Written by: Em Wessling, MD (NUEM ‘22) Edited by: Therese Whipple (NUEM ‘20) Expert Commentary by: Joseph Posluszny, MD
Expert Commentary
Establishing an airway via a cricothyroidotomy is a stressful and tense experience. In almost all of these cases, experienced airway staff have already attempted advanced airway maneuvers in patients typically at high risk for inability to intubate. As the oxygen saturation drops and the patient becomes unstable, the most adept proceduralist present (whether emergency department physicians or surgeons) are asked to step in to secure a surgical airway.
The scalpel-finger-bougie technique is one proven and reliable method to secure a surgical airway via a cricothyroidotomy. Some additions to the technique described above are:
Use a vertical incision through the skin and soft tissues. If you are too superior or inferior with your initial incision, then this incision can be easily extended as needed. A horizontal incision commits you to that cranial-caudal level. It is often more of a struggle to identify the cranial-caudal orientation of the cricothyroid membrane rather than the medial-lateral orientation.
In a patient with a stable and flexible neck, retract the neck via cranial pressure on the chin to bring the neck structures better into your working field. Insert a shoulder roll if available (unlikely) to augment this positioning.
After the tube is advanced, listen for bilateral breath sounds. It is common, in this adrenaline fueled procedure, to advance the endotracheal tube too far, leading to a right main stem intubation. This can limit your ventilation and oxygenation and can lead to confusion about the airway placement in the neck. If there are no left lung field breath sounds, then pull the tube back until bilateral breath sounds are confirmed with auscultation.
Always verify tube placement with capnography.
Persistent, moderate volume bleeding is often from injury to the anterior jugular vein. Gentle, directed pressure on the area can control this bleeding while the patient is being transported to the operating room for a more definitive airway.
Joseph Posluszny, MD
Assistant Professor of Surgery (Trauma and Critical Care)
Northwestern Memorial Hospital
How To Cite This Post:
[Peer-Reviewed, Web Publication] Wessling, E. Whipple, T. (2021, Aug 2). Scalpel Finger Bougie. [NUEM Blog. Expert Commentary by Posluszny, J]. Retrieved from http://www.nuemblog.com/blog/scalpel-finger-bougie
