Portex Surgical Airway

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Portex Surgical Airway

• SOCPC Winter 2007 CME

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Objectives

• Indications
• Conditions
• Contraindications
• Anatomy
• Equipment
• Procedure
• Complications
• Needle Cricothyrotomy

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Indications

• If the patient cannot be ventilated due to a
  suspected life-threatening upper airway
  obstruction AND
• The patient requires intubation AND
• Cannot be intubated OR
• Ventilated
• PATCH for the Order to insert a PORTEX
  Cricothyrotomy

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Conditions

• Age gt12
• Weight gt 40 kg
• Patch for orders for a needle cricothyrotomy

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Contraindications

• Suspected fractured larynx
• Inability to locate the cricothyroid membrane
• PATCH - consider needle cricothyrotomy

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Causes of Unresolved Upper AW Obstruction
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If there are steps you can take to treat the
patient without a cricothyrotomy

• DO THOSE FIRST

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Case 1

• 80 year old man taken to a Steakhouse for his
  birthday
• Witnessed choking on meat
• Collapses unconscious
• You are the ACP Crew en route
• How will you plan to manage the airway?

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Conscious FB Obstruction

• If they are conscious you can consider the
  Heimlich maneuver
• Minimize on scene time
• Alert the hospital

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Unconscious FB Obstruction

• LOOK in mouth,
• LOOK with a laryngoscope, and have Magills in
  hand
• Have partner do chest thrusts as this may push
  the FB up towards you (some gentle abdominal
  pressure may help)
• Minimize scene time and alert the hospital

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Case 2

• 53 year old gentleman with the worst sore throat
  he has ever had for the past 3 days
• Saw his GP yesterday was put on penicillin but
  much worse today
• Past History Neg
• Hurts to swallow, T 39, No cough
• Whispers when he talks, No stridor
• Chest Clear
• What do you suspect? How would you manage him?

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Case 2 continued

• Epiglottitis
• We dont see it in kids any more. Why?
• Sit this man up and give him blow by 02 if he
  needs it
• If you needed to intubate him how would you
  prepare your ETTs?
• If you were unsuccessful, what procedure would
  save his life?

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Case 3

• 26 year old patient involved in car accident
• Struck their anterior neck on steering wheel
• On crew arrival patient is unable to speak
• What do you think is injured?
• Crew puts him on a back board with a collar which
  immediately makes patient combative

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Case 3 continued

• He fractured his larynx
• Why is lying on his back making him combative?
• How can this patient be positioned while keeping
  his C-spine protected?
• What are your options for airway management in
  this situation?
• What could you consider?

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Case 4

• Severe Facial Burns need intubation but seldom a
  cricothyrotomy
• Why?
• Burn patients that resists intubation may be a
  candidate for facilitated intubation
• If they are unconscious, and you plan to
  intubate, do it orally with downsized tubes ready
  and dont cut them. Why?

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Cricothyrotomy

• ANATOMY REVIEW

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What you cant see you feel
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What you see and feel

• Skin
• Where is the thyroid notch?
• Platysmal muscle

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Structures to avoid
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Structures you will feel

• Thyroid Gland

• Muscle

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Deep Structures of Neck

• The notch on the thyroid cartilage is the
  easiest landmark to identify, especially in thin
  males
• The cricothyroid membrane is ultimately the space
  you want to find

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The Portex Airway
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Plastic Clamshell Kit
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Contents
ETT tie
thermovent T
6mm cuffed ETT
scalpel
veress needle
Suture- keep but dont use
syringe
gel
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Veress Needle

• Fig (a) spring loaded silver needle in a white
  plastic dilator
• Fig (b) Proper Grip
• Fig (c) Red warning flag appears when needle tip
  meets resistance
• Cricothyroid membrane AND back of trachea

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Procedure

• Don PPE
• Open Kit
• Sterile technique
• Check and lubricate cuff
• Position patient supine, with neck slightly
  extended
• (use C-spine precautions if necessary)

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Palpate the Landmarks

• Palpate for the notch at the top of the thyroid
  cartilage
• Feel down to the bottom of the thyroid cartilage,
  and you will touch the cricothyroid membrane in a
  small depression

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Prep area and make incision

• 2 cm horizontal incision over the cricothyroid
  membrane
• THROUGH SKIN ONLY

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Insert the needle

• Insert the needle PERPENDICULAR to the neck
• You will see the red indicator flag as you
  push through the cricothyroid membrane

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When the red indicator flag disappears

• You are IN the trachea

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Carefully keep going until the red flagre-appears

• When the red flag reappears
• You are touching the back of the trachea with the
  Veress needle
• DO NOT ADVANCE ANY FURTHER or you will go through
  the posterior tracheal wall

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Direct the needle towards the feet 45 degrees

• When the red bar disappears you are in the
  tracheal lumen and the needle is no longer
  touching the posterior tracheal wall

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Remove the needle
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Slide ETT off dilator into trachea without
advancing the dilator
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Inflate cuff

• Secure using provided tie
• Confirm placement by auscultating as ventilate,
  AND ETCO2
• Watch chest rise and fallwith smaller ETT may
  require longer exhalation time

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Potential Complications

• Penetration of posterior wall of trachea
• Bleeding
• Tissue swelling of surrounding structures
• Damage to the larynx
• Injury to the thyroid and parathyroid glands
• Inadequate ventilations
• Aggressive ventilations Barotrauma subcutaneous
  emphysema, pneumothorax

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What if you have a contraindication?

• Fractured Larynx

• Inability to Landmark
• Age lt12
• Weight lt40kg

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PATCH
Consider Needle Cricothyrotomy
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Needle Cricothyrotomy
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Equipment

• Syringe
• 14 G 1.25 inch
• Filter
• 15 mm adapter off a 3.0 ETT

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Landmark
Feel for cricothyroid membrane
Palpate top of thyroid cartilage
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Sterile Technique
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14 g IV cath with syringe attached
Puncture skin, 45 degree angle towards feet
Stabilize thyroid cartilage
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Aspirate as you advance needle

• When you have a loss of resistance and get air
  you are in the trachea
• Advance 2-3 mm more to insure tip of catheter is
  in and not just needle tip

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Slide Catheter off needle
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Attach BVM

• 15 mm adapter off a 3.0 ETT fits the end of the
  14 G needle
• Bag with short brisk compressions of BVM
• Watch chest rise
• Allow additional time for fall or exhalation

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Why consider needle cric for these?

• Fractured Larynx
• Swelling or uncertain anatomy

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Limitations of Needle Cricothyrotomy

• Although you can oxygenate relatively well, C02
  rises you have 20-30 minutes to get definitive
  care
• Small opening in 14 G, need relatively high
  pressure to ventilate, have to be careful not to
  cause barotrauma
• Need longer exhalation time or will get air
  trapping and barotrauma

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Complications

• Subcutaneous emphysema and barotrauma
• Bleeding
• Inadequate oxygenation

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Questions?