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Questions Answered: 127

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126
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Procedural Skills (SLO6)

Question 33 of 127

A 21 year old woman is brought to ED following a severe allergic reaction. Whilst in ED her lips and tongue continue to swell despite appropriate treatment. The anaesthetic team attempt to perform RSI, but are unable to intubate after several attempts with multiple airways. They are unable to ventilate the patient with a bag-valve mask and the decision is made to proceed to cricothyrotomy. Which of the following landmarks describes the most appropriate location to make the incision?

Answer:

A cricothyrotomy involves making an opening in the median cricothyroid ligament (the medial part of the cricothyroid membrane), between the cricoid cartilage below and the thyroid cartilage above.

Surgical Cricothyroidotomy

Surgical cricothyroidotomy is performed by making a skin incision that extends through the cricothyroid membrane. Surgical cricothyroidotomy provides a definitive airway that can be used to ventilate the lungs until semi-elective intubation or tracheostomy is performed.

Indications

  • Can't intubate, can't oxygenate scenario

Advantages vs disadvantages

  • Advantages
    • Definitive airway
    • Enables ventilation and oxygenation until semi-elective intubation or tracheostomy
    • Enables suctioning of trachea
  • Disadvantages
    • Trauma to surrounding structures
    • Risk of creating false passage in soft tissues or oesophagus
    • Technically more difficult than needle cricothyroidotomy

Procedure

  • Extension of the neck will improve surgical access and exposure
  • Palpate the thyroid notch, cricothyroid interval, and sternal notch for orientation
  • Make a horizontal stab incision through the cricothyroid membrane into the trachea with the scalpel (preferably 20 blade: rounded rather than pointed)
  • Open the incision with tracheal dilators or clip (with the scalpel blade still in situ)
  • Remove the scalpel blade and insert the intubating bougie into the trachea
  • Railroad the tracheal tube (6 or 7 mm cuffed) over the intubating bougie to place it in the trachea
  • Inflate the cuff and confirm the tube position
  • Secure the tube to the patient to prevent dislodging

Complications

  • Aspiration of blood
  • Creation of false passage into the tissues
  • Subglottic stenosis/oedema
  • Laryngeal stenosis
  • Oesophageal laceration
  • Thyroid laceration
  • Haemorrhage or haematoma formation
  • Perforation of posterior tracheal wall
  • Subcutaneous and/or mediastinal emphysema
  • Vocal cord paralysis, hoarseness

Clinical anatomy

Site of Airway Procedures. (Image by By PhilippN [CC-BY-SA-3.0 , via Wikimedia Commons)

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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