[Music] hi everyone this is Lahiru from abc's of anesthesia and right now i'm going to be
demonstrating the front and neck access or surgical airways now this is in the context
of your difficult airway algorithm so for example whatever algorithm you're using
whether it's the difficult airway society or the vortex approach you're going to be
trying all the different methods of supraglottic airway access for example you might be trying to
bag mask and optimize that use an lma or intubate with laryngoscopy and maybe even
try a video learning skill now if all of these things are failing that's when you need to start
preparing for a surgical area and that's what we're going to go through so let's get started
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so once you realize that you need to prepare for the surgical airway there's a really really useful
flowchart or algorithm that a lot of us follow in australia and that's andrew
herd's algorithm his algorithm the suggested first technique is a needle cricothyrotomy
now they've suggested a needle because this was the most familiar technique for most synesthetes
anesthetists are really used to putting needles in probably less familiar doing incisions with
a scalpel the equipment i need is some saline the 14 gauge inside cannula and a five mil syringe and
then i've got to make sure i've got some kind of rapid oxygen or jet ventilation oxygen device and
here we have the leroy rapid o2 device and i've got some oxygen there as well so first thing i
do is i take a five mil syringe and i put two mils of saline so i want two mils of saline because you
want to be able to aspirate air into the chamber to confirm you're in the right spot if i filled
it with five mils i wouldn't be able to aspirate that so two moles of saline is probably the right
amount you want a five mil syringe because it's probably the right size to hold you know what two
mil syringe is too small 10 mil spring is probably a bit too bulky next thing i do is get my 14 gauge
needle take the top off so you really need one of these candles where you can take the top off
and i load that syringe on there the next thing i'm doing i'm looking for that cricothyroid
membrane so here we have the thyroid prominence and i've got the cricoid ring here and in between
is a cricothyroid membrane now i use about a 45 degree angle and then now i've got this grip
on my cannula so as i'm inserting i aspirate now as soon as i get positive aspiration of air i stop
and i really stabilize my device and i pass the cannula down now notice i'm not moving the needle
at all so i've passed the cannula now at this point i never let go of that cannula i then take
the needle off and put that in the sharp spoon and then i using one hand get rid of that air
this next step is absolutely critical i want to confirm that i'm in the right spot so the way i
do that because i want to reattach my syringe and then i want to confirm aspiration of air now what
you notice is that the plunger doesn't recoil if this was in the wrong position or up against
an obstruction you'd get recoil of that plunger now i'll demonstrate what that looks like
so if i was in the wrong position such as a blockage or the wrong side uh aspirin
you can see that there is air in the chamber but if i let go you see the plunger recoils
you know that that's in the wrong position because there's no free aspiration of air
so now once you've confirmed in the correct position i need to jet ventilate
never letting go of the cannula or getting someone else to hand you this equipment i
get someone to connect my rapid oxygen device to the oxygen cylinder and turn the oxygen on
and you can turn it on to 15 liters absolutely fine i then connect this it's a lock connector
and i insufflate for four seconds one two three four and then i let go now four seconds at 15
leads per minute with this device is probably about a liter of oxygen and that's probably all
you need to make sure that you get a rise in the saturations and oxygenation to keep your patients
safe now a little bit about jet ventilation so jet ventilation is a really effective way of
getting oxygen rapidly into the lungs but it also has a lot of dangers if you're in the wrong site
it can cause subcutaneous emphysema and even if you're in the right side say you're in the trachea
too much airflow into the lungs and the trachea can cause barotrauma so just imagine that you've
got an obstructed airway so at the top there's complete obstruction and the only aperture is
an in aperture there through this needle rapidly inflating that much you know that many liters of
oxygen can cause barotrauma pretty easily so what they say is this flavor four seconds one two three
four and that's about a liter of oxygen i wait for over 20 seconds because that's what it takes for
the sats to rise and then i let it fall and what they say is five percent of the maximum achieved
then i can give another two seconds one two now what this does is it makes sure that i am giving
oxygen but i'm not over ventilating and giving the patient the risk of baritone which is a real risk
now this device is actually particularly good device because it's got quite a large orifice
here now this is important because you get a lot of tactile feel if i'm just insufflating i'll feel
not much back pressure but as soon as there's an obstruction you can hear that difference
that's unblocked and that's blocked and you'll feel an incredible amount of back pressure
there so you'll get a lot of tactile feel from this device simply because the tubing is quite
large and this thumb position here is also quite large so once i've got the patient to a level of
safe oxygenation i can then convert this to a melker kit so i remove the rapid oxygen device
so the melker kit is essentially a wire a dilator and the tracheostomy device here as well
so that's what it looks like together and this allows you to pass this over the wire and then
you know railroad it across the with the seldom technique into the trick here it also comes with
a scalpel now the way i convert this again i've never let go of this cannula i pass it through
once it doesn't take too many centimeters to be in the trick here so even four centimeters
in is absolutely fine at which point i then very carefully take the 14 gauge cannula off
at this point i need to widen the incision so i have the scalpel alongside my wire pointing the
blade down i just make a incision and you need to make this big enough to fit this so you know your
five millimeters one centimeter at this point you really just need to be able to get this kit slowly
in i then hold my fingers right to the tip so it's really close and that way i can really easily feed
it on without the tip wobbling now imagine you're trying to do this like this you might
have a bit of a trimmer and it's a lot harder to get through whereas this makes it a lot easier
so past the y you always want to see the wire before you start your motion
now there's a number of different grips you can use but the most important thing is
all of these three devices are held together so the grip i use is one that holds the wire without
bending it too much because you don't you don't really want to cause too much resistance there
and i also hold this dilator to the melter kit and make sure it's flush there i then using a rotating
kind of motion pass it through and make sure it's inserted into the trachea i then take the wire
and the dilator on mass out and once that's in i take my laerdel bag and i start test ventilating
so there we have it that was the needle crack technique converted to a melker tracheostomy set
so thanks so much for watching this series of videos i hope they're really useful to you
please share with anyone who might be interested and we'll see you next time for the next video
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