Transcript Seldinger Cricothyrotomy - Hamilton Health Sciences

Seldinger Cricothyrotomy
2002 ACP Recert
Agenda
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MORNING ROTATION
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08:45 Emergency Advanced Airway
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09:15 12 Lead Acquisition
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09:45 Pediatric Review
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10:30 Break
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10:45 What is an OSCE?
11:15 Quality Improvement Initiatives •
12:00 Lunch
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TIME
13:00
13:20
13:40
14:00
14:20
14:40
15:00
15:15
AFTERNOON ROTATION
GROUP 1 GROUP 2 GROUP 3
OSCE # 1 OSCE # 2 OSCE # 3
OSCE # 2 OSCE # 3 0SCE # 1
OSCE # 3 0SCE # 1 OSCE # 2
0SCE # 4 OSCE # 5 RECERT
OSCE # 5 RECERT OSCE # 4
RECERT OSCE # 4 OSCE # 5
BREAK
BREAK
BREAK
TEST
TEST
TEST
OSCE STATION 1 AIRWAY EMERGENCY (CRIC)
OSCE STATION 2 PEDIATRIC ASSESSMENT
OSCE STATION 3 CAPNOGRAPHY INTERPRETATION
OSCE STATION 4 NEEDLE THORACOTOMY
OSCE STATION 5 12 LEAD INTERPRETATION
AIRWAY RECERT ORAL BOARD - & EMERGENCY CRIC
Based on 6 – 12 (max) Paramedics !
What is an Indication for
Intubation?
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 LOC
Obtain / Maintain / Protect Airway
Oxygenation
Positive Pressure Ventilation or control ventilation
Drugs (NAVEL)
 Fatigue
Access Tracheal Toilet (suction)
Next Determination ?
Once the decision to intubate has been made a then
what?
• Is it a CRASH intubation?
– Death or near death (like “NIKE” “just do it”)
– Suction, stylette, lubed ETT, stethoscope, laryngoscope
• If Time assess for DIFFICULT intubation using?
– LEMON
(DO YOU NEED TO LOAD YOUR PATIENT ?)
CRASH AIRWAY
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VSA
Pending VSA
Respiratory Arrest
GCS < 5
Airway compromise (blood / vomit unable to clear)
Note: positioning is the number 1 airway procedure to
prevent aspiration.
What is Loading your
Patient?
• LOAD:
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Lidocaine
Opiate
Atropine
Depolarizing neuromuscular blocking agent (defasiculating)
– The art!!!
List the Steps for Difficult
Airway Assessment
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L - Look
1 point
E - Evaluate
2 points
M - Mallampati (1 - 4)
2 points
O - Obstruction
2 points
N - Neck
1 point
2 or more equals difficult
Critical Thinking!
• What are the advantages of facilitated
intubation?
• What if sedation has been granted and
respiratory arrest occurs and you are unable to
get the tube?
• What if you cannot ventilate?
• Explain why it is possible to be unable to
ventilate a previously spontaneously breathing
patient.
• Don’t paint yourself into a corner.
Airway Review
Landmark - 2 fingers
Airway Review
Causes of Obstruction
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Foreign Body
Trauma
Edema
Neoplasm
Blood
Foreign Bodies
• Food
• More common in
children
• In adults there are
typically co-factors
– Alcohol
– Aging
Fractured Larynx
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Blunt trauma
Rapid & severe
Posterior tear
Seldinger Cric can
cause expansion of
tear
• True surgical airway
emergency
Fractured Larynx - Radiograph
Fractured Larynx - Photo
Emergency Cricothyrotomy Protocol
If a patient cannot be ventilated due to life-threatening
suspected upper airway obstruction, the Advanced Care
Paramedic may attempt a cricothyrotomy according to the
following protocol after receiving orders from the BHP.
Indications:
A patient that requires intubation and
Unable to intubate and
Unable to adequately ventilate
Conditions:
Patient  40 kg and  12 years old
Contraindications:
Suspected fractured larynx
Inability to localize the cricothyroid membrane
Emergency Cricothyrotomy Protocol
Procedure:
1. Administer 100% O2.
2. Contact the BHP for on-line medical direction to proceed with this protocol.
3. If every attempt to contact a BHP has failed, the AC Paramedic may
continue with this protocol in a life-threatening situation if all other
indications and conditions are met. The AC Paramedic should contact the
BHP (and the Base Hospital) as soon as possible after the procedure and
document the patch failure and decision to proceed.
4. Place patient on his or her back, and then extend the head and neck
(provided there are no c-spine injuries).
5. Grasp the larynx with your thumb and middle finger. Locate the cricoid
cartilage and the cricothyroid membrane with the index finger. Prep the
area quickly.
Follow the appropriate procedures following for the specific equipment used.
The seldinger cricothyrotomy should be the primary method used but if the
equipment is not available, the needle cricothyrotomy procedures should be
followed.
Emergency Cricothyrotomy Protocol
Seldinger (Melker) Cricothyrotomy Kit:
1. While stabilizing the thyroid cartilage make a vertical incision in the midline
of the cricothyroid membrane with a scalpel.
2. Use the supplied 18g TFE catheter with the 6cc syringe attached. Insert the
catheter into the airway at a 45º caudal angle looking for free air in the syringe.
3. Remove the syringe and needle leaving the catheter in place. Always
maintain contact with the guidewire, never let go!
4. Advance the soft flexible end of the wire guide through the catheter and
into the airway several centimeters caudally.
5. Remove the catheter leaving the wire guide in place. (STEP # 1)
6. Feed the dilator (with airway catheter in place) over the wire. Ensure that
the stiff end of the wire protrudes out of the back of the dilator.
7. Advance the dilator into the airway until the flange of the 15mm airway
adapter is resting against the patient's neck.
8. Remove the dilator and wire guide. Use caution to ensure that the wire
guide is not lost into the trachea.
9. Secure the flange of the airway adapter to the patient.
10.Attach a BVM and attempt to ventilate the patient. Genesis or other ventilators
must not be used.
11.Initiate rapid transport to the closest appropriate hospital.
12.Patch to the Base Hospital if complications arise or further orders
are required.
Emergency Cricothyrotomy Protocol
Needle Cricothyrotomy:
7. Attach a 14 gauge over-the-needle catheter to a 10 cc syringe filled with
saline. Carefully insert the needle through the skin and cricothyroid
membrane into the trachea while aspirating for free air. Direct the needle
at a 45 degree angle caudally.
8. Aspirate with the syringe. If air is returned easily by way of seeing
bubbles in the saline filled syringe, you are in the trachea. If it is difficult to
aspirate with the syringe, or if you obtain blood, re-evaluate needle
placement.
9. Withdraw the stylette, while gently advancing the catheter downward into
position.
10.Attach an adapter to the hub of the catheter and begin ventilating with
100% O2 with a BVM. Genesis or other ventilators must not be used.
11.Secure the catheter and continue ventilation, allowing time for passive
expiration
12. Initiate rapid transport to the closest appropriate hospital.
13. Patch to the Base Hospital if complications arise or further orders are
required.
Cricothyroidotomy
(Melker)
Needle Cricothyroidotomy
SECOND LINE PROCEDURE that should be used if Seldinger
technique is not possible. (BHP may give orders from 8 - 12 year old patient)
Provides temporary oxygenation but no ventilation
Note:
Exhalation may be difficult through such a small diameter catheter and the
paramedic should lengthen the time between breaths to allow for exhalation.
The BHP may consider giving orders for a second catheter horizontally next to the
first to allow for better exhalation and this should be discussed during the patch.
Cricothyroidotomy
(Melker)
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Landmark cricothyroid
membrane between the
thyroid and cricoid
cartilages and prep area.
Maintain landmark with one hand & insert
the 6cc syringe with 18 guage TFE catheter
and introducer needle. Advance needle on
a 45° angle to the frontal plane in the
midline in a caudad direction. While
inserting needle draw back on syringe to
verify when trachea has been found.
Cricothyroidotomy
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Remove the syringe and needle
leaving the catheter in place.
Advance the soft, flexible end
of the guidewire through the
TFE catheter and into the
airway several centimeters.
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While holding on to the
guidewire ensuring not to let it
move carefully remove the
TFE.
Cricothyroidotomy
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While holding the guidewire
make a vertical incision with the
# 15 short handle scapel blade to
allow dilator to be inserted.
While holding on to the guidewire
advance the preassembled
dilator and airway catheter with the
tapered end first over the guidewire.
Cricothyroidotomy
Cricothyroidotomy
Airway Assessment Algorithm
CRASH INTUABTION
DEATH OR NEAR DEATH
INTUBATE:
Lubricated Tube
Stylette
Suction
Stethescope
Syringe
YES
NO
SUCCESSFUL?
NO
YES: Confirm
(see Note 1)
DIFFICULT AIRWAY
LEMON
No
CONSIDER
PATCH FOR
FACILITATED
INTUBATION:
Versed/Morphine
Consider
Lidocaine
Yes
SUCCESSFUL?
REASSESS (see Note 2)
Consider Adjunct Devices
 Lighted Stylette
 LMA
Can you ventilate the patient?
NO
Perform Cricothyrotomy
Note 1:
Note 2:
YES
Continue to ventilate
with adjunct or BVM
Confirmation by 3 methods; one must be end-tidal CO2 (when available).
Reassess continually to determine whether the patient’s condition reverts to
“Crash Intubation” or “Facilitated” criteria.
NO
Questions