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Thu Apr 3 22:28:03 BST 2008

Over the past 20 years or so I have done 10 cricothyrotomies mainly in the
prehospital environment and mainly for trapped patients.  One was an
unconscious driver who had run under a parked truck at night in the rain.
He was comprehensively trapped with apparently severe head injury.  He had
large pupils and was fitting.  Sats probe would not read.  Blood around
mouth and in airway.  Still making respiratory efforts.  Only access was
from the back seat.  Cricothyrotomy done from behind by feel.  AT the time I
thought he might become an organ donor at best but he walked out of
hospital.  4 others of the 10 also survived.  All procedures established a
secure airway.  All in less than one minute.  Most in less than 30 seconds.
All who died, died from their primary injury.

I invented one of the percutaneous tracheostomy kits now marketed and used
worldwide (except in the USA for reasons that have never been clear) (PORTEX
Guide wire forceps kit - GRIGGS WM, WORTHLEY LIG, GILLIGAN JE et al: A
Simple Percutaneous Tracheostomy Technique. Surg. Gyne. Obstets. 1990
June:170(6);543-545.). 
http://www.smiths-medical.com/catalog/portex-percutaneous-tracheostomy-kits/
pct-griggs/
Note: I have a financial interest in these kits. 
I have done a percutaneous tracheostomy in an ideal environment is less than
two minutes skin to ventilate.  I feel I am fairly competent at this
procedure but I would NEVER do one in a true "can't intubate / can't
ventilate" airway emergency. 

These are very stressful situations - it is one where you don’t have time to
consider options or to look for equipment.  Cricothyrotomy is a procedure
which is not ever done as a routine.  All these things make it a tough call.
Even so it has to be cricothyrotomy.

Personally I would not use any of the cricothyrotomy kits.  They add steps
and complicate a procedure which is very simple.  Added steps are added
time, and added time is added risk of brain injury or death.  This is one of
the few places in medicine where seconds are important.  I have seen a
number of successful emergency tracheotomies where the patient ended up
brain dead.  This is bad.

All you need is a knife and a tube. With appropriate permission you can
practice on an animal carcase or a cadaver.  There are also manikins to
practice on.  I also practice feeling necks and cricothyroids....

I firmly believe that committing to tracheostomy if cricothryotomy is
possible is minimising the chance for the patient to survive.  

I would never do a tracheostomy in these cases if cricothyrotomy was
possible and believe that one could strongly argue it would be
medico-legally negligent.

regards

Bill

A/Prof William Griggs AM
Director Trauma Services
Royal Adelaide Hospital
South Australia
wgriggs at bigpond.net.au

-----Original Message-----
From: Ivan Hronek [mailto:ivanhronek at yahoo.com] 
Sent: Thursday, 3 April 2008 05:10
To: Trauma &amp; Critical Care mailing list
Subject: Cricothyrotomy vs.tracheostomy ?

Jose, that's the very isue: most people have more experience with trachs -
obviously !
So they go and do a trach: however, as Eric says, this takes longer and in
an emergency in an anoxic patient 
the few minutes can make a big difference !

That's exactly the opposite what I was trying to say: it should NOT depend
on whichever you have more experience with but rather on the need of the
particular patient: a cric should be selected in an emergency if it is
technically feasible of course, as Tchaka points out. It is a Pyrrhic
victory to have a good permanent airway in a brain-dead person.

Ivan Hronek MD 
SFMC, Los Angeles
cell: 310 487-3288
http://health.groups.yahoo.com/group/Anesthideas/
Your most unhappy customers are your greatest source of learning. Bill
Gates.

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or approaches perfomed in the way suggested in this note. 

----- Original Message ----
From: josemaya01 <josemaya01 at prodigy.net.mx>
To: trauma-list <trauma-list at trauma.org>
Sent: Wednesday, April 2, 2008 11:02:13 AM
Subject: Ref:Cricothyrotomy vs.tracheostomy ?

Whichever you feel more comfortable with and have more experience.
José Mayagoitia, M.D.

De : "Ivan Hronek" ivanhronek at yahoo.com
Para : "Trauma &amp; Critical Care mailing list" trauma-list at trauma.org
Copia :
Fecha : Tue, 1 Apr 2008 06:55:25 -0700 (PDT)
Asunto : Cricothyrotomy vs.tracheostomy ?

> Cricothyrotomy vs. tracheostomy in a failure to intubate/failure to
ventilate anoxic patient:
> It appears some surgeons are more comfortable to go for a tracheostomy as
this is what they do more often.
> Cricothyrotomy is expected to be a much quicker way to obtain an airway.
>
> What are your views and experiences on this dilemma ?
>
>
> Ivan Hronek MD
> SFMC, Los Angeles
> cell: 310 487-3288
> http://health.groups.yahoo.com/group/Anesthideas/
> Your most unhappy customers are your greatest source of learning. Bill
Gates.
>
>
>
> Confidentiality Notice: This transmission and any attached documents may
be confidential and contain information protected by State and Federal
Medical Privacy statutes and is legally privileged. They are intended for
use only by the addressee. If you are not the intended recipient of this
transmission, or an agent of the intended recipient, you are prohibited from
reading, disclosing, printing, saving, copying, using, or otherwise
disseminating any information contained in this transmission. If you
received this transmission in error, please accept our apologies and notify
me at ivanhronek at yahoo.com and delete the entire message and its
attachments. Thank you. Disclaimer: this message contains the personal views
of the author. The author will not be responsible in any way for procedures
or approaches perfomed in the way suggested in this note.
>
>
>
>
>
>
>
> ----- Original Message ----
> From: "Sise, Mike MD"
> To: trauma-list at trauma.org
> Sent: Tuesday, April 1, 2008 6:29:27 AM
> Subject: RE: trauma-list Digest, Vol 58, Issue 1
>
> A question for the trauma.org-istas:
>
> You've completed a brilliantly conceived and daring executed trauma
laparotomy in an obese (5 ft 10 in - 250 lbs) hypotensive patient following
a motor vehicle crash who required significant resuscitative efforts (1:1
transfusions with a spritzer of normal saline) and is now a bit cold 95F
(35C) and you packed the liver which was mildly wet and you placed a drain
over a contused by not lacerated mid portion of the pancreas. The patent is
hemodynamically stable and you plan a return in 24 to 48 hours depending on
his status. There are not bowel anastamoses to perform. There are not other
associated injuries.
>
> How to you do your damage control closure: specific details please - do
you do anything to prevent recession of the abdominal wall - i.e., sutures
approximating the edges or other measures. What is you ventilation and
sedation strategy with the open, damage controlled abdomen. Please add any
other thoughts you find valuable.
>
> This is an area of much creativity (variation) and we need to share our
thoughts.
>
> Mike Sise
> San Diego, CA
>
> ________________________________
>
> From: trauma-list-bounces at trauma.org on behalf of
trauma-list-request at trauma.org
> Sent: Tue 4/1/2008 4:00 AM
> To: trauma-list at trauma.org
> Subject: trauma-list Digest, Vol 58, Issue 1
>
>
>
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Cricothyrotomy vs.tracheostomy ?