“Think about it, prepare for it, feel confident doing it.”

The Surgical Airway Module – By Jonathan St. George MD

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Are you ready to perform an emergent cricothyrotomy? Start by taking the self-assessment test below to find out where you need to focus your learning, and then dig in to all the great content here.

Introduction: the emergent cricothyroidotomy presents many educational challenges. It’s a high stakes, low-frequency procedure performed in the stressful failed airway situation, where time is not on your side. If you don’t think about it, prepare for it, or feel confident doing it, you will fail to perform this lifesaving maneuver in a timely manner. The goal of this module is to get you on the path to learning not just the procedure but all the tangible and intangible skills required to master the failed airway situation.

Stress & the Psychology of the Failed Airway

Arguably the most important step in performing an emergent cricothyrotomy is recognizing the failed airway early and making the decision to cut. Without this skill, it doesn’t matter what the level of your technical procedure skills are.

I want to emphasize here that the entire goal of this teaching module and any hands on training you have performing a cricothyrotomy should be designed around one goal: to give you the ability to act effectively when the situation requires it. This means you need to be confidant not only in your procedure skills but comfortable with the logistics of your unique practice environment, and in your ability overcome the mental and stress related obstacles a failed airway presents. So we will start here before moving on to the anatomy and procedure skills.

First consider that most of our training in airway management is focused on how to avoid the failed airway scenario not manage it; this results in an ingrained bias against recognizing it. The nomenclature says it all: we see the “failed” airway as just that, a failure (and something to avoid at all costs), rather than simply another airway mangement problem with a simple solution. This mental bias often leads to costly delays in performing a surgical airway.

To overcome this bias we might consider turning the whole paradigm on its head: when you review the specialized equipment designed just to overcome the small oral opening, the big floppy tongue, the awkward angles, and all the other obstacles involved in performing an orotracheal intubation, the cricothyrotomy is in truth the easy way to do things.  We should get rid of the “failed” airway nomenclature all together and call it the simplified airway. Because really if you can’t intubate and you can’t oxygenate with a BVM or an LMA then your choices are very simple. Think how much calmer the resuscitation room would be if the airway operator just said, “okay, were moving to the simplified airway algorithm now”.

Three stress-related killers:

In order to act effectively in the failed airway situation, you have to understand the adverse effects of stress. Here are three stress related killers all clinicians need to learn to identify and be able to address:

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• Impaired Recall. You may have been able to recite the latest airway textbook chapter and verse on the subway to work, but add the chaotic environment of a crash airway into the mix and suddenly your memory recall isn’t so great.
• Normalcy bias. When facing a disaster many people arrive at a mental state called normalcy bias, causing them to underestimate the impending consequences of inaction.
• Focus Lock. As the stress mounts the desire to try and succeed with one more attempt at endotracheal intubation becomes a thought that overrides all others. Meanwhile your patient’s oxygen level drops to levels not compatible with life. This is focus lock.

Cricothyrotomy – A Zen Exercise?

One way to overcome recall bias during a low frequency high stakes procedure such as the emergent cricothyrotomy is to pare it down to just the essentials. The emergent cricothyrotomy can be viewed as something of a Zen exercise.

A Zen approach is not a dumbed down approach. It’s about deep knowledge where the end goal is swift effective action.  In this exercise you’re asked to dive in and then deconstruct what you learn down to an uncluttered simplicity so that the right actions occur swiftly and successfully in the moment they are required.

To some it may seem counterintuitive to absorb knowledge and then actively forget it. Why not just skip to the essentials? Well, that’s just not how it works. It’s in the process of editing that mastery appears. To help get you there we’ve organized this module into “essentials” and “deep cuts”. Understand the deep cuts, absorb them, but then begin your editing process so you know the essentials in your sleep. Combine this with SIM and cadaver training and you’ll be ready.

More Strategies for Success

Normalcy bias and focus lock are not just something the airway operator has to be concerned with, it’s the responsibility of the entire team caring for the patient. In fact, if you’re in the room of a patient with a failed airway the best role you can perform is helping your colleague trapped in a moment of stress to make a clear decision. A simple phrase such as “I notice that we aren’t able to oxygenate or intubate this patient, should we prepare for a cric?” might be the just the thing break the focus lock and allow the team to move on to a definitive airway. This is also why SIM training in your unique practice setting is critical for effective teamwork.

Logistics & Your Environment

Understanding your team goes hand in hand with understanding the logistics of your environment. In Situ or mobile SIM training occurs with your team in your resuscitation room, and is a key part of training to perform FONA. If you don’t know how to find or get what you need under pressure, your much more likely to continue down the path you feel most comfortable with. If this is another attempt at orotracheal intubation in the failed airway it will only delay care and potentially harm your patient. In situ SIM can be low tech. Jon Gatward shares his experience and shows how easy it can be at his site mobilesim.

Anatomy (Deep Cuts) The moment you need to do an emergent cricothyroidotomy is not the time to be fuzzy on the essential anatomy needed to perform the procedure. This video by Andy Neill MD is a great place to start.

Anatomy (Essentials) How much anatomy knowledge you you need? The answer is not much, and that’s for the best. In this critical situation information overload is not the answer, having the right information when you need it is the answer. In this case the essential anatomy are the landmarks that allow you identify where to cut quickly, easily, and safely. The easiest way to find them are the Laryngeal handshake and direct palpation of the cricothyroid membrane with your finger after the initial vertical incision. The laryngeal handshake is a technique taught by airway expert Dr Rich Levitan. Watch this excellent video and then soak in these five slides.

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Procedure (Deep Cuts) A fews years ago I helped with this video for the NEJM. It’s a comprehensive video covering the traditional cricothyrotomy from start to finish. While it covers all aspects of the procedure, in retrospect I think it fails to address much of the real world considerations or the clinical context of performing the procedure. After absorbing the knowledge here, compare it to the paired down elegance of the “scalpel, finger, bougie” technique below.

Procedure (Essentials)

A real case In this amazing video of a surgical airway performed in Afghanistan you get the sense of what’s involved. You may never have to perform this procedure in a combat situation, but your body may not know the difference. All of the logistics, teamwork, and stress related obstacles we face in the ED are here. The first time I watched this video my palms were sweaty.

The Debrief: So why was this surgical airway successful?

• The team made a quick decision, and didn’t waste time trying other techniques likely to fail.
• Team approach: supported by team members that this was the right decision (do it dude!).
• Nothing fancy, the procedure was paired down to the essentials and performed in seconds.
• Logistics: team members knew how to find everything and negotiate their environment.

Summary in FIVE  Are you ready to cut to air? Here is my summary of the most important take-home points from this teaching module. Listen to it, learn it, be prepared.

The Next steps. Online learning can only get you so far. You need to do it!  Practicing the mechanics of the procedure first on models and cadavers, then moving on to preparing for real world logistics and the pressures of a failed airway scenario in your unique environment with SIM so that you and your team are ready for what stress will do to your mind and body.

• Bottom Line
• Use the KISS principle (that’s right keep it simple stupid)
• Recognize the stress-related killers: Impaired recall, Normalcy Bias, Focus Lock
• Practice procedure skills at regular intervals on airway models or cadavers
• Know your team and the logistics of your unique environment with SIM
• Be an effective team leader & team player

Deeper Cuts (Extended Remix) many great educators from around the world have helped to make this module possible. Thanks to them and all the great work being done in the FOAM world. Check out some of the bundles created by other online educators

• Cricothyrotomy – Cut to Air: Surgical Airway from EMCrit’s Scott Weingart.
• The Sharp End – Surgical Airway from Andrew Brainard and Chip Gresham
• Psychology of the Difficult Airway – Rich Levitan

Bonus Content Nothing is more important in the FOAM world than a sustainable environment. That’s why we wholeheartedly endorse the Edible Cric Model