A Tale of Two Crics


This post isn’t going to teach you the skills of performing a surgical cricothyrotomy. There are already some incredible resources out there. What I aim to do is highlight the differences between two surgical crics that I performed and what it taught me about the mental landscape of performing the cric. 


We’ll start with the two generalized and anonymous cases focusing more on Human Factors than on medicine. For this post, the medicine is taking a back seat. 


The Fist Cric-- The Oliver Twist

I was fresh out of my agency’s Field Training Program, feared but respected, known locally as “The Program”. I had been a medic well under six months and my partner hadn’t been a medic much longer. While I had great expectations for myself, I was still very green behind the ears. 

As an agency, we had just released a new Cardiac Arrest package, which among many deviations from ACLS, moved BVM and intubation to the six-minute mark for any cardiac arrest that was not presumed primary respiratory etiology. 


This all leads up to the scene; Unresponsive Party at the dialysis center, the perfect storm for premature closure and hard times for the new medic. We immediately get to work and before you know it some epi, calcium, and bicarb are in; we’re feeling like heroes. Dutifully, at six-minutes I begin to manage the airway. I hand a BVM to the EMT firefighter and begin to set up for an intubation. I get a good Grade IIb view, with a big ole’ epiglottis in the way of the cords but clearly identifiable arytenoid cartilage. I pass the tube, watch it pass anterior to the arytenoids and all of a sudden stop. Big left twist, nothing. I pull out, grab my trusty bougie and go for a second try. This time the bougie holds up. “Wow, I didn’t know I was this bad at intubation” was the self-talk as I grabbed the iGel and dropped it in buttery smooth like.


The scalpel-finger-bougie cric itself went well although resuscitative efforts were ultimately terminated in the field. 

The exact sound of an iGel NOT WORKING


Case 2: Improvement

 This case is much simpler. Arrive on-scene to a 20s F in a bathtub, covered in blood. Isolated GSW midline at the angle of the neck. No exit wound. She’s breathing and has a weak femoral pulse at 150s, unable to auscultate a blood pressure. Airway is a bloody mess and BVM ventilation results in air blowing out of the new hole in the neck. Suction can’t keep up with the hard palate bleeding but it doesn’t matter because the mandible is broken in two, the airway landmarks are mutilated and she’s now become apneic. A surgical cric is performed with success, although the patient does not survive the resulting TBI. 





Lessons Learned:


These cases serve to illustrate one of the most common pieces of “wisdom” you hear about performing a surgical cric: that the hardest part is making the decision. We set people up for failure by telling them that the cric is a “once in a career” procedure because it prevents providers from being a “loaded mousetrap”.It takes a lot of time to overcome the diagnostic momentum in order to “pull the trigger’on performing a cric IF you tell yourself you will probably never do one. In fact, a paramedic should be in a constant “surgical cric” OODA loop whenever managing an airway, and be ready to perform one as soon as the CICO is recognized. 


This is important though.   As the first case highlights, if you are not constantly asking yourself whether or not the situation you are in is in fact a CICO situation, you will have a delay to recognition. 


The goal in emergency medicine is to be able to run your OODA-loop

faster than your patient can decompensate


In real terms:  Due to the 6-minute delay in beginning airway maneuvers, it was likely 10-12 minutes before the failed airway was recognized, with the obvious implications that it has on survivability. In the second case, time from patient contact to surgical cric was well under 4-minutes--and this included the time to extricate the patient and begin transport to the regional trauma center. And remember, the patient still had spontaneous ventilatory effort for probably three of those minutes. 


I think the question that is worthy of digging into is why the second case felt so much smoother, so much more in control, and why the decision was made more quickly and assuredly. 


The obvious answer is that the case was much more obvious. When we think of the surgical cric case, we think of the traumatic airway. There’s more to it than just that.


As I mentioned earlier, the first case was the perfect storm for the cognitive trap of premature closure. You’d be hard pressed to find a medic who, when finding a patient down on the floor of dialysis with a story along the lines of “She’s a new patient here, we don’t know when her last dialysis was. We were getting stuff ready and came back to her like this” wouldn’t immediately leap to the Hyper-K+ arrest. This isn’t necessarily a bad thing either. This will allow for much more expedient treatment of the ongoing life threat. One of my favorite sayings though, in part because of this call, is “abandon bad ideas early”. I learned that not only is it okay, but it is the sign of the good medic to abandon their bad ideas. The wrong move is to allow the diagnostic and treatment momentum to keep pushing you in the wrong direction. 

The mental tool that I use to overcome this is a simple one. As soon as I feel that I have landed on a diagnosis that I am going to treat, I start treating it (whether that be Hyper-K+ arrest, or asthma, or any other diagnosis). Then, I try to prove myself wrong. I ask myself “what else could this be” over and over as I try to prove my initial diagnosis correct by proving everything else wrong. Obviously this is not to advocate for hasty treatment after a shoddy assessment. In fact, quite the opposite. Do that good assessment, but treat what you see. Then prove your eyes wrong. 


The idea of the “set mousetrap” is one that you should hold for multiple situations. Mike Lauria talks about the “emergency reflex action drill (ERAD)” and “recognition primed decision making”. The mousetrap is both of these ideas wrapped up in one simple model. You “set” the trap with recognition primed decision making: the CICO situation, or inability to visualize cords, or massive extremity hemorrhage. The ERAD is what happens when the mousetrap is sprung: the Cric, or the optimization, or the tourniquet. It is worth forming these for yourself and writing them down, practicing, and codifying them until they don’t require active thought. Defend your mental bandwidth on critical calls--this is one way of doing that.


Reading this blog so you can be the mousetrap, not the mouse


Finally, by having done a cric before and “breaking the seal”, I knew what to expect, had the confidence that my assessment of the CICO situation was appropriate. I also had that mental “mousetrap” (what Scott Weingart refers to as CriCon) set and ready to go. My goal with this is to help teach from my failures so that you don’t NEED a second cric in order to be ready to go. I hope this helps you prime yourself so that you are ready to recognize a CICO, and perform the procedure. You’ll nail it at it. It’s easy if you practice.


 Godspeed out there.




Ultrasound Guided Cardiac Arrest (Case 1)

As Mike sits down with his crew at the firehouse, he mentions how eye opening the utilization of ultrasound in cardiac arrest has been. You see, Mike works as a career firefighter/paramedic, but he also pulls shifts as a part-time flight medic for a program that is one year into their adoption of point of care ultrasound (POCUS). Mike would love nothing more than to see his med unit at the fire department adopt ultrasound as well. However, there are two things people in EMS/Fire hate - change, and the way things are. 
"Mike, I love you man - but you are literally one of the biggest nerds I know. I can just see you now replacing that stethoscope you wear around your neck with an ultrasound probe!
As he smirks and finishes his last few bites, Mike says, "I will tell you three situations just last month where I was able to make a clinical decision based on purely my ability to see what the heart is doing, as opposed to guessing."
Case 1
It was just about two weeks ago when my flight team was paged out to a car vs. tree with CPR in progress. We jumped in the back of the med unit to find a middle aged man receiving compressions by a LUCAS device. The crew mentioned he was in a PEA and they had already given three rounds of epinephrine. They were very much-so in the ACLS vortex.
They mentioned that they were coming up on a rhythm check, so I grabbed my ultrasound unit from my flight suit pocket and placed it just below the xiphoid process with the probe marker (a little marking on the probe) in the three o' clock position. "Ok, I need someone to start counting down from 10 when we stop compressions. When we hit 10, if we don't feel a pulse, we will continue compressions."
As the rhythm check approached, my probe was placed and I was all set to record a clip.
Recording allows you to give a more detailed analysis of the image when it is not at the expense of interupting chest compressions. As the LUCAS is paused, you can't help but notice that you have a perfusing rhythm. 
We know that a perfusing rhythm in the absense of a pulse has always been classfied as PEA, right? Well get this! The subxiphoid view of the heart shows movement! I don't see any tamponade and as far as I am concerned we have ROSC.
The medic up at the head has a hand on the carotid artery and says," I don't feel a pulse. We need to restart compressions." 
His partner speaks up and says: "man, why are we doing compressions on a guy whose heart is beating perfectly fine? Shouldn't we be like looking for other causes of hypotension besides his heart?"
Mike looks up at the guys eating lunch and asks:
"Well duh, he is in PEA," says the probationary firefighter who has been listening intently from the kitchen. Mike see's this has an awesome teaching opporunity and walks over to the whiteboard hanging in the dining area. He erases the fantasy football rankings and writes two words, PRESS & PREM. 
"You see as Forest Gump would say: 'PEA is like a box of chocoloates, you never know what you're gonna get.' There are two types of cardiac activity that may present with a perfusing rhythm on ECG."
PRESS: Perfusing Rhythm w/ Echocardio Stand Still
PREM: Perfusing Rhythm w/ Echocardio Motion
If the rhythm is perfusing and the heart is beating, there is no need to perform external compressions. Your time is better spent searching for reversible causes. However, if the heart is not beating, chest compressions are absolutley indicated in order to build up enough coronary perfusion to obtain ROSC. Mike sketches out his mental model of how he approaches a traumatic arrest.
We removed the LUCAS (get's in the way of the procedures), placed a pelvic binder, performed bilateral finger thoracostomy's and ran whole blood through the humeral head IO.
We ended up getting a pulse back before arriving at the trauma center. What's scary though is thinking this dude could have just as easily got stuck in the ACLS vortex of epi and compressions.
It appears Mike has his work cut out for him before he gets colleague buy-in. Join us next time as Mike discusses a medical case of why ultrasound convinced him to shock asystole. ?
Special shout out to Austin Quillet for the awesome artwork, Chris Kroboth/iSimulate for the monitor screen shots, and Philips Lumify for all their support. 
Further Reading:
Smith, J. E., Rickard, A., & Wise, D. (2015). Traumatic cardiac arrest. Journal of the Royal Society of Medicine108(1), 11–16.
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