way to communicate with med command for out of protocol procedure. I know my answer so have FUN...............
http://www.narescue.com/Video-Downloads-C236.aspxBrian Dunnigan said:Skip Kirkwood said:Is this a money issue, an evidence of benefit issue, a frequency of use issue, or a proficiency issue?
If it's a money issue, get over it! You can't ventilate somebody through an IV catheter, for the reasons described above. Dumb idea - always was, always will be. Buy devices with adequate lumens that can be quickly inserted.
If it's an evidence of benefit issue, I haven't seen a prospective study saying so. You only use this on way bad hurt patients, so "controlling" is an issue, but the fact that they all wound up dead from different causes doesn't persuade me - they didn't die because of the airway, they died in spite of it.
If it's a frequency of use issue, get over it. Taking something out of a protocol because it is rarely used would be like taking the guns away from patrol cops because they rarely use them. When you need your pistol, you need it very badly.
If it's a proficiency issue, find a way to maintain proficiency! It's called training, and specifically critical skills drills. What are they thinking, anyway?
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Permalink Reply by Brian Dunnigan on
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http://www.tacmedsolutions.com/07/products/product_detail.php?prod_... Another link to tactical medical solutions. This site is run by an ex military medic who has developed some nice tools for EMS providers in austere enviroments.
Click on the surgical cric. and you will see a more realistic film of the procedure. Also other cool video's. Sixteen to view for different techniques and tools available for paramedics.
http://www.tacmedsolutions.com/07/products/product_detail.php?prod_...Brian Dunnigan said:http://www.narescue.com/Video-Downloads-C236.aspx If you follow the link to narescue.com and then go to video downloads you will see a great film a surgical crics. Hope you all enjoy the film and the website has some good info on other video presentations. I don't work for them so I just found them a year ago and I think they have some great tools.
Also the videoscopes are good for intubation but if you have a fractured larynx they are useless. The surg cric. is your only alternative.
Have fun ...............Don't cut to deep and verticle cuts as suggested earlier are the best approach. Unless the patient has a huge fatpad surg. crics are not terribly difficult unless your from a state that does not allow them to be performed.
A good question is would you do one if it was not allowed in your protocols if you knew you could save your patient.This is open for discusion. And say you have no way to communicate with med command for out of protocol procedure. I know my answer so have FUN...............
http://www.narescue.com/Video-Downloads-C236.aspxBrian Dunnigan said:Skip Kirkwood said:Is this a money issue, an evidence of benefit issue, a frequency of use issue, or a proficiency issue?
If it's a money issue, get over it! You can't ventilate somebody through an IV catheter, for the reasons described above. Dumb idea - always was, always will be. Buy devices with adequate lumens that can be quickly inserted.
If it's an evidence of benefit issue, I haven't seen a prospective study saying so. You only use this on way bad hurt patients, so "controlling" is an issue, but the fact that they all wound up dead from different causes doesn't persuade me - they didn't die because of the airway, they died in spite of it.
If it's a frequency of use issue, get over it. Taking something out of a protocol because it is rarely used would be like taking the guns away from patrol cops because they rarely use them. When you need your pistol, you need it very badly.
If it's a proficiency issue, find a way to maintain proficiency! It's called training, and specifically critical skills drills. What are they thinking, anyway?
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