Episode 38 - Cricothyrotomy Considerations with Scott Weingart
Feb 12, 2021
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Dr. Scott Weingart, a renowned physician and the godfather of critical care podcasts, joins the discussion on surgical cricothyrotomy. He shares how his techniques have evolved and humorously claims trauma surgeons are not the best teachers for this procedure. The conversation delves into the psychological demands of emergency decision-making, advocating for a simplified approach using just a scalpel and bougie. Weingart emphasizes emotional resilience and mastering effective techniques, turning cricothyrotomy from a daunting task into a vital lifesaving skill.
Learning cricothyrotomy techniques from trauma surgeons may be misleading, emphasizing the need for standardized, reliable methods for better preparedness.
Managing airway control takes precedence over hemostasis during a cricothyrotomy, highlighting the importance of prioritizing breathing in emergency situations.
Deep dives
Understanding Surgical Cricothyrotomy
Surgical cricothyrotomy is a high-stakes but rare emergency procedure that is vital in managing failed airways. It entails making an incision to provide direct access to the airway when conventional intubation fails, making knowledge of this procedure critical for medical practitioners. In discussing the way to prepare for a cricothyrotomy, it is emphasized that learning the procedure from trauma surgeons can sometimes be misleading, as their experiences might not translate well to those who may face a patient's life-and-death scenario for the first time. The mental preparedness of a healthcare provider when performing this procedure is crucial, as they often operate under intense pressure and are unfamiliar with the nuances of the procedure outside a controlled learning environment.
Techniques and Approaches to Training
The evolution of techniques for performing cricothyrotomy has led to insights about the use of bougie-assisted methods rather than traditional ones. Bougie placement helps overcome the last failure mode, which involves ensuring the endotracheal tube is correctly inserted into the airway. The frustration of many practitioners with inadequate training highlights the need for standardized techniques, emphasizing the importance of practicing a singular approach that works reliably under distressing conditions. Simulated training and practice with models, including 3D-printed ones, can enhance muscle memory and ensure readiness when performing this vital procedure on a live patient.
Addressing the Challenges of Cricothyrotomy
While performing a cricothyrotomy, managing the bleeding that occurs once the incision is made is one of the significant challenges faced by practitioners. The bleeding is often intimidating for those unfamiliar with the procedure, leading to hesitance or second-guessing during a crisis. It is emphasized that controlling the airway must take priority over hemostasis; once the airway is established, then focus can shift to managing the bleeding. This approach highlights the critical nature of addressing breathing first before worrying about the results of the incision, which will often resolve naturally once the airway is secure.
Cricothyrotomy in Practice and Institutional Perspectives
Cricothyrotomy's perception varies greatly across institutions, and some may view its performance as a failure, while others consider it a necessary option that reflects preparedness for emergencies. Successful patient outcomes through proper airway management demonstrate the importance of being willing to perform a cricothyrotomy as a potentially lifesaving measure. Encouraging a culture where cricothyrotomy is seen as a standard response to failed intubations could significantly reduce mortality rates resulting from airway complications. This shift in institutional mindset could foster better training and confidence for healthcare providers who might need to conduct this procedure, ultimately benefiting patient safety and care.
Dr. Scott Weingart joins us on Rounds to discuss a topic that's of great interest to the both of us - surgical cricothyroidotomy. Tune in to hear how Scott's approach to performing a cric has evolved over time and why "trauma surgeons are the worst people to learn crics from?!" From 3 strikes and your out to the use of bougies, this episode covers all things cric.
Also check out Episode 23 of Rounds "Surgical Cricothyroidotomy: How I Do It". Even better go to: https://emcrit.org/emcrit/surgical-airway/ and review the FANTASTIC content that has been put together by Scott and his team at EMCrit.
