NORTH COAST EMERGENCY MEDICAL SERVICES Policy # 5430

POLICIES AND PROCEDURES

Subject: Medical Direction

Needle Cricothyrotomy with Jet Insufflation

Associated Policies: 02/08/98

  1. Indications:
  1. Upper airway obstruction in patients after other airway methods have failed.
  1. Contraindications:
  1. Absolute: None.
  2. Relative:
  1. Conscious patient
  2. Anterior neck hematomas or massive subcutaneous emphysema.
  1. Adverse Effects:
  1. SQ emphysema
  2. Mediastinal emphysema.
  3. Hemorrhage of:
    1. Thyroid.
    2. Major vessels.
  1. Pneumothorax.
  2. Esophageal perforation, if you penetrate the posterior wall of the trachea.
  3. Infection.
  4. Pulmonary barotrauma, (hyperinflation can cause rupture.)
  5. Vocal cord trauma.
  6. Elevated CO2 levels.
  1. Equipment:
  1. Transtracheal over the needle catheter 13 gauge (or 12 - 14 gauge angiocatheter)
  2. Female luer lock adapter
  3. Jet insufflation device.
  4. 3ml syringe
  5. Betadine swabs.
  6. Oxygen source at 40-60 psi.
  1. Procedure:
  1. Determine need for procedure.
  2. Locate landmarks
  3. Palpate for the cricothyroid membrane
  4. Stabilize the larynx using the thumb and middle finger of the other hand.
  5. Prep the skin and gloved fingers.
  6. If in transport, stop the vehicle.
  7. Relocate the landmarks.
  8. Attach 3 ml syringe to needle, control movement of the needle by holding the hub of the needle, not the syringe.
  9. Insert the catheter and syringe combination midline downward and towards the feet at a 45 degree angle to the skin.
  10. Apply negative pressure to the syringe during insertion.
  11. Entrance of air into the syringe indicates that the needle is in the trachea.
  12. Once air enters the syringe, angle the needle toward the feet and advance needle and catheter approximately 1 to 2 cm into the trachea.
  13. Slide the catheter down the needle into the trachea, advancing the catheter to the point where the flanges sit against the neck.
  14. Attach the luer lock adapter to the jet insufflation device.
  15. Set flow rate:
  1. Adult patients: 15 lpm - flush
  2. Pediatric patients: 6-10 lpm
  1. Ventilate the patient by opening the release valve.
  2. Observe for chest rise and turn off the release valve as the chest rises.
  3. Observe the chest for passive exhalation. If the chest does not deflate, a complete proximal airway obstruction may be present. A second catheter may be inserted next to the first to allow for exhalation.
  4. Rate of ventilation is determined by the rise and fall of the chest
  1. Average adult dose: 1: 4 ratio (on for one second, off for 4 = 5 second cycle) One second at 50 psi = 1000 cc volume.
  1. Adjust oxygen flow rates to provide adequate chest rise and to maintain the control of chest rise.
  2. Increase the rate of ventilations only as the rise and passive fall of the chest allows.
  3. Secure the device to the neck.
  4. Confirm placement:
  5. Auscultate lung fields and epigastrium frequently.
  6. Evaluate chest movement constantly throughout transport.
  7. Observe for improvement in patient condition.
  1. Special Instructions:
  1. High pressure ventilation and air entrapment may produce barotrauma very rapidly.
  2. Do not let go of the catheter during the procedure or ventilation(s) until completely secured.
  3. If high flow oxygen source is unavailable or delayed, a 3-mm adapter from a pediatric endotracheal tube can be attached to the catheter and the patient can be ventilated with a BVM.
  4. Alternatively, the barrel of a 3 ml syringe may remain attached and an 8 mm endotrachael tube adapter is inserted into the syringe barrel and patient ventilated with a BVM.
  5. Manually triggered ventilation devices (Demand valves) should not be used.