Tag Archives: crichothyroidotomy

The Three Strikes And You’re Out Airway Rule

Rapid airway control is key in critically injured trauma patients. But too many times, I’ve seen trauma professionals take far too much time to establish one. Here’s a good rule of thumb to use in these situations.

After pre-oxygenating the patient, your first pro gets a crack at it. They generally have the most time available, often 3-5 minutes before sats begin to drop.

In the unlikely situation that they are not successful, strike 1. Stop trying and resume bagging the patient. At this point, someone (trauma surgeon, lead medic) must get the crich set out. Then the next most experienced intubator gets a shot.

If they are not successful, strike 2. Resume bagging and open the crich set.

The most experienced intubator now gets their chance, using any advanced technology available. No success even now? Strike 3, use the crich set!

Bottom line: We should never allow more than 3 airway attempts, and sometimes clinical conditions will dictate fewer tries. Examples that come to mind are severe brain injury patients (hypoxia is bad) and patients who do not recover from oxygen desaturation when they are bagged. Don’t lose track of time and the number of attempts!

Cricothyroidotomy Using The Scalpel-Bougie Technique

Here’s a video from our colleagues in Australia that shows a slick way of performing a surgical cricothyroidotomy. The number of required instruments is the bare minimum: a scalpel and a bougie. I have not tried this technique, but it looks like it would be very handy when dealing with obese patients with a deep neck. It would also be useful to prehospital providers who are credentialed for crichs and are faced with a difficult airway.

If any of you have used this technique, please leave a comment for us!