Page 53 - Journal of Special Operations Medicine - Spring 2014

The Cric-Key and Cric-Knife :
™
™
A Combined Tube-Introducer and Scalpel-Hook
Open Cricothyrotomy System

Richard M. Levitan, MD

ABSTRACT
The author describes a cricothyrotomy system that consists cases in the United Kingdom, “the decision to perform
of two devices that, packaged together, are labeled the an emergency surgical airway was commonly inappro-
Control-Cric™ system. The Cric-Key™ was invented to priately delayed.” 3
verify tracheal location during surgical airway proce-
dures—without the need for visualization, aspiration To overcome perceived and real technical issues with
4
of air, or reliance on clinicians’ fine motor skills. The the open procedure, numerous alternative surgical air-
Cric-Knife™ combines a scalpel with an overlying sliding way devices have been created. These alternate de-
4,5
hook to facilitate a smooth transition from membrane vices involve either trocars that puncture the skin and
incision to hook insertion and tracheal control. In a re- membrane (Rusch QuickTrach . Cricothyrotomy Kit;
®
®
cent test versus a traditional open technique, this system Teleflex Inc. [http://www.teleflex.com/en/usa/product
had a higher success rate and was faster to implement. Areas] and Nu-Trake Adult Emergency Cricothyrotomy
®
Device; Mercury Medical [mercurymed.com/catalogs
Keywords: cricothyrotomy, airway device, Cric-Key™, Cric- /ADR_CricothyrotomyKits]) or wire-guided and needle
Knife™ aspiration devices with dilators (Pertrach Emergency
®
Cricothyrotomy Trach systems; Pulmodyne, Inc. [www
.pulmodyne.com/products/acute-care/pertrach/], Melker
®
Cricothyrotomy Set [www.QuadMed.com]). Although
Introduction
such devices eliminate the need to control a scalpel, tro-
Cricothyrotomy is a critical emergency procedure yet cars and needle devices can also damage the airway and
it rarely performed in civilian emergency settings. New vascular structures, especially if inserted off midline; dis-
intubation and ventilation devices have decreased the torted landmarks are common in traumatized airways.
1-5
need for cricothyrotomy in instances of failed intuba- Wire-guided and needle aspiration systems are not likely
tion or failed ventilation. Securing the airway through to work well when fine motor skills are compromised. In
the neck remains fundamentally important in instances combat, deterioration in fine motor skills is believed to
of severe facial injury, angioedema, and, occasionally, occur above 115 beats per minute. Blood and vomitus,
6
massive upper airway bleeding and vomitus. Despite an almost universal in battlefield situations requiring a sur-
expanding array of airway devices, cricothyrotomy is gical airway, make it very difficult to localize the trachea
still a crucial skill that is required in civilian trauma cen- via needle aspiration Percutaneous cricothyrotomy tech-
ters and in combat and tactical medicine. In the Iraq and niques have a lower likelihood of success than do open
Afghanistan conflicts, approximately 2% of potentially techniques in both hospital and prehospital settings. 3,4
survivable injuries involved airway injuries. 1
Finally, any nonintuitive and infrequently used device is
The procedure is not considered technically complex, not likely to be used correctly.
but when performed by clinicians with limited surgical
skills in combat situations, failure rates range between It is interesting to note that the commonly used tools used
15% and 33%. Though not well documented on the for cricothyrotomy were not specifically designed for the
2
battlefield, avoidance and delay of the procedure also procedure. Scalpels are one-sided, requiring the blade to
occur; in Mabry et al.’s study of potentially survivable be flipped to expand an incision. The No. 11 blade (most
airway related injuries from Iraq and Afghanistan, a commonly used in hospitals) is very long relative to its
surgical airway was performed in only 5 of 18 cases. narrow width and is very easy to insert too deeply (it
1
Delay and avoidance of surgical airways also occur in has no stopping mechanism). Tracheostomy tubes (i.e.,
®
hospitals. According to a national audit of anesthesia Shiley [www.covidien.com/rms/products/tracheostomy])

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