Sunday, January 7, 1996 10:50:41 Puget Sound EMSForum Item From: Sylvia Feder,Medic One OnLine EMED-L Reporter,dBug Wb7qni@aol.com,Internet Subject: Fwd(2): emed-l Pediatric crics... To: KC EMSForum,Medic One OnLine Puget Sound EMSForum Cc: > hi dr. li....what do you think about pediatric emergencies with upper > airway obstruction being treated with surgical cricothyrotomy in the > Emergency Department...What about the pre-hospital setting. Thanks > for your help. Wayne Longmore MD, FACEP, Bronx, NY I have never performed a cricothyrotomy on a child, so I'm not the ideal person to ask. However, I'm happy to give you my opinion. Standard teaching around here is that crics in kids are contraindicated because they are associated with more complications, particularly subglottic stenosis. No one who has repeated this dogma has, however, been able to come up with the reference. My main source on pediatric crics is the excellent Emergency Procedures text by Robert Simon and Barry Brenner, who *do* have experience with this technique. From page 75: "In the pediatric age group, cricothyroidotomy becomes progressively more difficult as the patient becomes smaller. Sufficient literature documenting the complication rate of this procedure is not yet available. The authors have been involved in approximately ten cases of pediatric cricothyroidotomy. They found it efficacious and life saving. Thus, this procedure merits further study. Some authors recommend needle cricothryoidotomy if an emergency airway is required. Emergency tracheostomy is preferable under controlled conditions." To this I'd add that I've heard an absolute age cutoff below which crics should not be performed. Taken too literally, however, one forgets the reason for such a cutoff. The only true limitation preventing cricothyrotomy is a cricothyroid membrane which is too small through which to pass a tube. This occurs somewhere around age 8, if I remember correctly, but should not prevent one from attempting the procedure if one palpates a membrane large enough to pass a tube through in a younger child. Because of lack of experience with crics in pediatrics (one abstract I heard on tape stated that in one peds critical care career, no crics had been necessary in that physician's experience), alternative airway methods have been proposed. I'm sure you're well aware of these. Two are popular in teaching circles: transtracheal jet ventilation (1) and retrograde wire intubation (2). I've very limited experience with these (one of each, both in adults), but find some problems with each. TTJV is simple to perform. Simply cram a big cannula on a needle into the trachea. The problem is ventilation. Supporting equipment required for proper TTJV is not easy to find, and it's a pain to set up for the first time during a code. We've got one tucked away in a corner: a 50 psi *pressure* regulator. The traditional *flow* regulator on a standard oxygen source is not adequate for ventilation in adults. It might be adequate with kids, but the time to find that out is not during treatment of an obstructed child. The tinkerer's BVM plus cannula-syringe-ETT connector is workable, but only until your hand wears out on the BVM. TTJV is a great technique to prevent hypoxia but only it is only temporizing while you figure out a way to intubate, cric, or trach your patient for true ventilation control. Retrograde wire intubation is also pretty simple conceptually, but takes a bit of preplanning (mostly with equipment, though practice is nice too) At least for adults, you also need a pretty stiff wire or some kind of plastic stent to act as a wire stiffener. When you have no wire, no pressure regulator or BVM cannula-syringe-ETTC, but you do have a child who is about to expire unless you get an airway, and you have a cricothyroid membrane, then my feeling is DO IT. My feeling is the same where paramedics are concerned. If a child is about to die from airway obstruction and no success has been obtained with oral intubation, TTJV, or retrograde wire intubation, the choice is to either let the kid die or try something else. Many paramedic services formally permit their personnel to perform advance surgical techniques, including crics. The literature supports prehospital crics in adults (3). If such a procedure is all that stands between a child and imminent death, however rarely that may occur, we should support the paramedic who chooses to perform the procedure. This is certainly only my own opinion. Legally a paramedic and his or her supervising physician can be held liable for any outcome which may follow such dramatic intervention. Written scope of practice for many paramedic services is vague or frankly unsupportive of this view. I am saddened by systems which treat their paramedics as liabilities rather than supporting them for providing patient care. I certainly didn't go to medical school to stand by while people died preventable deaths. James Li, MD (wb7qni@aol.com) (1) Myths and Pitfalls in Emergency Translaryngeal Ventilation: Correcting Misimpressions. Yealy DM, Stewart RD, Kaplan RM. Ann Emerg Med 17:690-692, July 1988 Much misinformation and confusion exist regarding the technique of translaryngeal jet ventilation. In an effort to clarify the role of this emergency airway alternative, investigators measured peak flow rates using a variety of oxygen sources and cannulas. The oxygen sources included a bag-valve device, a demand-valve device with a driving pressure of 60 cm H2O, and a 50-psi source. Five cannulas were tested: a 4 mm x 10 cm percutaneous tracheal catheter; standard 16-, 14-, and 12-gauge catheters; and a 13-gauge cannula designed specifically for translaryngeal jet ventilation. The mean of 6 readings was obtained for each combination. With each source the largest cannula provided the highest peak flow rates. With a range of 57 L/minute to 94 L/minute, the 50-psi jet source provided the highest peak flow rates. When a bag-valve device was used, only the 4-mm cannula provided ventilation adequate for apneic adults. When standard percutaneous cannulas are used, adults require an oxygen source of 50 psi or more, together with 16-gauge or larger cannulas. Sufficient driving pressures for these cannulas are not possible with demand-valve devices. Adequate oxygenation and ventilation may not be achieved if substitute materials are used. So if you are using a bag-valve-mask to ventilate an adult, you need a 4-mm cannula. If you place a 12- or 14-gauge intravenous cannula you need the full 50 psi that comes from an oxygen tank before the regulator (and the wall oxygen might not suffice). A bag-valve-mask and intravenous cannula might still be enough for an infant. - T.O. Stair, M.D. (2) Retrograde-Assisted Fiberoptic Tracheal Intubation in Children With Difficult Airways. Audenaert SM, Montgomery CL, Stone B, Akins RE, Lock RL. Anesth Analg 73:660-664, 1991 Background.-Retrograde and flexible fiber-optic techniques can be used for clinical management of difficult pediatric airways. Retrograde-assisted fiber-optic intubation in 20 pediatric patients, 7 of whom were less than 16 months of age, is reported. Case Report. -An 11-month-old, 7.8-kg boy with mandibular hypoplasia and Klippel-Feil anomaly was admitted for elective surgery. He received methohexital administered rectally for general anesthesia, 0.16 mg of glycopyrrolate through intravenous access, and incremental halothane in oxygen via a Patil-Syracuse mask to deepen anesthesia. Spontaneous ventilation was maintained. The airway was secured by the following method: needle cricothyrotomy was performed by using a 22-guage Teflon catheter over a needle. The needle and catheter were advanced until there was free aspiration of air. The needle was withdrawn, and a guidewire was passed through the catheter and cephalad to exit through the left nostril. The cephalad end of the wire was fed through the suction port of an intubating bronchoscope loaded with a softened, lubricated endotracheal tube. Phenylephrine was applied to the nasal mucosa, and the bronchoscope was fed along the wire past the vocal cords. The wire was withdrawn. The bronchoscope was then further advanced, and the endotracheal tube was inserted to an appropriate depth. Discussion.-Use of the pediatric bronchoscope makes "intubation over the scope" possible with endotracheal tubes as small as 3 mm internal diameter. The use of the retrograde wire allows even an inexperienced bronchoscopist to quickly follow the wire to the glottic opening. These combined techniques permit one to bypass abnormal landmarks, edema, and small amounts of blood. The bronchoscopist can also perform oxygen insufflation throughout bronchoscopy and intubation. Retrograde-assisted fiber-optic intubation, while not frequently used, is a useful method of securing a difficult pediatric airway. This is an interesting description of the use of retrograde-wire assisted, fiber-optic guided bronchoscopic intubation of the trachea in children with complicated airway management problems primarily resulting from congenital anomalies of the head, neck, and face. These patients were all intubated in the operating room for elective surgical procedures, and although the authors describe the technique as being relatively easy and straightforward, there are few details given as to the typical length of time to perform the procedure. We presume that the authors are all members of the department of anesthesia at their institution. Whether this technique would be immediately adaptable to the emergency department setting, particularly for practitioners who are relatively inexperienced with pediatric airway management, remains to be seen. To my knowledge, there have been no formal studies of retrograde-wireassisted tracheal intubation in children under any circumstances as yet, although I think that there might be a role for the use of such a techninque in a severely facially injured young infant or child, as has been described in the adult population.-F.M. Henretig, M.D. (3) Can Nurses Perform Surgical Cricothyrotomy With Acceptable Success and Complication Rates? Nugent WL, Rhee KJ, Wisner DH. Ann Emerg Med 20:367-370, 1991 It is very important to establish a definitive airway in the field, but this may be a problem when oral or nasal intubation is not possible or is contraindicated. Surgical cricothyrotomy may be useful in this setting. Fifty-five consecutive patients were studied in whom this procedure was attempted by a flight nurse during a 2 1/2-year period. The patients were aged 9-76 years. Cricothyrotomy was done primarily in 16 patients and in 39 patients when other methods failed. In 2 instances, the trachea was not cannulated successfully by a flight nurse. In 1 case, the trachea had been avulsed, and its proximal end could not be found. In the other case, a No. 6 tube could not be passed and a physician completed the procedure after the helicopter landed. In 2 cases, the tube was not in the cricothyroid space. Three patients bled from the operative site, and 3 others had the tube occluded by blood in the emergency department. Two patients had subglottic stenosis. Surgical cricothyrotomy can be reliably carried out by trained nurses in the field. A significant number of patients have complications, but these are acceptable in view of the potential of surgical cricothyrotomy for saving lives. In the field, prehospital cricothyrotomy is a procedure that can be performed by paramedics or nurses with special training. Because of the seriousness of the injuries in patients who need this procedure, though, the rate of complication is to be expected. - S.B. 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