Oops I misspoke. I was actually asking about a surgical cricothyrotomy and
not a needle cric. I have performed a few needle cric on infants between the
ages of a few days and 3-4 months. Their outcome was universally dismal. OTH
I have performed about 4 surgical cricothyrotomies on kids 8 and up ( oldest
was an elderly lady with a cervical fracture who arrested). All but one
survived ( male with traumatic asphyxia) . 


So let me ask again, what is your cut off for doing a surgical

I have used 8. Clearly Dr. Kumar is using 5. what about others ?


BTW, I concur with the indications and contraindications as listed. I just
challenge the age limit on the surgical cric. 






Le Bonheur Children's Medical Center {A Common Thread of 50 yrs of
Exceptional Pediatric Care} 


Martin Herman, M.D.,FAAP,FACEP

Pediatric Emergency Specialists, P.C.
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Ellendale TN 38029 

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From: santhanam kumar [mailto:[log in to unmask]] 
Sent: Wednesday, February 06, 2008 12:28 PM
To: Martin Herman
Subject: RE: Needle cric


thanks for the enquiry. I am a medical graduate from India and still trying
to get into a program here. In India I have worked in ER fro 5 years as a
trauma team leader. I have done a number of needle cricothyrotomy. 
In my opinion < 5 year old pediatric pts it can be performed, but it can
help only for about 115- 20 minutes and in the mean time I normally go to
modify that into a  formal tracheostomy 

Here are some point you can use for discussion or presentation of the case.

Indications for cricothyroidotomy

*         Any patient needing airway management who cannot be intubated by
oral/nasal route 

*         Basal skull/ cervical spine injury or fracture where need to avoid
neck manipulation prevents intubation 

*         Severe maxillofacial trauma 

*         Oedema of throat tissues causing inability to visualise cords:
angioneurotic oedema, anaphylaxis, burns, smoke inhalation 

*         Severe oropharyngeal/tracheobronchial hemorrhage 

*         Foreign body in upper airway 

*         Need for emergency airway where lack of equipment means that
endotracheal intubation cannot be performed quickly and safely 

*         Technical failure of intubation and need for emergency airway 

*         Severe trismus/clenched teeth 

*         Masseter spasm after succinylcholine 

Contraindications to cricothyroidotomy

*         A less invasive method of securing an airway is possible 

*         Patients <5 years old; needle technique may be used, formal
tracheostomy preferred 

*         Laryngeal fracture 

*         Pre-existing or acute laryngeal pathology 

*         Tracheal transection with retraction of trachea into mediastinum 

*         Obscuration of anatomical landmarks by gross haemorrhage/surgical
emphysema etc. 


> Date: Wed, 6 Feb 2008 11:52:25 -0600
> From: [log in to unmask]
> Subject: Re: Needle cric
> To: [log in to unmask]
> 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 -
> 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
> - 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 -
> 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
> time". There is the understandable (but mistaken) assumption, because we
> 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
> 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
> 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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