Transtracheal ventilation – Needle or Knife?

Transtracheal Vent

“I Can’t intubate and can’t ventilate. Now what? Surgical cric? That neck seems rather small… what do I do?”

Background

  • Transtracheal ventilation is imperative for the EM physician to know how to perform.
  • It is faster, easier, less cumbersome and less complications than surgical cricothyrotomy (even
    in adults, but especially in children).
  • Infants and children have smaller cricothyroid membranes and the entire larynx is more rostral
    with a more prominent hyoid bone, all of which make the surgical cricothyrotomy more difficult
    in children than adults.
  • “Many” state that a surgical cric. is contraindicated in patients less than 5 years of age
    (although, size more than age is the limiting factor).

You will need:

  • In-line valve to control gas flow
    • If you are lucky: a commercial device with built in pressure gauge and regulator (like the one we have in the Peds Airway Cart).
    • If you are MacGyver: oxygen tubing with a Y-connector or 3-way stopcock placed in-line as a regulator.
  • 16-18 gauge catheter

Recommended Inspiration:Expiration ratios

  • Standard – 1:4 to 1:5
  • Supraglottic airway obstruction – 1:9 (need more time to let gas escape, otherwise may build up too much pressure in the lungs)

Refereneces:Bould, M.D. and P. Bearfield, Techniques for emergency ventilation through a needle cricothyroidotomy. Anaesthesia, 2008. 63(5): p. 535-9.Mittal, M.K. and J.M. Baren, Percutaneous Transtracheal Ventilation, in Textbook of Pediatric Emergency Procedures, 2nd Edition, C. King and F.M. Henretig, Editors. 2008, Lippincott Williams & Wilkins. p. 237-246.Slutsky, A.S., et al., Tracheal insufflation of O2 (TRIO) at low flow rates sustains life for several hours. Anesthesiology, 1985. 63(3): p. 278-86.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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3 Responses

  1. Azfar Azfar says:

    nice to know

  1. May 20, 2016

    […] to contemplate how to manage this scenario before it arises.  We have previously discussed Transtracheal Ventilation and have several videos to view, but let us review this important topic briefly once more. […]

  2. April 21, 2017

    […] to contemplate how to manage this scenario before it arises.  We have previously discussed Transtracheal Ventilation and have several videos to view, but let us review this important topic briefly once more. Can’t […]

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