Page 105 - 2022 Spring JSOM

FIGURE 1 A–C, How to identify cricothyroid membrane location.
D, E, Insertion of the needle cric.

FIGURE 2 A 14-gauge
angiocatheter connected to a
3mL syringe after the needle
was removed. The plunger
was then replaced by the end
connector from a 7.0-mm
endotracheal tube.

correct insertion. We recommend a 3mL Luer-Loc syringe for
this for two reasons.

First, a small syringe is better suited for generating pressure
and hence is better for generative the negative pressure re- needle cric. If a sharps waste container is not available at the
quired for aspiration. To recall, pressure equals force divided time of use, the plastic cap of the needle can be used to care-
by area. Accordingly, the given force generated by the fingers fully re-cap the needle to reduce chances of harm to providers
pulling the syringe plunger is distributed across a smaller area from the sharp.
(i.e., the rubber plunger plate of the syringe) when the syringe
is smaller, and therefore more pressure is generated at the out- The Tactical Combat Casualty Care (TCCC) handbook is an
let tip. A 3mL size is the smallest syringe that is customarily excellent resource with a focused review of a surgical cric and
7
available with a Luer-Loc. Second, after the catheter is placed cric-key or cric kit use. When available, these options are likely
percutaneously into the trachea and the needle removed, the to be superior to a needle cric. We would suggest to add the
medic will need to connect the catheter to a ventilation source needle cric to the airway management options of the TCCC as
and oxygen supply. This can be contrived by securing the a back-up option. Needle cric is a good option for times when
Luer-Loc of the already connected 3mL syringe to the catheter. a cric kit is not readily available, if the medic ran out of air-
If the plunger is then removed, the stub connector tip of an en- way cannulas, or if a medic is not available. We would further
dotracheal tube can be inserted into the 3mL syringe as in Fig- propose to add the following to the TCCC medic inventory
ure 2. Standard endotracheal tubes of size 6.5, 7, or 7.5 mm list: a 14-gauge angiocatheter over a needle without a retract-
will generally come with an end-tip connector of inside di- ing safety mechanism and connected to a 3mL syringe. This is
ameter that will fit a 3mL syringe. These connectors have a relatively small and light high-yield equipment.
standard 15-mm outer diameter and hence the catheter- syringe
apparatus can then be ventilated manually via a standard bag- Financial Disclosures and Conflicts of Interest
valve or connected to a ventilator. If the inside stub of the None.
connector is wiped with an alcohol pad before inserting it into
the syringe, it will form an extra strong bond when in contact Author Contributions
with the syringe and will make it near impossible to undo the RN wrote the manuscript and designed the illustrations. AJI
connection by hand. The angiocatheter hub can be secured to reviewed the manuscript and improved its technical details.
the skin with a stitch or with tape.
References
Our clinical experience with different angiocatheters is that 1. American Society of Anesthesiologists. Practice guidelines for
most of the commercially available angiocatheters will not management of the difficult airway: an updated report. Anesthesi-
enable a syringe to be connected to the needle itself and ology 2003;98:1269–1277.
will therefore not permit aspiration on insertion. With these 2. Brown CA. Approach to the failed airway in adults outside the
operating room. UpToDate. Sep 30, 2019.
modern angiocatheter devices, the syringe Luer taper can be 3. Schauer SG, et al. An inventory of the combat medics’ aid bag. J
screwed on to the angiocatheter only once the needle is re- Spec Oper Med. 2020;Spring;20(1):61–64. PMID: 32203608.
moved. Furthermore, the safety feature of these modern angio- 4. Jaffe RA. Anesthesiologist’s Manual of Surgical Procedures, 5th
catheters is that the needle retracts into a plastic compartment ed. Wolters Kluwer Health. 2014.
when a button is pressed. This single-use design makes them 5. Butterworth JF, et al. Morgan & Mikhail’s Clinical Anesthesiol-
ogy, 6th ed, chap 5. McGraw-Hill Education; 2018.
less ideal for a needle cric as the button can accidentally get 6. Sukhupragarn W, Rosenblatt WH. Kinking of catheters during
pressed on insertion—especially when performed under our translaryngeal jet ventilation: a bench model investigation of eight
stressful conditions. The Jelco Peripheral IV catheter series devices. J Med Assoc Thailand. 2011;94:972–977.
(made in Italy by Smiths Medical International Ltd) are free of 7. Tactical Combat Casualty Care Handbook. Version 5. May 2017.
a retracting safety mechanism and are an example of an angio- No. 17-13.
catheter through which syringe aspiration is possible during a

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