A 26-year-old male was brought to the ER by EMS after a motorcycle crash where he was not wearing protective gear. He had a swollen face with crepitus and was bleeding from his nose and mouth. After failing to intubate, a cricothyrotomy was performed to secure the airway. Exams found an open femur fracture but otherwise intact. Head, neck, and facial CTs as well as consults to multiple specialties were ordered to further evaluate facial fractures and eye displacement.

1. Trauma Case 4
Jan 2016

2. Scenario
A 26 year old male brought in by EMS with C-collar and non-
rebreather face mask.
EMS states two motor cycles crashed and he was not wearing
a helmet or other protective gear.
BP 100/70 HR 130 RR 30 O2 sat 90%

3. ABC’s
A with C-spine – patient obtunded, gurgling with blood coming from nose
and mouth
Visual: swollen face, palpation –crepitus, when grab front teeth, upper face
moves
Rx – suction, jaw thrust, oral airway only if tolerates, gently placed
Patient improves a bit but soon, gurgling with back of throat filled with
blood
Call for back-up!
Must secure airway - ? Awake intubation – gags fighting
blood obscures vision – since difficult airway, consider Ketamine
1mg/kg with increments of .5mg/kg up to 2mg/kg total

4. Airway
Difficult – no RSI
Ketamine calms and BP and respiratory reflexes still intact
may cause increased oral secretions with higher doses
Back up equipment available, i.e. Bougie? Crico kit??
although LMA may actually help to tamponade upper source
of bleeding, since don’t know where bleeding is located,
would require a better more definitive airway plan.

5. Unable to visualize and intubate
O2 sat dropping now 80% with decreased visualization.
Only option: cricothryroidotomy
may use hook or bougie for placement but if don’t have hook, increased
chance of creating a false path
What size tube??
a pediatric 5.0 can be used to oxygenate and ventilate an average adult,
can change after airway secured (outer diameter should be smaller than
9mm because height of membrane is only 9mm…smaller in women
- average 7.5 tube has an outer diameter of >10 10mm, using this size
would increase likelihood of fracturing cartilage and leave pat with
permanent dysphonia.

6. Location, Location, Location!
1. For thin males –
locate Adam’s Apple - the
(prominent V-notch
at the top of the
thryroid cartilage).
2. Slide finger
inferiorly until find
second bump – the
cricoid cartilage.
3. Membrane just
cephalad to cricoid.

7. Membrane Location in
Females/Children
Adam’s Apple is not a
good locating landmark
in female/children since
much less prominent.

8. How do you perform crico
Location, location, location
slide finger up form sternal notch
if thryroid not enlarged, the first firm jugging structure is the
cricoid. Make a horizontal cut about a cm wide if you know
where you are.
If not start with vertical cut and locate membrane first
Open only front of c-collar and have someone stabilze neck

9. Cricoid Membrane Location
Note cricoid
cartilage projects
past tracheal
rings.

10. Membrane Location in
Females/Children
- Slide finger cephalad from the sternal notch.
- Cricoid cartilage juts past tracheal rings.
- Easy to find first bump jutting past rings if
no thyroid disease.
- Note: may be the only “bump” found in the neck
of woman/children.

11. Prepare a Crico Kit
Scalpel
Tracheal Hook
Trousseau Dilator (or Kelly clamp)
Cuffed Tracheostomy tube
(Bougie may substitute for dilator)

12. Tracheostomy Tube Size
Recommended Adult Crico tube size:
- ID (inner diameter) 5.0 mm or 6.0 mm
- OD (outer diameter) should be less than 9 mm
WHY?
Height of the cricothyroid membrane at widest
vertical point: 9 mm in adult (average)

13. Why Small Cricothyrotomy Tube Size?
Note: This endotrachal tube that has an internal diameter
of 7.5 mm and an outer diameter of 10.3 mm.
Placing a larger tube in the crico opening:
1. increases likelihood of thyroid cartilage fracture
2. increases the likelihood of creating a false passage.

14. Tracheostomy Tube Size
A 5mm ID tube is generally used for a
small child, but can adequately ventilate an
adult if needed.
Most important – place a tube to oxygenate.
Change tube size later.
Walls RM and Murphy MF: Manual of Emergency Airway Management,
4th Edition, Philadelphia, Lippincott, Williams and Wilkins, 2012.

15. Quick Technique
1. Vertical incision thru skin
only if can’t locate membrane.
2. Horizontal (1cm) incision
thru cricoid, dilate vertically.
3. Lift the cricoid cartilage – not the thyroid
cartilage – with the tracheal hook, as if using a
laryngoscope. (Reduces chance of false passage).
4. Insert tube with twisting motion.

16. Breathing
Lungs – clear
O2 sat 94% after airway stabilized
Sono – neg
Portable CXR -neg

17. Circulation
BP 100/70 HR 120 , active bleeding form open femur fx
Pelvis intact and no other external bleeding
Sono – good cardiac, IVC OK, FAST negative
Rx – IV X 2 liters, Tand C
- direct pressure over femur bleeding site – but do not
insert, needs OR for cleansing (order IV Cephalorsporin as
preventiion)
place on monitor and check rhythm strip – sinus tachycardia

18. Disability
- Does not open eyes to calling name or pain (swollen)
- Random moans
- Withdrawal to painful stimuli in all extremities
GCS: +1, +2, +4 = 7
Unabke to assess pupils since lids beginning to swell
tightly, options??

19. Bemt paper clips to open eyes – used outer lids but can also
be used to lift the lids from underneath!
Cheng LHH et al. Retraction of Oedematous Eyelids with Paper-Clips,
Ann R Coll Surg Engl. 2008 Apr; 90(3): 253.

20. Expose and
Primary Survey Adjuncts
Log roll and undress – no other lesions
Adjunts – Foley – after assessing for groin/pelvic trauma –
non bloody urine . Empty bag and start recording urine
output – needs 0.5 to 1 ml/kg/hour to be adequately
volume resuscitated
NGT – do not place thru nose – mouth with observation going
in correct direction
If CXR not yet done after intubation, call for CXR and pelvis

21. AMPLE
Allergies: Pen and Cephalosporin –anaphylaxisis
Meds: none
PMH: hospitalized for analphylaxsis
Last meal: unknown
Events: bystanders told EMS racing with friends and
hit bike that stopped short and was trhown further
His phone had number for “mom” and hx obtained
from mother.

22. Calling Consults or Transfers
If surgery has not already been called, must be called
now!
Neurosurgery, OMFS and ophthomology and
orthopedics should all be alerted.

23. Secondary Survey
HEENT: PERLL, unable to assess EOM but light reflex in
different portion of cornea suggesting dysconjugate gaze or
displacement of eyeball , +facial SQ emphysema palpable,
crepitus felt around the facial bones, marked swelling,
oozing blood from nose, bridge of nose unstable, TM’s
blood behind Rt side
Neck: WNL
Lungs: WNL RR per ventilator, O2 sat 94% on 40% FiO2
CVS: after 2 liters, BP 120/80 HR 110
Abd: +BS, unable to assess pain
Ext: open Rt femur Fx
Neuro: sedated on vent, no change

24. What ancillary tests?
CT head, neck, abd
CT facial views – different from head CT and better than
facial Xrays
If facial Xrays: use Waters view and Jug handle views

25. Waters view –
Normal and Tripod Fx

26. Le Forte Fx

27. Jughandle View –
Normal and Fx Zygomatic Arch

28. Critical or Important Actions
1. Assesses and manages airway compromise appropriately
and in a timely manner.
2. Searches for source of bleeding and controls external
bleeding
3. Obtains Hx of allergies/anaphylaxis and gives different
med for open fx prophylaxis
4. Dx Le Forte Fx and obtains facial CT in addition to head
CT and contacts appropriate consultation
6. Dx possible basilar skull fx from hemotypamum
7. Examines eye and recognizes displacement by light reflex
abnormalities and contacts ophthalmology