"Decision is a sharp knife that cuts clean and straight; indecision, a dull one that hacks and tears and leaves ragged edges behind it." --Gordon Graham

By Dr. Bill Hinckley, MD FACEP CMTE
Retrievalist and Medical Director, UC Health Air Care & Mobile Care, Cincinnati

CICO (can't intubate – can't oxygenate) is rare, especially given our teams' extraordinary prowess in laryngoscopy and our excellent supraglottic rescue airways, but it still occurs. CICO is real. The HEMS / CCTM literature from the last 20 years suggests that our teams will encounter a CICO situation on 0.7% - 2.4% of transport missions for which airway management by the CCTM team is required. If you haven't yet encountered it, you very likely will at some point in your career. When that day comes, your patient is depending on you to know how to handle it decisively and skillfully. Therefore, it's incumbent upon each of us to practice cricothyrotomy as often as possible, both physically and (especially) mentally.

Crics by CCTM crews are usually successful, in terms of getting plastic in trachea (94-100% published success rates). However, my personal experience has shown me that when CICO does occur, we hesitate. We're reluctant to admit the truth, that CICO has occurred, and we hesitate to move to the cric. Perhaps the term failed airway contributes to this hesitation. We've got to realize: a "failed airway" is not a failure. Some will happen to all of us. A failed airway is a diagnosis, not an accusation. So when it occurs, despite perfect BMV technique and/or supraglottic ventilation, we need to declare it. Share your mental model. CICO—say it loud!

The toughest part of the cric, then, is making the initial decision to perform it when it's indicated. Dr. Rich Levitan, airway master, argues that our hesitation may be borne from our lack of three things: technical skill, anatomic insight, or mental armor. In order to gain as much of these three as possible, there are several things we're going to need to recognize:

  • This procedure will be blind. Don't kid yourself otherwise. When you visualize it mentally, don't rehearse with the bloodless field you may have encountered in procedure labs. There will be blood. Lots of it. That's OK. We have Combat Gauze.
  • The vocal cords live behind the thyroid cartilage (the one with the laryngeal prominence). The entire procedure is done below them.
  • Ergonomics are huge. If you're right-handed, stand by the patient's right when cric-ing. If you're left-handed, stand by the patient's left. Your non-dominant hand perfectly controls the thyroid cartilage, guarding against movement, throughout the procedure.Your amped-up dominant hand rests on the patient's sternum as you cut, enabling you to maintain fine motor control.
  • None of us will ever get to physically practice this procedure enough, no matter how much we supplement our clinical practice with skills training in the sim lab or the cadaver lab. So we have to practice it mentally. My ritual during my commute to each and every shift involves visualizing every step, every detail, of successfully performing a cric. I've physically practiced the procedure about 100 times in my career. Mentally, I've done it at least 2000 times.

The second-most challenging part of this procedure, other than making the initial decision to cut, is actually passing the ETT or trach tube through the hole you've made in the cricothyroid membrane. If you don't do it correctly, losing the hole entirely, or creating a false passage, is all too easy. Therefore, once you've cut to air-- once the tip of your scalpel is in the lumen of the trachea—refuse to relinquish control of that tracheal lumen. Keep something in that lumen at all times until you're looking at nice, square capnographic boxes confirming you've succeeded. And, to do this procedure in 2015 without a bougie or a bougie-like introducer (like you'll find on Dr. Levitan's Cric-Key device) to help you avoid false passage, in my opinion, takes hubris that your patient cannot afford for you to have. In a 2010 study of novice medical students and EM residents cric-ing sheep, the bougie-aided cric outperformed standard (bougie-less) technique in terms of speed (67 sec vs 149 sec), ease (2 vs 3 on a 1-5 scale), and failure rates (10% vs 27%). With regard to the commercial percutaneous Seldinger-technique cric kits that are out there: many involve placement of uncuffed tracheal tubes that cannot deliver adequate tidal volumes, and even those that do cannot equal surgical Bougie-aided cric in terms of speed, ease, or success rates.

Step-by-step procedural cric videos are available here.

Bill Hinckley, MD FACEP CMTE
Retrievalist and Medical Director, UC Health Air Care & Mobile Care, Cincinnati

I have no relevant financial disclosures.

Braude D, Webb H, Stafford J, et al. The bougie-aided cricothyrotomy. Air Med J 2009 Jul-Aug; 28(4): 191-4. Link to abstract
McIntosh SE, Swanson ER, Barton ED. Cricothyrotomy in air medical transport. J Trauma 2008 Jun; 64(6): 1543-7. Link to abstract
Brown CA 3rd, Cox K, Hurwitz S, Walls RM. 4871 emergency aiway encounters by air medical providers: a report of the air transport emergency airway management (NEAR VI: "A-TEAM") project. West J Emerg Med 2014 Mar; 15(2): 188-93. Link to abstract
Hubble MW, Wilfong DA, Brown LH, et al. A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates. Prehosp Emerg Care 2010 Oct-Dec; 14(4): 515-30. Link to abstract
Hill C, Reardon R, Joing S, et al. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med 2010 Jun; 17(6): 666-9. Link to abstract
Mabry RL, Nichols MC, Shiner DC, et al. A comparison of two open surgical cricothyroidotomy techniques by military medics using a cadaver model. Ann Emerg Med 2014 Jan; 63(1): 1-5. Link to abstract

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