United states marine corps field Medical Training Battalion Camp Lejeune



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UNITED STATES MARINE CORPS

Field Medical Training Battalion

Camp Lejeune

FMST 1418

Perform Emergency Cricothyroidotomy

Terminal Learning Objectives

  1. Given a casualty that meets the needs for an emergency Cricothyroidotomy in a combat environment and standard field medical equipment and supplies, perform an emergency Cricothyroidotomy to prevent further injury or death. (FMST-HSS-1418)

Enabling Learning Objectives

  1. Without the aid of references, given a description or list, identify important anatomical landmarks for an Emergency Cricothyroidotomy, per the student handout. (FMST-HSS-1418a)

  2. Without the aid of references, given a description or list, identify the indications for performing an Emergency Cricothyroidotomy, per the student handout. (FMST-HSS-1418b)

  3. Without the aid of references, given a description or list, identify the contra-indications for performing an Emergency Cricothyroidotomy, per the student handout. (FMST-HSS-1418c)

  4. Without the aid of references, given a description or list, identify the proper equipment for performing an Emergency Cricothyroidotomy, per the student handout. (FMST-HSS-1418d)

  5. Without the aid of references, given a description or list, identify the procedural sequence for Emergency Cricothyroidotomy, per the student handout. (FMST-HSS-1418e)

  6. Without the aid of references, given a description or list, identify potential complications of Emergency Cricothyroidotomy, per the student handout. (FMST-HSS-1418f)

  7. Without the aid of references, given a simulated casualty and standard field medical equipment and supplies, perform an Emergency Cricothyroidotomy, per the student handout. (FMST -HSS-1418g)

  1. DEFINITION

Emergency cricothyroidotomy is a surgical procedure where an incision is made through the skin and cricothyroid membrane. This allows for the placement of an endotracheal tube into the trachea when control of the airway is not possible by other methods.

  1. CRICOTHYROIDOTOMY ANATOMICAL LANDMARKS (see figure 1)

Trachea - also known as the windpipe. It is the cartilaginous and membranous tube descending from, and continuous with, the lower part of the larynx to the bronchi.

Thyroid Cartilage - also known as the “Adam’s Apple.” The thyroid cartilage is located in the upper part of the throat. The thyroid cartilage tends to be more prominent in men than women.

Cricoid Cartilage - located approximately ¾-inch inferior to the thyroid cartilage. The cricoid and thyroid cartilage form the framework of the larynx.

Cricothyroid Membrane - soft tissue depression between the thyroid and cricoid cartilage. This membrane connects the two cartilages and is only covered by skin.

Carotid Arteries - two principal arteries of the neck

Jugular Veins - two principal veins of the neck

Esophagus - musculo-membranous tube extending downward from the pharynx to the stomach. The esophagus lies posterior to the trachea.

Thyroid Gland - largest endocrine gland, the thyroid gland is situated in front of the lower part of the neck. Consists of a right and left lobe on either side of the trachea.



Figure 1. Anatomy of the Respiratory System

  1. INDICATIONS

There are many reasons an emergency cricothyroidotomy may be required. Listed below are a few of the most common reasons:

Obstructed airway - obstructed airway and/or swelling of tissues will usually prevent the passage of an endotracheal tube through the airway. Therefore, a surgical airway distal to the obstruction is required. Causes of an obstructed airway include:

        1. Facial and oropharyngeal edema from burns

        2. Foreign objects (food or teeth)

Congenital deformities of the oropharynx or nasopharynx will inhibit or prevent nasotracheal or orotracheal intubation.

Trauma to the head and neck would preclude the use of an ambu-bag, oropharyngeal airway, nasopharyngeal airway, and endotracheal tube insertion.

Examples include:

- Facial and oropharyngeal edema from severe trauma

- Facial fractures (mandible fracture)

- Nasal bone fractures

- Cribiform fractures

Cervical spine fractures in a patient who needs an airway but whose intubation is unsuccessful or contraindicated.

Last resort - healthcare provider is unable to establish an airway by any other means.


  1. ADVANTAGES/DISADVANTAGES

Advantages of Emergency Cricothyroidotomy

- Provides a definitive airway for ventilating the patient.

- Can be performed quickly and has few complications associated with the procedure.

Disadvantages of Emergency Cricothyroidotomy

- Need advanced training to properly perform procedure.

- Bypasses the nares function of warming and filtering the air.

-


FYI… Although rare, there are a few contraindications for performing a cricothyroidotomy:

  • Casualties with laryngotracheal injuries.

  • Children under 10 years of age.

  • Casualties with laryngeal disease of traumatic or infectious origin.



May increase respiratory resistance.

- Improper placement.

- Casualty is now totally dependent on Corpsman


  1. PROCEDURAL STEPS

a. Make your decision

- Look, listen, and feel

- Attempt to secure airway by all other means

- Justify your decision

b. Assemble and Check Equipment (see figure 2)

- #11 scalpel blade

- Scalpel blade handle

- Endotracheal tube - shortened

- 10 cc syringe - used to fill the cuff at the end of the endotracheal tube

- Stylet - a wire inserted into the endotracheal tube in order to stiffen the tube during passage

- Water soluble lubrication - KY Jelly or Surgilube

- Stethoscope - to check for proper placement of the endotracheal tube

- Curved Kelly hemostat - used to open the incision site

- Tissue Forceps - used to retract skin tissue at the incision site

- Ambu-bag - to ventilate patient

- Sterile dressing

- Petroleum gauze

- Betadine or alcohol wipes

- Sterile or clean gloves

- Suture material

- Suction device

- Suture scissors

- Tape

- Sterile dressing




Figure 2. Required Equipment

c. Prepare patient

- Place patient in a supine or semi-recumbent position.

- The neck is placed in a neutral position.

- Explain procedure (if the patient is conscious).

d. Locate membrane

- Palpate thyroid and cricoid cartilage for orientation (see figure 3).

- Locate cricothyroid membrane.



- Cleanse the incision site with alcohol or betadine swabs.



A - Cricoid Cartilage B- Cricothyroid Membrane C- Incision Site D- Thyroid Cartilage



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