Surgical airways in the field

Surgical airways have fallen out of favor in the hospital setting due to the advent of RSI and supraglottic airway devices, and now represent less than 3% of attempted intubations. In the prehospital setting, they can represent up to nearly 15% of attempts, however. It’s been said that the only absolute contraindication to cricothyrotomy is securing the airway by some other means. Even with the A in ABC taking a backseat recently, there are certainly circumstances that require definitive airways. Accomplishing this task while in an austere environment adds more difficulty to the equation.

So how skilled are providers at performing surgical airways in the pre-hospital environment? And what differences are there to devices and techniques in the austere setting, versus in a hospital? The authors of this article set out to find those answers. The impetus appeared to be a case report published in the same issue of Wilderness & Environmental Medicine by one of the authors of the review article.

The better part of the article is where it discusses the improvised techniques for the austere environment. Lots of items have been used in place of standard items, including: 3 mL syringe barrels (modified by cutting), nasal specula, straws from sports bottles, and ETT, as well as devices made specifically for surgical airways. There may be anecdotes about using pen barrels, but nobody has bothered to publish a case report on an actual patient yet. Don’t fret though, if you want to be the first, somebody else has done the legwork on which ones to use, namely:

The 2 pens ultimately deemed acceptable were the Baron retractable ballpoint pen and the Bic Soft Feel Jumbo.

Importantly, they point out that using the spike from an IV drip chamber will only work if you’ve got a jet ventilator. The inner diameter simply doesn’t allow proper ventilation. I’m guessing if you thought to carry one of those into the wilderness, you’ve probably got better equipment to do a proper surgical airway. Likewise, needle crics may allow you to oxygenate, but you will not be able to ventilate, so at best they would be temporizing. Continuing the theme of improvising, the authors also describe using a bent 14 gauge needle as a makeshift hook, but sadly not how to make one.

Moving on to how successful the techniques are, in a review of 13 aeromedical papers on crics, the authors reported a 97% success rate on 296 patients, but they don’t break down physician vs flight nurse vs paramedic. A second review of ground EMS papers shows a lower rate of success at 89% for 405 patients, and this too includes all comers. A meta-analysis performed by other authors and referenced here showed no difference between flight and ground, but did show needle crics were much less successful at 66%, compared to the 90% for standard surgical airways.

Like many review articles, they have plenty of dry explanations of background, landmarks, indications, and contraindications. They review the incidence using prehospital and military literature, which is where the aforementioned statistics come from. They also mention that only one case report in the wilderness setting, also previously mentioned. There is then a table describing 12 current techniques for surgical airways. Taking up an entire page, it is a good primer, but not detailed enough to be your only source.

The authors recommend that providers pick a technique, and train in it often. Practicing less frequently than every 6 months leads to decreased skill maintenance, and perhaps training is needed as often as every month. Fidelity is important, as live-tissue models, and fresh cadaver specimens are much more realistic than mannequins. These recommendations are valid, as you don’t want to be trying something for the first time, when all you’ve got is what’s in your pack.

Hessert MJ, Bennett BL. Optimizing emergent surgical cricothyrotomy for use in austere environments. Wilderness Environ Med. 2013 Mar;24(1):53-66 [PMID 23062323]

Further Reading

  • Wharton DR, Bennett BL. Surgical cricothyrotomy in the wilderness: a case report. Wilderness Environ Med. 2013 Mar;24(1):12-4 [PMID 23137436]

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EBM Gone Wild

Wilderness Medicine

Emergency physician with interests in wilderness and prehospital medicine. Medical Director of the Texas State Aquarium, Padre Island National Seashore, Robstown EMS, and Code 3 ER | EBM gone Wild | @EBMGoneWild |

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