Emergency Procedures for the Anesthesiologist

Carlos Brun MD¹

Frederick G. Mihm MD¹

¹ANESTHESIOLOGISTS

EMERGENCY CRICOTHYROTOMY

Clinical situation: Typically, this procedure is performed in a hypoxic patient with an obstructed airway who cannot be ventilated with a mask or LMA, and cannot be intubated.

Emergency “Stab” Cricothyrotomy⁵

Equipment

Scalpel, preferably with #11 blade
ETT #6
Syringe for inflating cuff
Prep solution such as alcohol, chlorhexidine, or povidone-iodine

Procedure

1. Prep skin if time permits.

2. Identify cricothyroid membrane between cricoid and thyroid cartilages (Fig. 15-1).

3. Make 2-3 cm transverse or vertical incision through skin.

4. Make 2.5-cm incision through cricothyroid membrane with single stab (Fig. 15-2).

5. Reverse scalpel, place handle into wound, and turn 90° to expand incision.

6. Pass tracheostomy tube (or standard ETT) into trachea.

7. Inflate cuff on tracheosomy/ETT.

8. Ventilate patient with capnography if possible.

9. Secure tube.

Emergency “Four-Step” Cricothyrotomy¹^,²

Equipment

Scalpel with #11 blade
Tracheal hook (may be improvised by bending a 16-g needle into a hook with a hemostat)
ETT #6
Syringe for inflating cuff
Prep solution such as alcohol, chlorhexidine, or povidone-iodine

Procedure

1. Right hand dominant operator stands on patient’s left side. Position with head and neck extended.

2. Prep skin if time permits.

3. Nondominant hand identifies cricothyroid membrane while stabilizing thyroid cartilage. Dominant hand makes 2.5-cm transverse incision through skin and cricothyroid membrane with single stab, keeping blade in place.

4. Nondominant hand places tracheal hook into incision, lifting cricoid cartilage ventrally, then scalpel is removed.

5. Dominant hand inserts ETT, then removes tracheal hook.

6. Inflate cuff.

7. Ventilate patient with capnography if possible.

8. Secure tube.

Figure 15-1. Identify cricoid membrane.

Figure 15-2. If possible extend head and place bolster between scapula. Palpate thryoid and cricoid cartilages, then identify cricothryoidmembrane (CTM). Skin incision may be vertical if unsure of CTM location, as a finger inserted through a vertical incision may have more ability to palpate the CTM by blunt pressure in a vertical or horizontal search.

Emergency “Bougie-Guided” Cricothyrotomy³

Equipment

Scalpel and hemostat (central line kit)
ETT #6
Syringe for inflating cuff
Bougie (pediatric 10 Fr for ETT 4.0-5.5 or adult 15 Fr for ETT 6.0)
Prep solution such as alcohol, chlorhexidine, or povidone-iodine

Procedure

1. Operator may stand at head or either side of patient. Position with head and neck extended.

2. Prep skin if time permits.

3. Nondominant hand identifies cricothyroid membrane while stabilizing thyroid cartilage.

4. Dominant hand makes a 3-cm incision through skin.

5. Nondominant hand index finger placed into incision, palpates cricothyroid membrane with a side-to-side motion, then finger is removed from incision.

6. Dominant hand makes a 2.5 cm horizontal incision in the cricothyroid membrane.

7. Dominant hand inserts coude tip end of bougie via incision seeking tracheal clicks and hang-up sign.

8. Pass ETT over bougie into trachea. If difficult, use hemostat to dilate cricothyroid membrane with bougie in place, and then pass ETT (Fig. 15-3).

9. Remove bougie.

10. Inflate cuff.

11. Ventilate patient and monitor capnogram if possible.

12. Secure tube.

Figure 15-3. Adult bougie 15 Fr passed via incision with coude tip directed caudally attempting to feel for tracheal clicks and/or carinal hang-up sign. Average depth from skin to carina is 12-15 cm. A 6.0 or greater ETT will pass over an Adult 15 Fr bougie.

Emergency “Guidewire” Cricothyrotomy

Equipment

Melker Emergency Cricothyrotomy Set (Cook Critical Care), or equivalent
Scalpel
6-mL syringe (half-filled with crystalloid or local anesthetic if time allows)
18-ga introducer needle or iv catheter/needle
Amplatz extra-stiff guidewire 0.038”
Curved dilator
Airway catheter
Umbilical or twill tape

Procedure

1. Attach syringe to iv catheter and needle, and assemble emergency airway device (Fig. 15-4) by inserting the dilator through the airway catheter until the handle stops against the connector of the airway catheter.

2. Identify cricothyroid membrane between cricoid and thyroid cartilages (Fig. 15-1).

3. Nondominant hand stabilizes cricothyroid membrane.

4. Dominant hand makes a vertical midline incision (Fig. 15-5).

5. Dominant hand advances syringe with catheter/needle at a 45° caudad angle through incision until air bubbles can be aspirated (tracheal lumen) (Fig. 15-5).

6. Remove syringe and needle, leaving catheter in place.

7. Advance soft end of guidewire into catheter several cm past end of catheter.

8. Remove catheter.

9. Advance the dilator/airway catheter assembly over the guidewire into the trachea, keeping proximal end of guidewire visible at all times. If difficult to pass dilator/airway, withdraw from incision, use hemostat to dilate cricothyroid membrane with guidewire in place, and reattempt to advance assembly. (Consider replacing angiocatheter over guidewire, removing guidewire, and verifying position with capnography.) Remove guidewire and dilator, leaving airway catheter in place.

10. Ventilate patient and monitor capnogram if possible.

11. Secure airway with umbilical or twill tape around neck.

Figure 15-4. Melker cricothryoidotomy kit with dilator passed firmly into airway catheter prior to accessing the CTM.

Figure 15-5. Emergency guidewire cricothyroidotomy.

EMERGENCY PERICARDIOCENTESIS

Clinical situation: The patient typically has severe ↓ BP unexplained by any other causes (e.g., anesthetic drugs, autoPEEP, tension pneumothorax) and consistent with acute cardiac tamponade (dyspnea, tachypnea, ↓ BP, ↑ HR, electrical alternans, ↓ voltage EKG, ↓ pulse pressure or pulsus paradoxus, ↑ CVP/JVD, distant heart sounds) ± equalization of pressures (RAP˜RVEDP˜PAD˜PAOP) ± confirmation by TEE/TTE. Because of the high intrapericardial pressures, all “filling pressures” of both right and left heart appear high when preload is actually very low. In severe cases, patients will experience cardiac arrest with pulseless electrical activity (PEA).