Lesson 8 - Surgical Airway: MICU Fellows Airway Course

Desperate times demand...
Everything we have discussed up to this point is geared towards avoiding the need for a surgical airway. We assess the airway carefully, make preparations, have good teamwork, and we master the art of mask ventilation, including using the LMA. We practice good laryngoscopy, practice with the Glidescope, and gain facility with the fiberoptic. And we do ALL of this so we don't have to emergently perform surgical entry to the trachea. And with any luck, you will NEVER have to do this.
But things don't always go the way we want them to go, do they? Surprises happen, patients have unusual reactions, equipment is missing or malfunctions, and all of a sudden -- we have to do it.
Once you decide, then go for it.
-it will be messy
-it will be scary
But keep this in mind, when the choice is death or brain injury, then you just let go of any inhibitions and cut.
Here's the mental construct that will guide you in this, most harrowing of airway emergencies:

-you have done a ton of central lines
-consider a cricothyrotomy a "central line in a big air-containing vein".

Keep in mind, there is never an emergency TRACH, there is only an emergency CRIC. Doing a tracheostomy is too deep, too time-consuming. Go for the shallow, reachable cricothyroid membrane. Stick -→ get air -→pass wire -→ cut along wire -→pass small endotracheal tube over wire into the trachea.

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