Pulling the Trigger on the Surgical Airway with Dr. Chizmar

Pulling the Trigger on a Surgical Airway

Season 1, Episode 1

Guest: Timothy Chizmar, MD, FACEP,State EMS Medical Director MIEMSS

Narrator:  James Clopein

  • Airway Process
    • BLS Airways first
      • At least one, preferably two
    • Good seal for BVM, with good compliance (Two-thumbs down Technique)
    • Airway assessment
      • Allows for decision-making process re: best tool for the circumstances (Direct laryngoscopy, Video Laryngoscopy, Supraglottic Airway, Surgical Airway)
    • Airway attempt should occur, unless a reason for moving directly to surgical airway can be clearly articulated (i.e. obstructed airway, displaced airway due to trauma, etc)
    •  Failure of a device is not failure to manage the airway, as long as the clinician continues to work through the management plan
    • If advanced airway management efforts are not successful, the clinician should return to BLS efforts
    • If BLS efforts are no longer successful, and a Cannot Intubate, Cannot Ventilate situation exists, a brief consult should be completed
    • Briefly communicate the Cannot Intubate, Cannot Ventilate situation
      • Powerful to include a basic description of the situation that makes the severity of the situation clear to the consulting physician
    • Clinicians can take excessive time to reach point of “pulling the trigger” on the surgical airway related to:
      • Understanding of the anatomy
      • limited training 
      • Limited experience
    • Anatomy
    • Procedures vary
      • Specific procedure preferred will be guided by the local Medical Director
      • Generally Required Equipment
        • 6.0 ET Tube
        • Scalpel
        • “Placeholder”
          • Tracheal hook
          • Bougie (Gum-elastic bougie)
    • Surgical airway indicated in patients 8 years old, and above
    • Pediatric Patients
      • Under 8 years old should have a needle cricothyrotomy performed
      • 12 or 14 gauge IV catheter used to puncture the cricothyroid membrane
    • Secure the placed device
    • Device placement confirmed with waveform End-Tidal CO2
  • Notification (Per Dr. Chizmar)
    • Notify the receiving physician
    • Notify the Jurisdictional Medical Director
      • Discuss/Debrief
        • “How the call went”
        • What challenges were identified
          • “Was there equipment needed, but unable to access?”
          • “Were you able to follow the airway management algorhythm?”
    • Jurisdictional Medical Director, with clinician will notify MD State Operational Medical Director
      • Per Dr. Chizmar, goals of state notification
        • Wants to make the situation an “educational opportunity”
        • Was the situation something that could have been avoided “through additional training or equipment?”
        • Was the clinician “able to successfully carry out the procedure?”
        • Was the clinician, based on their training, “able to go through an organized airway algorhythm”?
        • “Is there any educational follow-up that needs to be provided?”
      • Goal is to reduce fear on the part of the EMS Clinician

EMCrit Podcast 131 – Cricothyrotomy – Cut to Air: Emergency Surgical Airway