'emergency cricothyrotomy'

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     I have seen an impossible intubation converted to a successful one
even as I was performing an emergency tracheostomy in the operating
room, probably from the release of skin tension after the incision.

> Hi All
>
> I am an ALS paramedic from SA just south of Johannesburg. Just recently
> I received a call of a male patient 29 who came off a quad bike in a
> remote area just out side the town where I live. The mechanism was that
> he veered off the road and hit a wire fence and well cemented pole next
> to the road. He was not wearing a helmet.
>
> O/A I found the patient lying supine about 4 m from the point of impact.
> The patients vitals were as follows:
>
> GCS = 12/15
> BP = 110/45
> Pulse = 64 bpm no significant pathology on the ECG tracing
> HGT = 5.4 mmol/l
> SpO2 = 94% with 60 % re-breather.
>
> H-T revealed that the patient has no neurological function from the
> shoulders down, even to deep pain stimulation. there were areas of
> mottling and the patient had parasthaesia over the left anterior
> abdominal area. There were abrasions to the hands and the left flank.
> The patient had an ethanol smell on the breath and bystanders mentioned
> that he had been drinking.
>
> My immediate action was to control c-spine manually and fully immobilize
> the patient, insert bilateral large bore I.V. lines. We were about 100
> km from the nearest facility with a neurosurgeon. My reaction was to
> task the medical helicopter to cas-evac the patient to the hospital.
>
> When the Chopper arrived the attending Doctor assessed the patient and
> elected to RSI the patient, due to the distance (20 min flight) and
> patient was intoxicated. After administering etomidate and sux  the
> Doctor then proceeded the intubation, first attempt was unsuccessful the
> patient was then pre-oxygenated to a sats of 99%. Second and third
> attempt was also unsuccessful, but managing to pre-oxygenate the patient
> after each failed attempt. He mentioned that the patient has a difficult
> air-way and was difficult to visualize the cords.
>
> After the third failed attempt the Doctor then elected for an "emergency
> cric" on the patient. I requested one more attempt by my self and he
> refused me to have an attempt, I made it known to him that I thought to
> go for an cric was a bit of a harsh move now. None the less he still
> proceeded. Several attempts were made at the cric, but with no success,
> I then stood in and lost my temper a bit and told the Doctor to stand
> aside and that I would take over now and attempt to intubate the patient
> orally. I managed to intubate the patient on the first attempt
> visualizing the cords with ease. I would score the patients air way a 2
> for difficulty at the most as he did have a rather large tongue and the
> epiglottis was also larger than usual.
>
> I am just requesting the view of any one on this call, on the 24th
> January 2007 I will be attending a M&M on this matter.
>
> Regards,
>
> Lance
> Critical Care Assistant Paramedic South Africa.
>
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