We’ve recently looked at wound packing as one of the more effective methods to control hemorrhage. This week let’s look at surgical crichoidthyrotomy as an airway option in tactical environments.
Surgical airways are recommended by both C-TECC and CoTCCC relatively early in the airway management flowchart, below NPA and positioning and above placement of an ET tube. Unlike the civilian setting where equipment is readily available and one monitor/patient is the norm, the Tactical Field Care (TCCC) and Indirect Threat Care (TECC) phase recommendations recognize that time and equipment constraints may not allow us to use tools like ETCO2 waveform capnography to confirm tube placement, or even Direct Laryngoscopy or Video Laryngoscopy to place a tube. In those settings, a scalpel-bougie crich may be your best bet for definitive tactical airway management.
Watch this video of Dr Dennis Kim demonstrating a very deliberate surgical method on a cadaver, and think about doing this in a dust-storm in Iraq (or a blizzard in the BC Alpine), or in the pitch black with IR illumination and NVG’s while balancing the equipment on the cleanest surface you can find, your jumpkit or your lap.
If they are done quickly and smoothly out of prepared stripped-down kits they are significantly easier and safer than ETT placement. There is no technology to depend upon. No Laryngoscope, no waveform capnography to confirm placement.
Equipment is simple: A scalpel, a bougie, and a cut down #6 ETT with 10 ml syringe attached.
If necessary, make a vertical incision to mark your midline. Cut the skin laterally across the neck to expose the crichoid membrane. Pierce the membrane, extend the incision and do not remove the scalpel. Insert the bougie over top of the scalpel blade into the tracheal lumen. Remove the scalpel and pass the tube over the bougie.
The technique starts at 2:30 in this video!
If you compare the two techniques, you’ll see that the scalpel-bougie Crich is the easier, safer method. By keeping the surgical tract open continuously, via scalpel, then bougie, then tube, there is a major reduction in the chance of losing the tract. Losing the tract in the dark, in the dust, in the snow, isn’t an option. This is your last ditch airway procedure. It must work!