Airway Emergencies - special techniques

CRICOTHYROIDOTOMY

Oxygenation can be achieved with:

IPPV using standard anaesthetic circuit

High pressure jet ventilation

Continuous surveillance of airway access is vital as surgical emphysema will render any other emergency procedure (eg tracheostomy) more difficult if not impossible.
IPPV with anaesthetic circuit via cricothyroidotomy
Specific cricothyroidotomy kit with 15mm tapered connector allowing connection to anaesthetic circuit
14 or 16G cannula with size 7.5 ETT connector connected to 3ml plungerless syringe can be put together to use with breathing circuit
Others……
Be familiar with a system that uses equipment that is readily available in theatre

Transtracheal jet ventilation

Percutaneous TTJV using a large bore ( 14G) intravenous catheter through the cricothryoid membrane is relatively quick and simple.
Require a high pressure O2 source ( 50 psi)
Formal minitrach kits which can be attached directly to a normal circuit provide a more stable airway which is almost as quick

Transtrachael Jet Ventilation

14G needle midline through cricothyroid membrane
3 way tap to cannula which allows exhalation port if glottis closed.
Means of connecting to anaesthetic machine

e.g. 1): 2ml syringe with plunger removed attached to 3 way tap. 7.5mm ETT connector removed and inserted into barrel of the 2ml syringe. This then allows connection to anaesthetic circuit.

e.g. 2): Pump set connected to 3 way tap. Hand pump section cut obliquely and placed over common gas outlet.

Pushing flush valve then allows oxygenation of patient. Ventilation may not be adequate but oxygenation will give time for formal airway.
Alternatively a jet injector may be connected to 3 way tap which will provide adequate oxygenation and ventilation

AFTER CRICOTHYROIDOTOMY?

Successful oxygenation via cricothyroidotomy should be followed by a definitive airway:

Tracheostomy
Tracheal intubation
Restoration of spontaneous ventilation by patient

Retrograde Intubation

18G intravenous cannula through cricothyroid (confirm with air drawn through syringe with saline)
Feed epidural catheter out through mouth/ nose
ETT over epidural catheter (best ETT is Fastrach blunt tipped ETT)
Advance ETT through to glottis
FOB through ETT which should be on or just beyond vocal cords
Pass FOB through to carina
Remove epidural catheter
Pass ETT over FOB
Confirm with EtCO2

TRACHEOSTOMY