1. #8 Crash Cricothyrotomy Learning Objectives – Review Prep team/plan/room/equipment Discuss Difficult Airway Algorithm Describe a “Crash Airway” Declare: Can’t Intubate, Can’t Oxygenate! – Surgical Cric Locate equipment Double Setup Proper technique – Scalpel – Bougie – Tube Indications R40: 40 y/o M swollen tongue, difficulty breathing – Hx angioedema – Obtunded, GCS 6, SaO2 80% On Arrival – Sitting Up, Nasal O 2, rebreather 0 2 >15lpm – SaO2 75% and GCS 5 – LEMON Protruding tongue, Swollen face, 0-3-2, stridor – Consultant suggests Crash Cric Declare: Can’t Intubate, Can’t Oxygenate – Skip Checklist +/- sedation/paralysis Difficult Airway Call (888) Crash Cricothyrotomy – End scenario after tube confirmation

2. Locate Cric Kit

3. Cric Assessment Laryngeal Handshake Ultrasound SHORT S: surgery (previous) H: haematoma (swelling) O: obesity R: radiation T: tumor

4. Indications Cant intubate, can’t oxygenate (CICO). When an experienced clinician thinks it will be safer than intubation from the top. – Continue to attempt to ventilate from the top with an LMA/BVM Age cut-offs? – APLS suggests <12y/o – Some say <6y/o – Others say <3y/o – AKA: it depends

5. Preparation Can use the “double prep” – Assess, clean, and mark neck

7. Equipment Simple Cric Kit – Scalpel – ( Bougie on Airway Cart) – 6-0 endotracheal tube (cuffed) – Dressing Pack Skin Marker Antiseptic KY 10ml syringe Blue pad Cook surgical-and percutaneous airway kit

8. Cric Technique Scalpel-Bougie-Tube Optimize patient Oxygenate with BVM/LMA Locate cricothyroid membrane Vertical cut skin Horizontal cut membrane Bougie 6-0 ETT over bougie until cuff enters Confirm and ventilate Bougie Cric http://www.youtube.com/watch?v=wVQFJR7qmrQhttp://www.youtube.com/watch?v=wVQFJR7qmrQ (7min)

9. We have prepared a “double setup” We are are ready for an emergent cricothyrotomy We can not intubate and we can not oxygenate. Declare an 888 airway emergency Our plan is: A- Attempt direct/bougie/tube B- Oxygenate with #5 I-LMA C- Perform scalpel/bougie/cric if sats <80% D- Perform open cric Questions? Oxygenate the patient! Airway Briefing and checklist