1 00:00:00,040 --> 00:00:03,240 Welcome back to the Deep Dive. Today isn't just another 2 00:00:03,240 --> 00:00:07,080 exploration of a topic. We are shifting gears. 3 00:00:07,080 --> 00:00:09,800 We're entering some pretty high stakes territory. 4 00:00:10,400 --> 00:00:13,080 I want you to imagine the lights are bright, the air conditioning 5 00:00:13,080 --> 00:00:16,320 is humming a bit too loudly, your palms are sweating, and you 6 00:00:16,320 --> 00:00:20,040 are standing in front of a senior professor and he's 7 00:00:20,040 --> 00:00:23,360 looking at you over the top of his spectacles. 8 00:00:23,600 --> 00:00:27,960 That is a very specific and I have to say, a universally 9 00:00:27,960 --> 00:00:31,600 terrifying visualization for any medical resident. 10 00:00:31,760 --> 00:00:34,480 It is because today we are treating this deep dive as a 11 00:00:34,480 --> 00:00:36,640 dedicated exam preparation session. 12 00:00:36,760 --> 00:00:39,840 Specifically, we're simulating the Gujarat University MD 13 00:00:39,840 --> 00:00:42,000 Anesthesiology exam preparation, right? 14 00:00:42,320 --> 00:00:45,200 So for today, I am the resident, I'm the learner, the one in the 15 00:00:45,200 --> 00:00:47,880 hot seat, and you? I'm the senior faculty, the 16 00:00:47,880 --> 00:00:49,680 examiner conducting this mock Viva. 17 00:00:49,800 --> 00:00:51,720 I see. So the pressure is entirely on 18 00:00:51,720 --> 00:00:54,000 me to perform. And my job is to drill you on 19 00:00:54,000 --> 00:00:55,720 the details to make sure you're ready. 20 00:00:56,160 --> 00:01:00,240 Exactly my entire medical career, at least my degree is on 21 00:01:00,240 --> 00:01:03,040 the line here. And the topic you have chosen 22 00:01:03,040 --> 00:01:07,920 for me today, it is the ultimate emergency, the the absolute 23 00:01:07,920 --> 00:01:11,240 nightmare scenario we are talking about Cricothyrootomy. 24 00:01:11,280 --> 00:01:14,160 It's the procedure that every anesthesiologist praise they 25 00:01:14,160 --> 00:01:16,120 never have to do. But must know how to do 26 00:01:16,120 --> 00:01:18,520 perfectly. Absolutely, if you are sitting 27 00:01:18,520 --> 00:01:20,760 for your MBA exams. This is not just a technical 28 00:01:20,760 --> 00:01:24,240 skill, it is a goldmine for theory questions, for short 29 00:01:24,240 --> 00:01:26,800 notes, and for those breaded Viva stations. 30 00:01:26,800 --> 00:01:28,480 So our mission today is really twofold. 31 00:01:28,560 --> 00:01:31,840 First we need to decode that clinical nightmare of cannot 32 00:01:31,840 --> 00:01:34,640 intubate, cannot oxygenate or CICO. 33 00:01:34,720 --> 00:01:36,960 The big one. But secondly, and this is for 34 00:01:36,960 --> 00:01:39,880 you, our listener who's prepping for that exam, we need to 35 00:01:39,880 --> 00:01:44,680 provide the exact keywords, the structure and the examiner safe 36 00:01:44,680 --> 00:01:46,120 answers that will get you high marks. 37 00:01:46,120 --> 00:01:48,920 Examiner safe. That is the key phrase there in 38 00:01:48,920 --> 00:01:51,040 an exam, and even more so in a crisis. 39 00:01:51,160 --> 00:01:53,600 You want clarity. You want standard textbooks back 40 00:01:53,760 --> 00:01:55,160 you up, right? You don't want to be quoting 41 00:01:55,160 --> 00:01:57,600 some blog post you read. You want to be quoting the Bible 42 00:01:57,600 --> 00:02:00,480 of anesthesia. Speaking of Bibles, I have 43 00:02:00,480 --> 00:02:03,440 pulled a massive stack for this deep dive. 44 00:02:03,800 --> 00:02:07,440 We are looking at the heavy hitters, Miller's anesthesia, 45 00:02:07,720 --> 00:02:11,560 Morgan McHale, the ICU book by Marino, and for the surgical 46 00:02:11,560 --> 00:02:15,280 details, BD Sharage's anatomy. All good choices, solid. 47 00:02:15,320 --> 00:02:18,360 And also some practical guides like long and short cases and 48 00:02:18,360 --> 00:02:20,200 anesthesiology. We're going to filter out the 49 00:02:20,200 --> 00:02:21,760 noise and just stick to what the books say. 50 00:02:21,920 --> 00:02:23,160 Excellent. Let's begin then. 51 00:02:23,440 --> 00:02:26,000 Resident defined cricothyrotomy for me. 52 00:02:26,040 --> 00:02:30,560 OK, putting on my exam face. Cricothyroidomy is an emergency 53 00:02:30,560 --> 00:02:32,520 invasive airway access technique. 54 00:02:32,760 --> 00:02:35,680 It's performed through the cricothyroid membrane or CTM. 55 00:02:35,760 --> 00:02:37,280 OK. It's distinct from a 56 00:02:37,280 --> 00:02:40,200 tracheostomy in that it's higher up in the neck, and it's 57 00:02:40,200 --> 00:02:42,240 intended primarily as a rescue measure. 58 00:02:42,240 --> 00:02:45,360 That is a solid start, a very solid start, but let's refine 59 00:02:45,360 --> 00:02:48,000 that for the exam. Miller's anesthesia makes a very 60 00:02:48,000 --> 00:02:50,600 specific distinction that examiners absolutely love to 61 00:02:50,600 --> 00:02:52,440 hear. OK, It emphasizes that this is a 62 00:02:52,440 --> 00:02:55,120 rescue technique, not a permanent airway. 63 00:02:55,360 --> 00:02:57,960 That is a critical nuance. So I should use the word rescue? 64 00:02:58,040 --> 00:03:01,360 You must. If you call it a surgical airway 65 00:03:01,800 --> 00:03:04,840 without qualifying it as a rescue bridge, you might lose 66 00:03:04,840 --> 00:03:07,160 marks. It shows you don't appreciate 67 00:03:07,160 --> 00:03:09,960 it's temporarily. Nature now differentiated 68 00:03:09,960 --> 00:03:13,080 immediately from a tracheostomy. Why aren't we just doing a 69 00:03:13,080 --> 00:03:14,600 tracheostomy in the emergency room? 70 00:03:14,760 --> 00:03:18,200 Right. So a tracheostomy is, it's 71 00:03:18,200 --> 00:03:20,960 usually an elective procedure. It's performed lower down, 72 00:03:20,960 --> 00:03:23,440 typically between the 2nd and 4th tracheal rings. 73 00:03:24,160 --> 00:03:28,120 And it takes longer, maybe 15 to 30 minutes in a controlled 74 00:03:28,120 --> 00:03:30,600 setting because you have to dissect through more tissue. 75 00:03:30,600 --> 00:03:33,600 You'd have to move the thyroid, dismiss, manage bleeding. 76 00:03:33,600 --> 00:03:36,440 Where is a Crico. A cricothyroidomy is emergent. 77 00:03:36,440 --> 00:03:39,320 It's done higher up at the CTM, which is superficial. 78 00:03:39,320 --> 00:03:42,880 It needs to be done in seconds to minutes, not 10s of minutes. 79 00:03:42,880 --> 00:03:44,320 Correct. So here's a phrase for you to 80 00:03:44,320 --> 00:03:46,280 remember. Cricothyroatomy is for 81 00:03:46,280 --> 00:03:49,600 resuscitation. Tracheostomy is for maintenance. 82 00:03:49,800 --> 00:03:51,720 I like that. Resuscitation versus 83 00:03:51,720 --> 00:03:53,360 maintenance. That is the fundamental divide. 84 00:03:53,480 --> 00:03:56,080 So where does this fit in the grand scheme of airway 85 00:03:56,080 --> 00:03:58,000 management? It's the final step. 86 00:03:58,000 --> 00:04:01,560 It's the end of the line. It's indicated in the cannot 87 00:04:01,560 --> 00:04:03,360 intubate, cannot oxygenate scenario. 88 00:04:03,360 --> 00:04:09,360 The CICO scenario it it bridges the gap between a failed airway 89 00:04:09,360 --> 00:04:12,600 and a definitive surgical airway, like a tracheostomy. 90 00:04:12,600 --> 00:04:15,720 Exactly now before we get into the, you know, the blood and 91 00:04:15,720 --> 00:04:17,920 guts of the procedure, keep in mind how this appears in the 92 00:04:17,920 --> 00:04:20,399 exam paper. You might get a short note 93 00:04:20,399 --> 00:04:25,040 simply titled Needle versus surgical Cricothyrotomy or you 94 00:04:25,040 --> 00:04:27,640 could get a massive 20 mark long question. 95 00:04:28,160 --> 00:04:32,000 Describe the anatomy, the larynx relevant to cricothyrotomy and 96 00:04:32,000 --> 00:04:34,360 the steps of the scalpel bougie technique. 97 00:04:34,440 --> 00:04:37,360 And in the Viva they might just point to a mannequin and say 98 00:04:37,360 --> 00:04:39,800 show me the membrane. Or draw the surface anatomy on 99 00:04:39,800 --> 00:04:42,360 your own neck. Which brings us to Part B, the 100 00:04:42,360 --> 00:04:44,760 anatomy. You absolutely cannot pass this 101 00:04:44,760 --> 00:04:47,040 section without anatomical precision. 102 00:04:47,440 --> 00:04:50,080 If you were holding a scalpel over a patient's neck, you 103 00:04:50,080 --> 00:04:51,600 better know what is under the skin. 104 00:04:51,640 --> 00:04:53,920 Definitely. So walk me through the surface 105 00:04:53,920 --> 00:04:55,320 anatomy. How do you find the spot? 106 00:04:55,560 --> 00:04:56,960 Let's say you're in that emergency. 107 00:04:57,200 --> 00:04:59,720 OK, visualizing the neck. I'm walking my finger down the 108 00:04:59,720 --> 00:05:02,440 midline. The first hard structure I'd hit 109 00:05:02,440 --> 00:05:05,400 is the high weight bone, but coming down further I feel the 110 00:05:05,400 --> 00:05:08,520 Adam's apple, which is that's a laryngeal prominence of the 111 00:05:08,520 --> 00:05:09,640 thyroid cartilage. Good. 112 00:05:09,640 --> 00:05:11,240 Stop there now, keep moving down. 113 00:05:11,240 --> 00:05:13,520 OK. So below the thyroid cartilage, 114 00:05:13,560 --> 00:05:17,080 there's a soft depression. That's the dip, and immediately 115 00:05:17,080 --> 00:05:20,600 below that dip is a hard ring. A very firm ring. 116 00:05:20,680 --> 00:05:23,480 That's the cricoid cartilage. Right, and anatomy for 117 00:05:23,480 --> 00:05:26,760 anesthetists places the cricoid cartilage at what vertebral 118 00:05:26,760 --> 00:05:28,720 level? It's a classic MCQ fact. 119 00:05:28,720 --> 00:05:31,400 C6 level of the C6 vertebrae. Correct. 120 00:05:31,800 --> 00:05:35,480 So your target is that dip, that soft spot between the thyroid 121 00:05:35,480 --> 00:05:38,680 and cricoid cartilages, that is the cricothyroid membrane. 122 00:05:38,680 --> 00:05:42,400 It feels, it feels really small when you actually palpate it on 123 00:05:42,400 --> 00:05:44,000 yourself. It's not a big window at. 124 00:05:44,000 --> 00:05:46,720 All it is small and you should be palpating it on yourself 125 00:05:46,720 --> 00:05:49,400 right now as you listen. Oh, it's intensive care manual 126 00:05:49,400 --> 00:05:52,720 gives us the dimensions. It's approximately 9mm high 127 00:05:52,720 --> 00:05:58,200 vertically and about 30mm wide. 9mm that is not a lot of room 128 00:05:58,200 --> 00:06:00,880 for error when you're stressed and the SAT's are dropping. 129 00:06:01,080 --> 00:06:05,280 Not at all, and according to BD Char Asia, the membrane itself 130 00:06:05,280 --> 00:06:09,160 is described as yellow, elastic and relatively avascular. 131 00:06:09,360 --> 00:06:12,440 That relatively avascular part sounds promising. 132 00:06:12,440 --> 00:06:15,360 It is promising, but the word relatively is doing a lot of 133 00:06:15,360 --> 00:06:18,000 heavy lifting in that sentence. What are the relations? 134 00:06:18,000 --> 00:06:20,600 What are the structures you were terrified of hitting when you 135 00:06:20,600 --> 00:06:22,880 make that cut? Well, the vessels, definitely 136 00:06:22,880 --> 00:06:27,280 the vessels, the cricothyroid arteries, which run horizontally 137 00:06:27,280 --> 00:06:29,080 across the upper part of the membrane. 138 00:06:29,080 --> 00:06:31,360 Which means clinically, what does that mean for your 139 00:06:31,360 --> 00:06:33,760 technique? It means I have to stay low, 140 00:06:34,120 --> 00:06:37,600 make my incision or puncture in the lower half of the membrane 141 00:06:37,720 --> 00:06:39,560 to avoid those arteries. Precisely. 142 00:06:39,760 --> 00:06:42,560 Let's dig a little deeper into those vessels, because this is 143 00:06:42,560 --> 00:06:44,760 the kind of detail that separates a pass from a 144 00:06:44,880 --> 00:06:47,960 distinction. The cricothyroid arteries are 145 00:06:47,960 --> 00:06:50,360 usually branches of the superior thyroid artery. 146 00:06:50,880 --> 00:06:54,720 In asthmos, they join together right across the upper part of 147 00:06:54,720 --> 00:06:57,720 the membrane. So if you cut high right under 148 00:06:57,720 --> 00:07:00,760 the thyroid cartilage, you are slicing directly through that 149 00:07:00,760 --> 00:07:03,640 arterial arch. And that's arterial bleeding, 150 00:07:04,400 --> 00:07:07,280 which in an airway emergency is just a complete disaster. 151 00:07:07,280 --> 00:07:09,080 It would obscure your view instantly. 152 00:07:09,080 --> 00:07:13,760 Correct blood sprays into the field or even worse down into 153 00:07:13,760 --> 00:07:16,360 the trachea. That is why the recommendation 154 00:07:16,360 --> 00:07:18,840 is always the lower third of the membrane. 155 00:07:19,360 --> 00:07:21,640 You are using anatomy to buy yourself safety. 156 00:07:21,640 --> 00:07:25,440 So it's not just stay low, it's stay in the lower 3rd. 157 00:07:25,600 --> 00:07:28,160 That's the exam safe answer. That's the answer that gets you 158 00:07:28,160 --> 00:07:29,880 the marks. What about veins? 159 00:07:29,880 --> 00:07:32,800 We know the jugulars are lateral, but are there any veins 160 00:07:32,800 --> 00:07:36,760 directly over the membrane? The anterior jugular veins run 161 00:07:36,760 --> 00:07:39,600 vertically, but they're usually lateral to the midline, aren't 162 00:07:39,600 --> 00:07:41,640 they? They are, but there can be 163 00:07:41,640 --> 00:07:45,440 communicating veins, anatomical variants, but the bigger venous 164 00:07:45,440 --> 00:07:48,680 risk is actually hitting the inferior thyroid veins if you go 165 00:07:48,680 --> 00:07:51,760 too low and you're below the cricoid on the trachea or the 166 00:07:51,760 --> 00:07:53,640 isthmus. Right, which is why staying 167 00:07:53,640 --> 00:07:56,520 strictly within the CTM boundaries is absolutely vital. 168 00:07:56,640 --> 00:07:58,840 And strictly midline. Strictly midline. 169 00:07:59,160 --> 00:08:01,560 If you deviate laterally, what do you hit? 170 00:08:01,720 --> 00:08:03,160 The cricothyroid muscles and what's? 171 00:08:03,160 --> 00:08:05,440 The problem with that? Well, it's going to be bloody 172 00:08:05,600 --> 00:08:08,800 for one, but that's also the tensor muscle for the vocal 173 00:08:08,800 --> 00:08:10,840 cords. If you damage that, you could 174 00:08:10,840 --> 00:08:12,960 alter the patient's voice pitch permanently. 175 00:08:12,960 --> 00:08:17,080 Exactly, BD Troasia also mentions the external laryngeal 176 00:08:17,080 --> 00:08:19,840 nerve is nearby. Oh right, the external branch of 177 00:08:19,840 --> 00:08:22,600 the superior laryngeal nerve supplies that muscle. 178 00:08:22,760 --> 00:08:25,840 It runs deep to it. But you know, inflammation or a 179 00:08:25,920 --> 00:08:28,760 very wide dissection could theoretically endanger it. 180 00:08:28,880 --> 00:08:33,080 I see, but let's be honest, in a cannot oxygenate situation, 181 00:08:33,360 --> 00:08:37,320 bleeding is a secondary concern to death and voice changes are a 182 00:08:37,320 --> 00:08:41,039 very distant third. Life over voice like that as a 183 00:08:41,039 --> 00:08:42,240 mantra. OK, what else? 184 00:08:42,240 --> 00:08:44,880 What lies behind the trachea? The esophagus. 185 00:08:44,880 --> 00:08:47,120 The esophagus. It lies immediately posterior, 186 00:08:47,120 --> 00:08:49,320 so if you stab too deep you could get a through and through 187 00:08:49,320 --> 00:08:50,720 puncture. You've just created a 188 00:08:50,720 --> 00:08:53,760 tracheoesophageal fistula with. A scalpel, which is. 189 00:08:53,880 --> 00:08:56,360 Not ideal. Definitely not so for the 190 00:08:56,360 --> 00:08:58,640 examiner. What are the two key anatomical 191 00:08:58,640 --> 00:09:00,360 landmarks you must mention by name? 192 00:09:00,440 --> 00:09:02,520 The thyroid notch and the cricoid ring. 193 00:09:03,000 --> 00:09:05,200 Good and the technique of identifying them. 194 00:09:05,400 --> 00:09:08,320 The laryngeal handshake, stabilizing the larynx with one 195 00:09:08,320 --> 00:09:10,880 hand while identifying these landmarks with the other. 196 00:09:10,880 --> 00:09:12,840 Excellent. The physical manifestation of 197 00:09:12,840 --> 00:09:16,080 that anatomical knowledge. Now let's move on Part C 198 00:09:16,440 --> 00:09:18,720 indications. Why are we even doing this? 199 00:09:18,720 --> 00:09:23,200 So the primary indication is CICO, cannot intubate, cannot 200 00:09:23,200 --> 00:09:24,800 oxygenate. Define that for me. 201 00:09:24,800 --> 00:09:27,200 What does it mean? It means that mask ventilation 202 00:09:27,200 --> 00:09:31,480 has failed, a superglottic airway like an LMA has failed, 203 00:09:31,480 --> 00:09:33,520 and tracheal intubation has failed. 204 00:09:33,920 --> 00:09:36,400 All non invasive options are off the table. 205 00:09:36,440 --> 00:09:39,120 And the textbooks. Milla and long and short cases 206 00:09:39,120 --> 00:09:42,640 are very clear. This is the definitive rescue. 207 00:09:42,760 --> 00:09:44,520 Is it only for failed intubation? 208 00:09:44,520 --> 00:09:47,840 No, no, it's also for a primary upper airway obstruction, a 209 00:09:47,880 --> 00:09:50,280 situation where you can't even try to go in from the top. 210 00:09:50,400 --> 00:09:54,400 For example, massive facial trauma, A smashed face injury 211 00:09:54,400 --> 00:09:57,640 where the oral and nasal routes are just blocked by blood and 212 00:09:57,640 --> 00:10:01,880 bone, or severe angioedema like Ludwig's angina where the 213 00:10:01,880 --> 00:10:04,560 tissues of the tongue and glottis are so swollen you can't 214 00:10:04,560 --> 00:10:05,880 see anything. Correct. 215 00:10:06,080 --> 00:10:09,840 Or a foreign body that's impacted at the glottis, a piece 216 00:10:09,840 --> 00:10:13,840 of food for example. Now imagine you are in the Beva. 217 00:10:14,320 --> 00:10:17,760 The examiner leans forward and asks candidate, give me a one 218 00:10:17,760 --> 00:10:19,360 sentence definition of the indication. 219 00:10:19,360 --> 00:10:22,440 What do you say? I would say Sir, the indication 220 00:10:22,440 --> 00:10:25,760 is the immediate need for an airway when all non invasive 221 00:10:25,760 --> 00:10:27,000 methods have failed. Good. 222 00:10:27,440 --> 00:10:30,080 Concise to the point. Now the trap question. 223 00:10:30,080 --> 00:10:33,920 What are the contraindications? Is there anytime you would never 224 00:10:33,920 --> 00:10:38,480 do a surgical cricothyrotomy? Yes, the age limit in young 225 00:10:38,480 --> 00:10:42,760 children, specifically under say 6 to 12 years depending on the 226 00:10:42,760 --> 00:10:44,040 text. Let's use a safe number 227 00:10:44,040 --> 00:10:46,080 prepubertal. OK prepubertal children. 228 00:10:46,240 --> 00:10:48,640 Surgical cricothyrootomy is contraindicated. 229 00:10:48,640 --> 00:10:50,240 Why? This is the why question that 230 00:10:50,240 --> 00:10:52,840 gets you the distinction. Tell me the path of Physiology. 231 00:10:53,000 --> 00:10:55,400 It's because in young children the cricoid cartilage is the 232 00:10:55,400 --> 00:10:58,280 narrowest part of the airway, not the glottis like in adults. 233 00:10:58,520 --> 00:11:02,360 And the membrane itself is tiny, way smaller than that 9mm we 234 00:11:02,360 --> 00:11:04,920 talked about. It's too small to accept a tube 235 00:11:04,920 --> 00:11:07,040 without completely destroying the cartilage ring. 236 00:11:07,720 --> 00:11:09,400 Miller is very specific about this. 237 00:11:09,400 --> 00:11:12,720 It says for them you have to do a needle crocothyrotomy. 238 00:11:13,120 --> 00:11:16,800 Correct, it is a bit of a Gray zone because children grow at 239 00:11:16,800 --> 00:11:19,360 different rates. Miller suggests 6 years is a 240 00:11:19,360 --> 00:11:22,360 hard cut off. Morgan sometimes references 10 241 00:11:22,360 --> 00:11:24,840 or 12. So what do I say in the exam if 242 00:11:24,840 --> 00:11:28,200 they give me an age like 8? Acknowledge the controversy. 243 00:11:28,440 --> 00:11:29,960 That shows advanced understanding. 244 00:11:30,160 --> 00:11:33,680 You say Sir, in an 8 year old the anatomy is transitioning. 245 00:11:33,920 --> 00:11:35,720 I would need to assess the size of the neck. 246 00:11:36,200 --> 00:11:39,800 However, the needle technique remains the safer initial choice 247 00:11:40,080 --> 00:11:43,160 to avoid the devastating complication of cryptoid damage. 248 00:11:43,160 --> 00:11:46,160 That sounds very nuanced. Examiners must love that. 249 00:11:46,280 --> 00:11:47,960 They do. It shows you aren't a robot 250 00:11:47,960 --> 00:11:49,640 repeating facts. You're a clinician weighing 251 00:11:49,640 --> 00:11:51,760 risks. What's the other absolute 252 00:11:51,760 --> 00:11:55,240 contraindication? Laryngeal fracture A smashed 253 00:11:55,240 --> 00:11:58,000 larynx. Because if the larynx is already 254 00:11:58,000 --> 00:12:00,960 fractured, digging around in the CTM could cause complete 255 00:12:00,960 --> 00:12:02,920 laryngotrycheal separation. You could. 256 00:12:02,960 --> 00:12:05,240 You could effectively evolve the entire airway. 257 00:12:05,400 --> 00:12:09,240 You pull the 2 ends apart, it's an unsurvivable injury in that 258 00:12:09,240 --> 00:12:11,560 setting. In that case, you might need a 259 00:12:11,560 --> 00:12:14,720 formal tracheotomy or to go in below the site of injury. 260 00:12:14,720 --> 00:12:17,400 That makes perfect sense. So let's talk about where this 261 00:12:17,400 --> 00:12:20,560 fits in the algorithms, The difficult Airway society, the 262 00:12:20,560 --> 00:12:23,120 DAS Guidelines. They're the Bible for this. 263 00:12:23,120 --> 00:12:25,240 Right, they are in the DAS guidelines, where is. 264 00:12:25,240 --> 00:12:27,560 This it's Plan D, the last resort. 265 00:12:27,600 --> 00:12:31,480 Walk me through the plans. OK, so plan A is intubation. 266 00:12:31,720 --> 00:12:34,040 That's your primary goal. If that fails. 267 00:12:34,040 --> 00:12:35,640 After a reasonable number of attempts. 268 00:12:35,640 --> 00:12:39,480 Right, Not endless attempts. Then you move to Plan B, which 269 00:12:39,480 --> 00:12:43,040 is a super glottic airway device like an LMA to try and rescue 270 00:12:43,040 --> 00:12:47,160 oxygenation. If that fails, plan C wake the 271 00:12:47,160 --> 00:12:51,200 patient up, go back to face mask ventilation if you can abort the 272 00:12:51,200 --> 00:12:52,800 procedure. What if you can't? 273 00:12:53,080 --> 00:12:55,480 What if you can't mask ventilate them and you can't wake them up 274 00:12:55,480 --> 00:12:57,560 fast enough? But then you're at plan DCICO 275 00:12:57,560 --> 00:13:00,440 rescue cricothyronomy. Right. 276 00:13:00,840 --> 00:13:03,480 And Miller discusses the vortex approach, which is a really 277 00:13:03,480 --> 00:13:05,720 great visual. You have these three life lines, 278 00:13:06,120 --> 00:13:10,200 ace mask, tube, LMA. If one fails you siral inwards. 279 00:13:10,520 --> 00:13:13,240 If they all fail, you hit the center of the vortex. 280 00:13:13,280 --> 00:13:15,360 Which is CICO rescue. Exactly. 281 00:13:15,760 --> 00:13:18,960 The key for the exam and for your clinical practice is that 282 00:13:18,960 --> 00:13:21,800 transition. When do you move from Plan C to 283 00:13:21,800 --> 00:13:24,280 Plan D? When do you decide to cut? 284 00:13:24,440 --> 00:13:27,360 When the patient is becoming hypoxic and you cannot wake them 285 00:13:27,360 --> 00:13:29,960 up, you have to declare it. I think that's the examiner safe 286 00:13:29,960 --> 00:13:33,760 point stressing the importance of declaring CICO out loud. 287 00:13:33,840 --> 00:13:36,840 Yes, you don't just keep trying to intubate a hypoxic patient. 288 00:13:36,840 --> 00:13:39,760 You have to announce to the team, I cannot intubate, I 289 00:13:39,760 --> 00:13:42,640 cannot oxygenate. We are proceeding to a surgical 290 00:13:42,640 --> 00:13:43,560 airway. That's it. 291 00:13:43,720 --> 00:13:46,360 Decisiveness is a markable quality in the Viva. 292 00:13:46,600 --> 00:13:49,720 It shows leadership and a clear thought process under pressure. 293 00:13:49,840 --> 00:13:52,480 Now Part D the meat of the matter. 294 00:13:53,080 --> 00:13:55,880 Types and techniques. OK, so we have what, 3 main 295 00:13:55,880 --> 00:13:58,120 flavors here, Needle crooked thyrotomy, surgical crooked 296 00:13:58,120 --> 00:14:00,160 thyrotomy, and then the percutaneous or Seldinger 297 00:14:00,160 --> 00:14:01,320 techniques. Let's break them down. 298 00:14:02,040 --> 00:14:03,480 Differentiate needle from surgical for me. 299 00:14:03,480 --> 00:14:06,360 What's the core difference? Needle crooked thyrotomy uses a 300 00:14:06,360 --> 00:14:11,520 wide bore cannula, something like a 14 gauge or 16 gauge IV 301 00:14:11,600 --> 00:14:14,120 cannula. It requires a high pressure gas 302 00:14:14,120 --> 00:14:17,120 source, which we call jet ventilation, but. 303 00:14:17,240 --> 00:14:19,400 There's a big but. But, and this is the huge 304 00:14:19,400 --> 00:14:21,600 distinction, is a temporizing measure. 305 00:14:21,920 --> 00:14:25,960 It only buys you time, maybe 30 to 45 minutes, because you can't 306 00:14:25,960 --> 00:14:29,240 effectively blow off CO2 through that tiny needle. 307 00:14:29,240 --> 00:14:31,520 Correct. It oxygenates, but it doesn't 308 00:14:31,520 --> 00:14:34,360 ventilate well. Carbon dioxide accumulates, 309 00:14:34,440 --> 00:14:37,080 leading to a severe respiratory acidosis. 310 00:14:37,760 --> 00:14:39,000 What about? Surgical Surgical cricket 311 00:14:39,000 --> 00:14:42,880 thyrotomy uses a scalpel and a small cuff tube, usually a six 312 00:14:42,880 --> 00:14:45,040 point O millimeter internal diameter tube. 313 00:14:45,480 --> 00:14:47,400 This is considered a definitive airway. 314 00:14:47,400 --> 00:14:49,280 Like definitive. Because you can ventilate 315 00:14:49,280 --> 00:14:52,800 properly, you can scrub CO2 and the cuff protects the airway 316 00:14:52,800 --> 00:14:55,680 against aspiration. Good and the percutaneous or 317 00:14:55,680 --> 00:14:58,080 Seldinger technique. That's using a guide wire and a 318 00:14:58,080 --> 00:15:01,200 dilator like a milker. Kit Miller notes that while we 319 00:15:01,200 --> 00:15:03,560 anesthetists are comfortable with this because it feels like 320 00:15:03,560 --> 00:15:04,840 putting in a central line, which. 321 00:15:04,840 --> 00:15:07,280 We do all the time. Right, but it can actually be 322 00:15:07,280 --> 00:15:09,400 slow, lower than the scalpel technique. 323 00:15:09,400 --> 00:15:12,800 In a true crisis, fiddling with wires and dilators when a 324 00:15:12,800 --> 00:15:16,160 patient is turning blue is stressful and prone to error. 325 00:15:16,280 --> 00:15:18,560 It is. That's why the DAS guidelines 326 00:15:18,560 --> 00:15:21,080 have shifted. They now heavily recommend the 327 00:15:21,080 --> 00:15:24,920 scalpel bougie technique. This is an exam favorite. 328 00:15:25,200 --> 00:15:28,480 If they ask you for the steps of a surgical critco, this is the 329 00:15:28,480 --> 00:15:31,600 technique they want to hear. Walk me through it step by step. 330 00:15:32,080 --> 00:15:36,000 Step one position, you extend the neck to bring the airway 331 00:15:36,000 --> 00:15:37,600 forward. Unless, of course, there's a 332 00:15:37,600 --> 00:15:39,840 suspected C spine injury. Good Step 2. 333 00:15:40,040 --> 00:15:42,920 Identify. Palpate the CTM, use the 334 00:15:42,920 --> 00:15:45,800 laryngeal handshake we talked about, stabilize the larynx. 335 00:15:45,800 --> 00:15:47,400 Step 3. The scary part? 336 00:15:47,440 --> 00:15:50,160 Incision. Make a horizontal stab incision 337 00:15:50,160 --> 00:15:51,600 through the skin and the membrane. 338 00:15:51,600 --> 00:15:54,560 At the same time. Yes, simultaneously 1 decisive 339 00:15:54,560 --> 00:15:55,480 movement. Just go for. 340 00:15:55,480 --> 00:15:58,760 It Step 4. This is a crucial, often 341 00:15:58,760 --> 00:16:01,040 forgotten step. The twist This is critical. 342 00:16:01,160 --> 00:16:05,840 You rotate the scalpel 90° and the edge should be facing 343 00:16:05,840 --> 00:16:08,680 caudally towards the feet. This holds the hole open. 344 00:16:08,960 --> 00:16:11,200 Let's pause there. I want to really visualize that 345 00:16:11,200 --> 00:16:13,280 twist. I've heard people ask why not 346 00:16:13,280 --> 00:16:14,760 just put the bougie in through the slit? 347 00:16:14,960 --> 00:16:16,520 Why do we need to rotate the blade? 348 00:16:16,520 --> 00:16:18,560 Well, you have to think about the tissue. 349 00:16:18,720 --> 00:16:21,600 The CTM is elastic like a rubber sheet. 350 00:16:21,960 --> 00:16:24,680 You make a horizontal slit. The moment you remove the 351 00:16:24,680 --> 00:16:27,560 pressure, that slit just wants to close up. 352 00:16:28,240 --> 00:16:31,480 If you try to push a soft flexlogum elastic bougie against 353 00:16:31,480 --> 00:16:35,360 that closed slit, it might just bunch up, or worse, create a 354 00:16:35,360 --> 00:16:37,680 false passage in the subcutaneous tissue. 355 00:16:37,680 --> 00:16:40,760 Exactly. The twist turns that linear slit 356 00:16:40,760 --> 00:16:42,720 into a triangular or square opening. 357 00:16:43,120 --> 00:16:46,480 It physically levers the cartilages apart slightly and 358 00:16:46,480 --> 00:16:49,320 creates a patent hole. You can often hear a gasp or a 359 00:16:49,320 --> 00:16:52,360 hiss of air immediately. So it confirms you're in too 360 00:16:52,360 --> 00:16:54,240 and. It creates a clear open path for 361 00:16:54,240 --> 00:16:56,840 the bougie to slide down alongside the flat of the blade. 362 00:16:57,000 --> 00:16:59,400 Right, because if you take the scalpel out to put the bougie 363 00:16:59,400 --> 00:17:02,640 in, you've lost the hole. You'll never find it again 364 00:17:02,640 --> 00:17:05,800 through the blood and the panic. Precisely, the blade acts as a 365 00:17:05,800 --> 00:17:08,680 guide and pointing the sharp edge caudally. 366 00:17:08,680 --> 00:17:11,520 Why is that detail so important? It's for safety. 367 00:17:11,720 --> 00:17:14,520 If the patient bucks or your hand slips and the sharp edge is 368 00:17:14,520 --> 00:17:17,920 pointing up cephalid, you could cut the vocal cords. 369 00:17:18,000 --> 00:17:20,880 A disaster. But if it points down coddle, 370 00:17:20,880 --> 00:17:22,640 you just cut into the tough crickoid ring. 371 00:17:22,640 --> 00:17:24,480 It's cartilage, it'll stop the blade. 372 00:17:24,480 --> 00:17:27,720 That is a critical examiner. Safe detail, sharp edge down. 373 00:17:28,520 --> 00:17:30,880 You've twisted Step 5. Bougie. 374 00:17:31,160 --> 00:17:34,320 Slide a gum elastic bougie down the side of the blade into the 375 00:17:34,320 --> 00:17:35,880 trachea. You should feel for the 376 00:17:35,880 --> 00:17:36,680 tracheal. Click. 377 00:17:36,680 --> 00:17:40,200 We'll come back to that Step 6. Railroading you slide a 378 00:17:40,200 --> 00:17:43,440 lubricated 6 pointer millimeter cuff tube over the boozy and 379 00:17:43,440 --> 00:17:45,680 into the airway. And the final, most important 380 00:17:45,680 --> 00:17:46,760 step. Step 7. 381 00:17:46,840 --> 00:17:50,200 Confirm, inflate the cuff, check for chest rise and most 382 00:17:50,200 --> 00:17:53,160 importantly get a waveform on your end title CO2 monitor. 383 00:17:53,160 --> 00:17:58,000 The AB twist, bougie tube. Memorize that sequence in the 384 00:17:58,000 --> 00:17:59,720 exam. Use active verbs. 385 00:18:00,160 --> 00:18:02,760 I will stab, I will twist. It shows confidence. 386 00:18:02,800 --> 00:18:04,760 Got it. Now can we loop back to the 387 00:18:04,760 --> 00:18:06,720 needle technique you mentioned jet ventilation? 388 00:18:06,720 --> 00:18:08,560 That seems like a high yield Viva topic. 389 00:18:08,560 --> 00:18:09,400 It is. How do you do it? 390 00:18:09,640 --> 00:18:15,400 You insert a 14 gauge cannula at a 45° angle pointing caudally 391 00:18:15,400 --> 00:18:18,160 towards the lungs. You confirm you're in by 392 00:18:18,160 --> 00:18:21,520 aspirating air bubbles in a saline filled syringe. 393 00:18:21,800 --> 00:18:24,040 Then you connect it to a high pressure source. 394 00:18:24,040 --> 00:18:26,640 Oh wait, Morgan adds a very specific detail here about 395 00:18:26,640 --> 00:18:29,040 confirmation. Do you just aspirate once? 396 00:18:29,760 --> 00:18:33,240 No good point. You aspirate air when the needle 397 00:18:33,240 --> 00:18:36,400 tip enters the trachea. Then you slide the plastic 398 00:18:36,400 --> 00:18:39,880 catheter forward off the needle. But you must aspirate again 399 00:18:39,880 --> 00:18:42,680 after the catheter is in place. And why is that double check so 400 00:18:42,680 --> 00:18:44,320 critical? Because it's a very common 401 00:18:44,320 --> 00:18:46,480 failure point. You might hit the trachea with 402 00:18:46,480 --> 00:18:49,400 needle tip, great, you get air. But as you slide the plastic 403 00:18:49,400 --> 00:18:52,520 catheter forward, maybe the needle was barely in the 404 00:18:52,520 --> 00:18:55,080 catheter catches on the cartilage or pushes the membrane 405 00:18:55,080 --> 00:18:55,440 away. Where? 406 00:18:55,600 --> 00:18:57,680 Does it end up? In the subcutaneous tissue, the 407 00:18:57,680 --> 00:18:59,000 needle is out. You, I think you're in. 408 00:18:59,000 --> 00:19:01,840 You hook up the jet ventilator and you inflate the patient's 409 00:19:01,840 --> 00:19:05,360 neck instead of their lungs. Catastrophic subcutaneous 410 00:19:05,360 --> 00:19:08,400 emphysema. So the sequence is puncture, 411 00:19:08,720 --> 00:19:11,200 aspirate, slide, catheter, aspirate again. 412 00:19:11,520 --> 00:19:13,280 Only then do you connect the jet. 413 00:19:13,560 --> 00:19:16,240 That double check is a Viva Gold Star right there. 414 00:19:16,440 --> 00:19:18,000 OK, that's burned into my brain now. 415 00:19:18,400 --> 00:19:21,080 What about the pressure? What pressure do you need for 416 00:19:21,080 --> 00:19:24,160 jet ventilation? It's high 50 PSI pounds per 417 00:19:24,160 --> 00:19:25,880 square inch. You need that driving pressure 418 00:19:26,240 --> 00:19:28,200 because the cannula is so narrow and. 419 00:19:28,360 --> 00:19:31,360 Where do you get that from? You can use a dedicated device 420 00:19:31,360 --> 00:19:35,040 like a Sanders injector, or you can use the oxygen flush valve 421 00:19:35,040 --> 00:19:37,920 on the anesthesia machine, often with some self-made tubing. 422 00:19:38,240 --> 00:19:40,440 Let's expand on the physics of jet ventilation. 423 00:19:40,840 --> 00:19:43,680 The classic teaching was about the Venturi effect, wasn't it? 424 00:19:43,880 --> 00:19:46,960 That the high velocity jet entrains room air? 425 00:19:47,080 --> 00:19:48,640 Is that what's happening in CICO? 426 00:19:49,080 --> 00:19:52,320 Actually, Miller clarifies this. While that's true in an open 427 00:19:52,320 --> 00:19:56,040 system like rigid bronchoscopy, in a CICO situation with a 428 00:19:56,040 --> 00:19:59,320 narrow 14 gauge needle and a potentially obstructed upper 429 00:19:59,320 --> 00:20:01,600 airway, the entrainment is minimal. 430 00:20:01,600 --> 00:20:04,040 So what's the main mechanism? It's just high pressure mass 431 00:20:04,040 --> 00:20:06,080 flow. You're just blasting oxygen into 432 00:20:06,080 --> 00:20:08,920 the lungs to keep the sats up. It oxygenates, but it doesn't 433 00:20:08,920 --> 00:20:11,360 ventilate. Good and the IE ratio 434 00:20:11,560 --> 00:20:14,840 inspiration to expiration time. Inspiration has to be short one 435 00:20:14,840 --> 00:20:18,120 second on, but expiration needs to be long, 3 to 4 seconds off. 436 00:20:18,400 --> 00:20:22,200 Why this is the most critical Viva point about TTJV? 437 00:20:22,480 --> 00:20:26,200 Why the long expiratory time? Because expiration is passive, 438 00:20:26,320 --> 00:20:29,480 you're pushing air in under high pressure through a tiny hole, 439 00:20:29,800 --> 00:20:32,560 but the air has to get out through the patient's natural 440 00:20:32,560 --> 00:20:34,760 upper airway, through the glottis. 441 00:20:35,120 --> 00:20:36,920 It can't come back out the needle efficiently. 442 00:20:37,080 --> 00:20:41,440 Precisely which leads us to the absolute contraindication for 443 00:20:41,440 --> 00:20:44,640 transtrycheal jet ventilation. Complete upper airway 444 00:20:44,640 --> 00:20:46,400 obstruction. If the glottis is totally 445 00:20:46,400 --> 00:20:48,400 blocked, the air goes in but it can't get out. 446 00:20:48,400 --> 00:20:51,520 You just start stacking breaths, the pressure builds and builds 447 00:20:51,520 --> 00:20:55,320 in the lungs until massive Barra trauma and bilateral 448 00:20:55,320 --> 00:20:56,720 pneumothorsis. Excellent. 449 00:20:56,920 --> 00:20:59,320 If the plumbing is blocked at the top, do not pump from the 450 00:20:59,320 --> 00:21:00,320 bottom. Remember that? 451 00:21:00,360 --> 00:21:03,280 Got it. OK, moving on to part E 452 00:21:03,280 --> 00:21:07,440 anaesthetic considerations, What are we the anaesthetists doing 453 00:21:07,440 --> 00:21:09,520 while all this cutting and jetting is happening? 454 00:21:09,520 --> 00:21:12,520 Well, oxygenation is priority number one. 100% oxygen 455 00:21:12,520 --> 00:21:14,280 immediately. What about drugs? 456 00:21:15,400 --> 00:21:18,720 If the patient is arresting or unconscious, which is very 457 00:21:18,720 --> 00:21:21,560 likely in a CICO scenario, you don't need any drugs, you just 458 00:21:21,560 --> 00:21:24,320 need the airway now. And if they're not, If they're 459 00:21:24,320 --> 00:21:26,680 awake or struggling? Then the ICU book mentions 460 00:21:26,680 --> 00:21:29,600 ketamine as a good choice. It preserves respiratory drive. 461 00:21:30,120 --> 00:21:33,320 Or if you're converting to a surgical airway in a semi 462 00:21:33,320 --> 00:21:36,120 controlled way, you might use a rapid sequence induction agent. 463 00:21:36,200 --> 00:21:39,400 Why ketamine specifically? Why not give a slug of propofol? 464 00:21:39,640 --> 00:21:43,400 Oh, because propofol causes apnea and a total loss of airway 465 00:21:43,400 --> 00:21:45,480 tone. If you have a patient who is 466 00:21:45,480 --> 00:21:49,320 maintaining their own airway, gasping but moving some air, and 467 00:21:49,320 --> 00:21:52,760 you give them propofol, their airway completely collapses. 468 00:21:53,040 --> 00:21:55,840 Now you have a total obstruction where you had a partial 1. 469 00:21:56,400 --> 00:21:58,520 Ketamine is a dissociative anesthetic. 470 00:21:58,800 --> 00:22:02,640 It provides analgesia and amnesia, but the pharyngeal and 471 00:22:02,640 --> 00:22:04,880 laryngeal reflexes often remain intact. 472 00:22:05,040 --> 00:22:08,080 And crucially, spontaneous respiration continues. 473 00:22:08,520 --> 00:22:10,680 It allows you to operate on the neck while the patient keeps 474 00:22:10,680 --> 00:22:12,960 trying to breathe. What about muscle relaxants? 475 00:22:13,080 --> 00:22:14,960 Rachronium. This is controversial and it 476 00:22:14,960 --> 00:22:16,280 depends on the guidelines you follow. 477 00:22:16,560 --> 00:22:19,600 In a true CICO, where laryngospasm might be the cause, 478 00:22:19,880 --> 00:22:23,040 a dose of muscle relaxant might break the spasm and allow you to 479 00:22:23,040 --> 00:22:24,920 ventilate. So the DAS guidelines. 480 00:22:25,120 --> 00:22:28,160 The DAS guidelines generally suggest ensuring the patient is 481 00:22:28,160 --> 00:22:32,080 fully paralyzed before you declare a failed intubation, 482 00:22:32,320 --> 00:22:35,200 just to rule out inadequate relaxation as the cause. 483 00:22:35,200 --> 00:22:39,080 So so the sequences ensure paralysis, try to intubate, 484 00:22:39,080 --> 00:22:45,120 fail, try LMA, fail, mask, fail, then you declare CICO and you 485 00:22:45,120 --> 00:22:46,680 cut. That is the sequence. 486 00:22:46,960 --> 00:22:50,560 But if you are doing a primary cricyrotomy, say on an awake 487 00:22:50,560 --> 00:22:53,440 patient with that smashed face we talked about, you would avoid 488 00:22:53,440 --> 00:22:55,400 paralysis. You want them breathing until 489 00:22:55,400 --> 00:22:58,280 that tube is in and secure. That's a key distinction. 490 00:22:58,560 --> 00:23:01,280 Rescue CSO versus primary emergency airway. 491 00:23:01,360 --> 00:23:04,640 What about local anaesthesia? If time permits, which it rarely 492 00:23:04,640 --> 00:23:08,160 does in a true CICO crisis, you can you can infiltrate lidocaine 493 00:23:08,160 --> 00:23:10,640 with adrenaline to reduce bleeding, but honestly as we 494 00:23:10,640 --> 00:23:12,880 said, in a cannot oxygenate situation you just cut. 495 00:23:12,960 --> 00:23:15,360 Right speed Is everything OK? Confirmation. 496 00:23:15,360 --> 00:23:17,080 How do you know the tube is in the right place? 497 00:23:17,080 --> 00:23:19,800 Clinical science first. Chest rise misting in the tube. 498 00:23:20,000 --> 00:23:22,800 But the gold standard, the one you must mention is capnography. 499 00:23:23,120 --> 00:23:26,280 You want to see that square wave ETCO 2 trace on the monitor. 500 00:23:26,280 --> 00:23:28,960 Why not just auscultation? I will listen to the chest. 501 00:23:29,120 --> 00:23:33,480 Examiner safe answer in a noisy trauma room or a chaotic 502 00:23:33,480 --> 00:23:36,880 resuscitation, auscultation is completely unreliable. 503 00:23:36,880 --> 00:23:41,000 You can hear sounds everywhere. You have to rely on capnography 504 00:23:41,000 --> 00:23:43,040 and direct visualization of chest rise. 505 00:23:43,040 --> 00:23:48,320 Good now part F complications. You save the life, but what mess 506 00:23:48,320 --> 00:23:50,920 have you potentially made? Well, there are immediate and 507 00:23:50,920 --> 00:23:53,400 late complications. Immediate would be hemorrhage 508 00:23:54,040 --> 00:23:57,400 from the thyroid vessels or even the jugular veins if you deviate 509 00:23:57,400 --> 00:23:59,320 too far laterally. And what about air? 510 00:23:59,640 --> 00:24:03,080 Subcutaneous emphysema. If the tube is placed in the 511 00:24:03,080 --> 00:24:05,960 pretracheal tissue, a false passage, you're just pumping air 512 00:24:05,960 --> 00:24:08,480 into the skin. It causes that Rice Krispies 513 00:24:08,480 --> 00:24:10,520 crackling feeling on palpation. Let's. 514 00:24:10,520 --> 00:24:13,320 Talk about that false passage. How do you know in the moment 515 00:24:13,560 --> 00:24:15,720 that you've made one? The tactile feel might be 516 00:24:15,720 --> 00:24:18,680 different, but clinically you place the tube, you inflate the 517 00:24:18,680 --> 00:24:21,880 cuff and you try to ventilate and one the chest does not rise 518 00:24:21,960 --> 00:24:27,080 2 the end title CO2 trace is flat, it's 03 the next starts to 519 00:24:27,080 --> 00:24:30,400 swell up like a balloon. That is a terrifying triad of 520 00:24:30,400 --> 00:24:31,400 signs. What do you do? 521 00:24:31,760 --> 00:24:34,000 You have to pull the tube out immediately. 522 00:24:34,120 --> 00:24:38,360 You are not in the airway, you are in the pre tracheal space. 523 00:24:38,960 --> 00:24:43,080 You need to repelpate, re stab or more likely extend your 524 00:24:43,080 --> 00:24:45,720 incision so you can visualize the trachea directly. 525 00:24:45,720 --> 00:24:47,560 This is why the bougie is so important. 526 00:24:47,560 --> 00:24:49,440 It gives you that tactile confirmation. 527 00:24:49,440 --> 00:24:51,880 You mentioned it earlier. Feeling the tracheal clicks. 528 00:24:51,880 --> 00:24:55,120 Yes, as the bougie goes down, you can often feel the tip 529 00:24:55,400 --> 00:24:57,760 bumping over the cartilage in his tracheal rings. 530 00:24:58,280 --> 00:25:01,960 It's a very distinct sensation. If you don't feel clicks, or if 531 00:25:01,960 --> 00:25:04,560 the bougie stops after just a couple of centimeters, it's in 532 00:25:04,560 --> 00:25:05,040 the. Wrong place. 533 00:25:05,320 --> 00:25:08,400 It's in the wrong place or it's hit the Karina the hold up sign. 534 00:25:08,920 --> 00:25:12,200 If it goes down a bronchus it will also stop, but if it's in 535 00:25:12,200 --> 00:25:14,720 soft tissue it might just feel mushy or keep going 536 00:25:14,720 --> 00:25:16,520 indefinitely. And if you go too deep with the 537 00:25:16,520 --> 00:25:19,480 initial stab. Esophageal perforation and the 538 00:25:19,480 --> 00:25:21,360 big one with jet ventilation that we already covered. 539 00:25:21,440 --> 00:25:25,280 Barotrauma and pneumothorax. Now, late complications. 540 00:25:25,280 --> 00:25:27,640 This is what the ENT surgeons will be worried about later. 541 00:25:27,760 --> 00:25:32,000 Subglottic stenosis, the ICU book states this is the most 542 00:25:32,000 --> 00:25:35,960 feared long term complication and the risk is very high if the 543 00:25:35,960 --> 00:25:38,080 cricothyrotomy tube is left in for too long. 544 00:25:38,120 --> 00:25:41,560 Why is it so bad there? Because the cricoid cartilage is 545 00:25:41,560 --> 00:25:44,320 a complete ring, it's the only one in the airway, so 546 00:25:44,320 --> 00:25:47,800 inflammation and scarring there can lead to a fixed narrowing of 547 00:25:47,800 --> 00:25:50,720 the airway that is permanent and very difficult to treat. 548 00:25:50,720 --> 00:25:53,760 And voice changes. Yes, damage to the cricothyroid 549 00:25:53,760 --> 00:25:56,360 muscle or the recurrent laryngeal nerve can affect the 550 00:25:56,360 --> 00:25:59,280 quality and pitch of the voice. So how do we manage these 551 00:25:59,280 --> 00:26:01,920 complications? Immediate recognition is key. 552 00:26:02,240 --> 00:26:05,600 If you see that subcutaneous emphysema spreading, stop 553 00:26:05,600 --> 00:26:08,240 ventilating immediately. If there's significant bleeding, 554 00:26:08,240 --> 00:26:10,560 you pack it. But the real management is 555 00:26:10,560 --> 00:26:14,120 prevention and conversion. Which leads us perfectly to Part 556 00:26:14,120 --> 00:26:17,400 G post procedure care. You've done the Crico, the 557 00:26:17,400 --> 00:26:19,240 patient is alive, the Sats are up. 558 00:26:19,760 --> 00:26:21,800 What do you do now? First you have to secure it 559 00:26:21,800 --> 00:26:25,240 properly, suture it in place, use ties, don't let it fall out. 560 00:26:25,600 --> 00:26:28,040 But then you immediately need to plan the exit strategy. 561 00:26:28,240 --> 00:26:30,680 You need to convert to a definitive airway. 562 00:26:30,680 --> 00:26:33,160 What is the time frame for that conversion? 563 00:26:33,200 --> 00:26:35,800 Both Miller and Morgan suggest converting to a formal 564 00:26:35,800 --> 00:26:38,600 tracheostomy within 24 to 72 hours. 565 00:26:39,320 --> 00:26:42,320 You want to get that tube out of the CTM as soon as the patient 566 00:26:42,320 --> 00:26:43,680 is stable enough for the procedure. 567 00:26:43,800 --> 00:26:46,120 And the reason is. To minimize the risk of 568 00:26:46,120 --> 00:26:48,800 subglottic stenosis and partly erosion. 569 00:26:48,840 --> 00:26:50,480 Correct. Remember our phrase? 570 00:26:50,960 --> 00:26:53,800 It's a temporary bridge. You cross it, then you build 571 00:26:53,800 --> 00:26:56,960 something more permanent. Also remember the ICU care. 572 00:26:57,400 --> 00:26:59,160 You've bypassed the nose and mouth. 573 00:26:59,280 --> 00:27:01,560 What do they do? They are the body's natural 574 00:27:01,560 --> 00:27:03,760 humidifiers and filters. Exactly. 575 00:27:04,200 --> 00:27:08,720 Now you are blasting dry cold gas directly into the trachea. 576 00:27:08,720 --> 00:27:11,400 What happens? Crusting thick, tenacious 577 00:27:11,400 --> 00:27:13,480 secretions. Massive crusting. 578 00:27:13,840 --> 00:27:16,840 The secretions can dry out and form concrete like plugs. 579 00:27:17,160 --> 00:27:19,640 You can obstruct your life saving airway within hours. 580 00:27:19,960 --> 00:27:22,440 So what is mandatory immediately post procedure? 581 00:27:22,520 --> 00:27:25,880 Heated humidification and regular diligent sectioning. 582 00:27:25,880 --> 00:27:27,480 Absolutely. And what about sedation? 583 00:27:27,640 --> 00:27:29,960 You generally want to keep them heavily sedated. 584 00:27:30,040 --> 00:27:32,560 Having a tube through your cricothyroid membrane must be 585 00:27:32,560 --> 00:27:34,640 incredibly irritating. It would trigger the cough 586 00:27:34,640 --> 00:27:37,120 reflex constantly. And you don't want the patient 587 00:27:37,760 --> 00:27:41,000 coughing the tube out or causing more trauma to the site. 588 00:27:41,200 --> 00:27:44,160 Makes sense? OK, Part H This is about 589 00:27:44,160 --> 00:27:46,920 comparison and exam integration, bringing it all together. 590 00:27:46,960 --> 00:27:48,560 Let's do a rapid fire comparison. 591 00:27:48,560 --> 00:27:52,000 Creeco versus Trac site. Creeco is the CTM. 592 00:27:52,000 --> 00:27:54,960 Trac is the 2nd to 4th tracheal rings seed. 593 00:27:55,240 --> 00:27:58,600 Creeco is 1 to 2 minutes, Trac is 15 to 30 minutes. 594 00:27:58,600 --> 00:28:01,760 Well, you can risk. Creeco is low, it's midline and 595 00:28:01,760 --> 00:28:03,680 they're relatively A vascular membrane. 596 00:28:04,040 --> 00:28:06,920 TRAC is higher. The thyroidismus and a plexus of 597 00:28:06,920 --> 00:28:09,320 veins are right in the way. Long term use. 598 00:28:09,360 --> 00:28:12,600 Crico is contraindicated. Long term track is suitable for 599 00:28:12,600 --> 00:28:14,680 maintenance and long term airway access. 600 00:28:14,800 --> 00:28:16,880 Excellent. Now let's talk about Viva traps. 601 00:28:16,880 --> 00:28:18,840 These are the questions designed to trip you up where you 602 00:28:18,840 --> 00:28:20,160 mentioned the age trap. Right. 603 00:28:20,360 --> 00:28:24,120 Would you perform a surgical cricothyrotomy on a three-year 604 00:28:24,120 --> 00:28:26,440 old? The answer is an emphatic no. 605 00:28:26,600 --> 00:28:29,320 Needle Creek atherotomy only. What about the delay trap? 606 00:28:29,400 --> 00:28:31,520 When should you cut? The answer is not after 10 607 00:28:31,520 --> 00:28:35,880 minutes or when the Sats hit 50. The answer is as soon as CICO is 608 00:28:35,880 --> 00:28:38,120 declared. The delay is what leads to 609 00:28:38,120 --> 00:28:40,280 hypoxic brain injury. Precisely. 610 00:28:40,800 --> 00:28:45,480 And the landmark trap What if the patient has a short fat neck 611 00:28:45,640 --> 00:28:48,600 or massive edema and you cannot feel the membrane? 612 00:28:48,600 --> 00:28:51,280 This is. This is the nightmare scenario. 613 00:28:51,720 --> 00:28:54,240 The book answer is you have to use a vertical midline incision 614 00:28:54,240 --> 00:28:56,520 to dissect down. You cut through the fat and 615 00:28:56,520 --> 00:28:59,360 fascia until you can physically feel the cartilage with your 616 00:28:59,360 --> 00:29:01,000 finger. And ultrasound. 617 00:29:01,440 --> 00:29:05,120 Miller does mention ultrasound, but in a true CICO crash, you 618 00:29:05,120 --> 00:29:08,120 probably don't have time to go get the machine, turn it on, 619 00:29:08,120 --> 00:29:10,600 find the probe. You just have to cut to feel. 620 00:29:10,680 --> 00:29:15,040 Cut to feel that is a brave but necessary answer for the exam. 621 00:29:15,680 --> 00:29:18,200 But what about using Ultrapound before the crisis? 622 00:29:18,360 --> 00:29:20,720 Oh, in an anticipated difficult airway. 623 00:29:20,720 --> 00:29:22,400 Exactly. Tell me about that. 624 00:29:22,680 --> 00:29:26,200 So if you have a patient with say a huge goiter or distorted 625 00:29:26,200 --> 00:29:29,680 anatomy from previous surgery or radiation, but you are planning 626 00:29:29,680 --> 00:29:32,960 a standard intubation. You're worried, but hopeful. 627 00:29:33,120 --> 00:29:36,440 Right, you can use ultrasound to identify the CTM and mark it on 628 00:29:36,440 --> 00:29:39,400 the skin with a pen before you even put the patient to sleep. 629 00:29:39,400 --> 00:29:41,240 That's brilliant. So if everything goes South and 630 00:29:41,240 --> 00:29:44,480 you end up in a CICO situation. You have an X that marks the 631 00:29:44,480 --> 00:29:46,880 spot. It shows incredible foresight. 632 00:29:47,360 --> 00:29:50,560 If you mentioned that in an exam answer about management of the 633 00:29:50,560 --> 00:29:53,720 anticipated difficult airway, you will score very, very 634 00:29:53,720 --> 00:29:56,080 highly. It mitigates the landmark trap. 635 00:29:56,400 --> 00:29:57,880 You don't have to find it through the panic. 636 00:29:57,880 --> 00:29:59,200 You found it while you were calm. 637 00:29:59,360 --> 00:30:02,240 Pre procedure ultrasound marking of the CTM. 638 00:30:02,360 --> 00:30:05,280 Adding that to my notes. Finally, for the exam 639 00:30:05,280 --> 00:30:08,240 presentation itself, if you're asked to draw this. 640 00:30:08,440 --> 00:30:11,720 Always start with a definition, then anatomy, boundaries, 641 00:30:11,800 --> 00:30:15,680 contents, relations and you must draw the diagram, a simple 642 00:30:15,680 --> 00:30:18,240 square showing the thyroid cartilage, the cricoid in the 643 00:30:18,240 --> 00:30:21,520 membrane in between, draw the cricothyroid arteries running 644 00:30:21,520 --> 00:30:24,880 across the top half and then label safe zone in the bottom 645 00:30:24,880 --> 00:30:27,360 half. Diagrams actually get marks. 646 00:30:27,440 --> 00:30:29,440 Diagrams save you time and they get you marks. 647 00:30:29,680 --> 00:30:32,400 A bad drawing is often better than a good paragraph because it 648 00:30:32,400 --> 00:30:34,480 shows you understand the spatial relationships. 649 00:30:34,480 --> 00:30:36,840 Then list your indications and contraindications, then the 650 00:30:36,840 --> 00:30:41,440 step, stab, twist, bougie tube, then complications, then your 651 00:30:41,440 --> 00:30:43,680 conclusion. The conclusion we drafted was 652 00:30:44,360 --> 00:30:48,320 cricothyrotomy is a life saving, albeit temporary, procedure that 653 00:30:48,320 --> 00:30:51,760 demands precise anatomical knowledge and decisive action. 654 00:30:52,120 --> 00:30:55,800 Mastery of the CICO algorithm and the Scalpelbuji technique is 655 00:30:55,800 --> 00:30:58,200 mandatory for every anesthesiologist. 656 00:30:58,240 --> 00:30:59,920 That is a consultant level conclusion. 657 00:30:59,920 --> 00:31:01,080 Memorize it. Use it. 658 00:31:01,440 --> 00:31:02,960 OK, so let's summarize for everyone. 659 00:31:02,960 --> 00:31:05,320 Give me the bullet points for the listener who might be 660 00:31:05,320 --> 00:31:09,320 driving to their exam right now. The absolute must knows. 661 00:31:09,320 --> 00:31:13,440 All right, one cricothyronomy is an emergency rescue procedure, 662 00:31:13,440 --> 00:31:17,000 not a permanent airway. The anatomy is the CTM, the soft 663 00:31:17,000 --> 00:31:19,480 spot between the thyroid and cricoid cartilages. 664 00:31:19,680 --> 00:31:22,640 The technique of choice in the UK, and increasingly everywhere, 665 00:31:22,760 --> 00:31:24,680 is the scalpel booty tube technique. 666 00:31:24,680 --> 00:31:28,280 The main long term complication to fear is subglottic stenosis. 667 00:31:28,280 --> 00:31:31,720 You must convert to a formal tracheostomy, usually within 24 668 00:31:31,720 --> 00:31:32,920 to 72 hours. Perfect. 669 00:31:33,040 --> 00:31:37,120 So, expert, before we sign off, what is your single final piece 670 00:31:37,120 --> 00:31:40,040 of advice for the exam day when the examiner stares at you and 671 00:31:40,040 --> 00:31:41,560 asks about airway away emergencies? 672 00:31:41,880 --> 00:31:44,720 In the Viva, when you're asked about an airway emergency, the 673 00:31:44,720 --> 00:31:47,480 most important thing you could do is take a breath, Don't panic 674 00:31:47,480 --> 00:31:49,360 and ramble. Structure your answer. 675 00:31:49,360 --> 00:31:53,120 Say first I will call for help, then I will optimize 676 00:31:53,120 --> 00:31:55,600 oxygenation. If that fails I will declare 677 00:31:55,600 --> 00:32:00,000 CICL and I will cut early. Confidence saves lives and 678 00:32:00,000 --> 00:32:03,320 confidence passes exams. Declare CICO and cut early. 679 00:32:03,320 --> 00:32:06,480 I will remember that and for our listeners, I would say visualize 680 00:32:06,480 --> 00:32:10,360 that anatomy on your own neck right now, find the dip, feel 681 00:32:10,360 --> 00:32:12,600 the ring. That tactile memory might just 682 00:32:12,600 --> 00:32:15,880 save a life or your exam results one day and. 683 00:32:16,040 --> 00:32:18,360 Remember, everything we discussed today is based 684 00:32:18,360 --> 00:32:21,600 strictly on standard medical texts like Miller, Morgan and 685 00:32:21,600 --> 00:32:23,800 Cherasia. Stick to the books and you will 686 00:32:23,800 --> 00:32:25,440 be safe. Thanks for joining us on this 687 00:32:25,440 --> 00:32:27,840 very high stakes deep dive. Good luck with the exams. 688 00:32:27,840 --> 00:32:28,640 We'll see you next time.