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My point exactly Don. 
IF we are to believe that needle crics are futile, what are our other
options? I know surgical crics work, and have saved a few lives with them.
Needle crics at least for me have not been associated with a successful
resus.


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Pediatric Emergency Specialists, P.C.
Martin Herman, M.D.,FAAP,FACEP
President
[log in to unmask]
PO box 637
Ellendale TN 38029
tel: 901 405 1407
fax: 901 405 1524
mobile: 901 219 9202 
------------------------------------

-----Original Message-----
From: Don Zweig [mailto:[log in to unmask]] 
Sent: Wednesday, February 06, 2008 8:33 PM
To: Martin Herman
Subject: Re: Needle cric

I thought that in children under 8 is when you were supposed to do a  
needle cric (if you cant get other access)???
On Feb 6, 2008, at 9:52 AM, Martin Herman wrote:

> Has anyone done a needle cricothyrotomy on anyone under 8?
>
> I believe that is the cut off age for this technique. So for a pt  
> under 8 ,
> what are your options?
>
> We have tried to learn and used a lighted stylette..
> We are looking into getting a video assist devise like the glide-o- 
> scope.
>
> A difficult airway in a young child poses significant challenges.
>
> Marty
>
> ------------------------------------
> Pediatric Emergency Specialists, P.C.
> Martin Herman, M.D.,FAAP,FACEP
> President
> [log in to unmask]
> PO box 637
> Ellendale TN 38029
> tel: 901 405 1407
> fax: 901 405 1524
> mobile: 901 219 9202
> ------------------------------------
> -----Original Message-----
> From: Pediatric Emergency Medicine Discussion List
> [mailto:[log in to unmask]] On Behalf Of Doc Holiday
> Sent: Wednesday, February 06, 2008 4:59 AM
> To: [log in to unmask]
> Subject: Re: Needle cric
>
> From: Erik Schobitz
>> Needle cric was performed with an 18 guage angiocath...briefly able  
>> to
> oxygenate, but lost the needle cric while trying to re-start her  
> heart - she
> unfortunately died.
>
> --> My personal experience on this issue...
> Please forgive the style. I am autistic and write things a bit more  
> "black &
> white" than perhaps you are used to...
>
> Based upon work in a "Level 1 Trauma Centre" equivalent in the UK and
> experience since the late 80s, including various environments and
> pre-hospital work. Also teach on ATLS, etc and thus try to keep up to
> date...
>
> - Needle cric has NO advantages over "proper" cric
> - As you have already experienced, it does have a number of  
> disadvantages...
>
> - Main causes for failure with needles:
>   - It often produces a "core biopsy" of skin & tissue, which blocks  
> the
> needle and thus fails. This may be overcome by having 0.5ml of  
> saline in a
> syringe to flush it
>   - It often blocks LATER by blood or secretions
>   - Over-needle caths are flimsy and WILL kink
>   - ALL THESE BLOCKAGES, at any stage, are OFTEN missed and go  
> unnoticed!!!
>   - Many needles, designed to CUT through skin, have a long, sharp  
> bevel,
> dangerous for the posterior internal aspects of the younger smaller
> tracheas...
>   - It only provides oxygenation, not allowing CO2 to be removed
>   - High pressure required to oxygenate - with its dangers
>   - Tough to monitor: usually no chest rise and no CO2 monitoring...
>   - Difficult to secure (especially without kinking)... As in the case
> mentioned...
> - I will not bore you with how a needle has no cuff, like the proper  
> cric
> kits do...
>
> - There are a number of suitable task-specific cric kits, rather than
> "adapting" a needle or angiocath for a task they are not designed  
> for - this
> temporising measure was invented over 25 years ago, BEFORE all the  
> modern
> kits and training became available. We should no longer be using 2nd  
> best
> - ATLS still teaches both methods. The needle version being supposed  
> to "buy
> time". There is the understandable (but mistaken) assumption,  
> because we are
> still teaching it, that there must be some use for it. YES - if you  
> do not
> possess the proper equipment (e.g. you work in some poor 3rd world
> environment), then you can think needle cric
> - Hope you're sitting down, but a lot of military and other pre- 
> hospital
> teaching is that definitive cric is even the choice BEFORE oral  
> intubation,
> ESPCIALLY for non-experts in intubation. Think about it - intubation  
> is a
> skill so much time is spent learning and practising and worrying  
> about the
> difficulties and failures of. But finding the cric membrance and  
> getting
> something through it is not as tough as finding the cords! There is no
> frequent problem with "visualisation" or secretions or bleeding in the
> way... No problem with positioning in trauma patients. MUCH MUCH  
> MUCH easier
> to teach new paramedics to do well than is intubation!
>
>> Ugly situation all the way around but if you get to that point I  
>> belive
> your likelihood of survival is pretty low no matter what you do.
>
> --> "Likelihood of survival"?
> That's epidemiology! NOT emergency medicine...
> You have a patient. You do your best. The statistics will take care of
> themselves.
> Which means that, if you THINK you need a DEFINITIVE AIRWAY, you  
> might as
> well put one in. Then, at least, even in your case, if the patient  
> does
> unfortunately die, it's DEFINITELY NOT because some second-best device
> (needle cric) has failed.
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Donald Zweig MD
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