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On Feb 6, 2008, at 2:09 PM, Martin Herman wrote:

> 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
> cricothyrotomy?
>
> 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.
>
>
>
>
>
> Marty
>
>
>
>
>
>
>
>
>
> Le Bonheur Children's Medical Center {A Common Thread of 50 yrs of
> Exceptional Pediatric Care}
>
>
>
>
>
> Martin Herman, M.D.,FAAP,FACEP
> President
>
> Pediatric Emergency Specialists, P.C.
>
> <http://maps.yahoo.com/py/maps.py?Pyt=Tmap&addr=PO+box+637&csz=Ellendale+TN+
> 38029&country=us> PO box 637
> 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 -
> 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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