Page 104 - 2022 Spring JSOM

Contrived Breathing Circuit Connection for Emergency Percutaneous
Transtracheal Ventilation by Needle Cricothyrotomy in the Field

Rotem Naftalovich, MD, MBA *; Andrew John Iskander, MD 2
1

ABSTRACT
Surgical airway approaches are, at times, last resort options in catheter (e.g., 14 gauge) that is passed over-the-needle into the
difficult airway management. In Special Operations these in- cricothyroid membrane to enable limited ventilation and ox-
terventions confront distorted anatomy from combat trauma, ygenation through the catheter. A needle cric is considered a
extreme conditions, and may be performed by non-medically temporary airway and is not an ideal airway as the catheter is
trained personnel. Under these circumstances, needle cricothy- small and prone to kinking. A small catheter limits the effec-
6
roidotomy using a large bore intravenous catheter can be con- tive tidal volumes and will result in rising hypercapnia. If a cric
sidered. A small syringe connected to the needle can confirm kit or a tracheal cannula is available, those cric approaches
transtracheal placement through air aspiration before passing are likely to be superior to a needle cric. A commercial cric kit
the angiocatheter over the needle. Button activated retracting such as the Quicktrach (VBM Medizintechnik GmbH, Sulz am
needles should be avoided for this when possible. We recom- Neckar, Germany) would provide a larger ventilating diameter
mend a 3-mL Luer-lock syringe because a small syringe is bet- than a simple needle cric and would also enable a valuable cuff
ter suited for generating pressure and once the catheter is in to protect the airway. Nonetheless, a needle cric is a valuable
the trachea, this same syringe can be connected to bag valve airway management option that can enable oxygenation until
ventilation by replacing its plunger with a connector from a a more definitive surgical airway such as a trach or a cric with
6.5-, 7-, or 7.5-mm endotracheal tube. Adding these small and a tracheal cannula can be established, ideally by a surgeon.
light high-yield items to the Tactical Combat Casualty Care In contrast to a cric performed with a scalpel, a needle cric
medic inventory should be considered in future revisions. is relatively easier to execute than a surgical cut-down. This
distinction is meaningful in the Special Operations setting
Keywords: military medicine; airway management; combat dis- where performing a cric may be required by someone without
orders; intubation, intratracheal surgical or medical training, under intense stress, and perhaps
performing with shaking hands. Special Operations personnel
are also more likely to end up in situations where a tracheal
cannula or a cric kit is not available. The relative simplicity of
Introduction
the needle cric makes it an important option in airway man-
A surgical approach to securing an airway is an important cat- agement, particularly in rare times when a cric kit is not avail-
egory of available last resort life-saving options in the man- able. The particular gap in the literature that this brief aims to
agement of a difficult airway. In emergency circumstances of address is how to physically connect a needle cric cannula to a
1
“cannot intubate, cannot ventilate” where seconds count, the ventilation source for oxygenation, especially in the absence of
surgical approach of choice is usually a cricothyroidotomy jet ventilation equipment or a tracheal cannula.
(cric) rather than a tracheostomy (trach). The authors of the
UpToDate chapter note “we equate ‘can’t intubate, can’t ox- The cricothyroid membrane spans from the thyroid cartilage,
ygenate’ with cricothyrotomy in the emergency setting.” It the prominent Adam’s apple, and connects it down (i.e., cau-
2
is important to appreciate that these scenarios will inevitably dally) to the cricoid cartilage below it. The cricoid cartilage
involve extreme conditions that will make a cric invariably is the next bump below the thyroid cartilage when the front
more difficult. This is particularly the case in Special Oper- (i.e., anterior) of the neck is palpated. Figure 1 illustrates a
ations medical interventions whereby the anatomy may well straightforward process to locating the cricothyroid mem-
be distorted as a result of combat trauma and the conditions brane and inserting a needle cric. The midline of the neck can
likely to be subpar. The difficulty is further compounded by be oriented by straddling the trachea between the index and
the understandably limited inventory of medical equipment middle fingers. Next the index finger can be used to palpate
and supplies in the combat medics’ aid bag. 3 and slide into place in the groove between the thyroid cartilage
and the cricoid cartilage. A small syringe connected to the an-
Needle cricothyroidotomy is a quick approach to a cric air- giocatheter can be used to confirm transtracheal placement by
way and is commonly described in the major airway texts. aspiration of air on insertion. If the syringe is filled with some
4,5
A needle cric can be done using a large-bore intravenous (IV) fluid such as saline, visualization of air bubbles will facilitate
*Correspondence to naftalro@njms.rutgers.edu
1 CPT Rotem Naftalovich is a physician in the Medical Corps of the US Army at Fort Sam Houston, TX, and head of Neurosurgical Anesthesia
in the Department of Anesthesia and Perioperative Care at Rutgers New Jersey Medical School, Newark, NJ. Dr Andrew John Iskander is a
2
pediatric anesthesiologist at Rutgers - Robert Wood Johnson Medical School in New Brunswick, NJ
102