Death & Complications:Emergent Cricothyroidotomy

Rajesh RamanathanGeneral Surgery, PGY-2

June 21st, 2012

► HPI: 49yo M transfer with a large incarcerated abdominal hernia upon which he had fallen on earlier in the day.

Had been previously seen for repair but deferred due to high cardiac risk.

► PMH: Non-ischemic cardiomyopathy (EF 25-30%), Severe MR, CAD s/p CABG, HTN, hard to control chronic A-fib

► Taken to the OR urgently by General Surgery and found to have necrotic transverse colon. Brought to STICU post op, intubated.

Hospital Course Highlights

► Per anesthesia, patient visibly aspirated during induction and intubation.

► Developed pneumonitis, did not progress to PNA► Hospital course punctuated by difficult-to-manage Afib with HR

persistently 130-160► Respiratory failure with inability to extubate

POD 8

► Vitals: BP 105-188/63-99 HR 115-136

CPAP 45%, PS 10, PEEP 8► Exam: Alert, RASS 0, communicative

Irregular rate, on amiodarone

NGT in place with a soft abdomen

► Versed previously running at 2mg/hr, stopped at 8am for trial of extubation protocol. Soft extremity restraints x4 on at all times.

POD 8: Airway loss Alerted to self extubation at approx 945am

ETT taped to the face and was in his mouth but no tidal volumes on the vent and upon digital exam, found to be coiled in the mouth.

Anesthesia and attending were immediately called since he was a known difficult intubation

Began bagging, however seal was hard to accomplish with saturations in 75-85%

Within ten mins: anesthesia, STICU attending, glidescope, and cricothyroidotomy kit were at the bedside

POD 8: Response Anesthesia attempted

intubation, but had difficulty visualizing the cords

Sats contined to decrease quickly to the 50s and intubation abandoned, and bagging resumed

Concurrently, neck was prepped with chlorhexidine, sterile field and suction set up and cric tray opened

3cm vertical incision made in the midline and sharply carried down

Large neck and large thyroid gland

Hook placed below the cricoid and horizontal tracheotomy made approx 2nd tracheal ring

7.5mm ETT passed into the airway and balloon inflated.

Secured with sutures

POD 8: Complication

Difficult to bag initially with return of blood in the airway, but sats remained 75-90%, unable to get sats any higher and frequently suctioning ETT required

CXR arrived about 10 mins later and ETT tip noted to be in the right main stem

CXR

POD 8: Complication Upon reexamination, balloon

also noted to be ruptured

Bougie was passed easily through the ETT and we attempted to pass a Bivona over the ETT.

Bivona could not be passed through the tracheotomy

New 7.5mm ETT passed over the bougie and balloon inflated

Sats began dropping again to about 55% by the time new ETT was placed.

Also became progressively more bradycardic.

Atropine given with no response.Asystolic – initiation of ACLS.

After several rounds of drugs and compressions, patient was pronounced dead.

Probable cause of death: Cardiac arrest from hypoxia

Analysis

► How could the complication be avoided? Better sedation/restraints Initial (crico)thyroidotomy was successful, complication was

in the balloon rupture and tube change Balloon: Likely technical error during securing or unsecuring

the tube Tube change:

►Choice of airway►Size of airway

Airway options

Analysis

► Contributing Factors Obesity, difficult airway (Mallampati class 4) Underlying cardiac vulnerability Emergent nature Delay in cxr

► What worked: quick attending and anesthesia response, staff and resource availability for the procedure, STICU team response

Learning points

► For junior housestaff: Read about these emergent procedures Prepare for the worst and have everything available Be a leader and pretend to be calm Escalate airway concerns early

Emergent cricothyroidotomy

Emergent cricothyroidotomy

Does it work?Isaacs JH & Pedersen AD. Emergency cricothyroidotomy. Am Surg. (1997)

- Review of emergent crics at Univ of Florida Jacksonville- Aggregate of literature case reports: 320 patients, 308 successful

airways, 99 survivors. - At Univ of Florida, 65 crics with 62 successful airways and 27

survivors- 33 had vital signs at time of cric (25/27 survivors)- Acute complications: misplacement/failure to get airway

(10) , chest tube (2)- Long-term complication: Failure to decanulate (2), vocal cord

paralysis (1)- Conclusion: Effective. Better if patient isn’t already arrested.