ETM Podcast Episode 12 – Bruce Paix & Andrew Perry – Approach to the surgical airway

Andrew and Bruce are back, taking a deep-dive into the neck to discuss a procedure that can strike fear into even the most experienced trauma practitioner and one which has created much debate regarding the “best” method (i.e. needle vs knife).  (Go to audio)

Bruce is the co-author of a seminal paper on this topic:

Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel-finger-tube’ method. Paix BR, Griggs WM Emerg Med Australas. 2012 Feb;24(1):23-30  (Full text available here – thanks EMCrit)

To date, between them, Bruce and Bill have performed 26 surgical airways.  In this episode you will hear Bruce describe in detail his first-hand, real-world, extensive experience with this procedure and his rationale for supporting the simple “scalpel-finger-tube” technique over the many other methods that have been described.  Andrew was also recently indoctrinated into the “cric-club” and provides some immensely valuable insights for those of us who are yet to do this procedure “in anger”.

This is a timely episode, with the Royal College of Anaesthetists (ROCA) UK only days ago publishing the findings of a working group of anaesthetists and ear, nose and throat surgeons that recommend the scalpel-bougie-tube technique as the preferred technique for front of neck access (FONA) in a can’t intubate, can’t oxygenate (CICO) situation.  (Bruce discusses the pros and cons of using a bougie in the podcast!)

Surgical intervention during a Can’t Intubate Can’t Oxygenate (CICO) event: Emergency Front-of-neck Airway (FONA)? (Full text free)

A description of the rationale for this paper from ROCA can be read here:

Anaesthetists and surgeons reach agreement on front of neck emergency techniques in life-threatening ‘CICO’ situations

Enjoy the podcast and please leave a comment below (we’re sure this topic will generate some robust debate!)



9 Comments on “ETM Podcast Episode 12 – Bruce Paix & Andrew Perry – Approach to the surgical airway”

  1. Minh Le Cong

    thanks guys for a great podcast!

    one question for Bruce please. at 4min37 s into the podcast he mentions he got rocuronium and sux out of his prehosp kit bag and injected them via IO with no obvious effect. Did he mean he gave both or did he mean he gave only sux or roc ( i.e paralytic only administration)?

  2. Minh Le Cong

    Another question for Bruce and Andrew. It is mentioned in the podcast about children and surgical airways., so thanks to Andrew to raising the issue. Bruce provides some basic comments on this but admits he has no experience and offers no real advice on what to actually do in that 3 yo with epiglottis and a CICO situation. He dismisses needle techniques but doesnt really say what are the options that would be useful in a child needing a surgical airway.

    Does he think he would try scalpel finger tube cricothyroidotomy on a 3 yo? or does he think he would attempt an open tracheostomy? Would he do a stab incision into a childs neck, even if it may go straight through the trachea?

    One other thing that the podcast didnt really address is optimal training for the surgical airway. Can they comment on this please? are plastic models adequate? cadaver labs? live animal labs?

    I really enjoyed Bruce’s simple approach to the issue and non reliance on multiple items of kit.

    thanks again

  3. ETM ETM

    Hi Minh – here’s a reply from Bruce on the Roc-Sux question:

    I routinely give both Sux and Roc simultaneously for my RSIs, particularly ‘one way’ RSIs where the patient is definitely ending up with an ETT, and backing out isn’t an option: Sux still has the fastest onset of any paralytic, but it also has a number of downsides, including rapid offset, active de-oxygenation of the patient, and the potential for hyperkalemia. To address the first and second of these points:

    1) The rapid offset of Sux has long been advertised as a benefit in RSI as it potentially allows you to ‘wake the patient up’ if you cannot intubate them. I doubt this is really true in a real world ‘CICO after sux’ situation because I don’t think effective respiration returns fast enough to get you out of trouble in a blue and bradycardic patient in which you cannot move any air after induction. In fact, I think the converse is true, with the return of muscle tone during your 2nd or 3rd attempts at a difficult intubation actually impeding your efforts, and placing you in a position of deciding whether to give more Sux (+/- Atropine for the bradycardia – incidentally can the world please STOP giving Atropine to treat HYPOXIC bradycardia!! – the poor heart is making a very sensible decision to stop trying so hard when the blood isn’t carrying much oxygen anyway).

    2) I have noticed that sick patients desaturate very quickly when given Sux, often even before you get the laryngoscope in the mouth. I think this happens because the fasciculations consume oxygen and increase chest wall tone, reducing FRC and expelling air from the lungs. This early desaturation is compounded by the ‘cricoid on – don’t ventilate’ mindset we adopt whenever we give Sux, which means we just keep on trying to intubate the patient as they grow ever bluer, and are late to attempt to ventilate as this is an admission that the intubation has failed. In contrast, when we give a non depolarising relaxant like Roc, it is normal practice to ventilate the patient before and during the intubation attempts.

    By giving both Sux and Roc, I believe I combine the benefit of early onset (from Sux) with the avoidance of early offset (from Roc). I also think the Roc reduces early desaturation from Sux because it reduces the strength of fasciculations, and changes the intubator mindset to allow ventilation before/during intubation attempts. Given most ED/ICU/Retrieval intubations are ‘one way’ intubations anyway, there is little advantage to keeping the ‘wake up and do something else’ option open.

    Cheers Bruce Paix

    PS (from Andy) – If you want to discuss the minutiae of drug choice further Minh, please contact Bruce directly as we have to email him the comments and await reply!

  4. ETM ETM

    And to answer Minh’s other Q

    (Regarding crike technique in small children)

    As noted, crikes are very rare in small children, hence there is little real world experience reported in the literature, and the best advice out there is ‘the CTM is small and hard to find – better to use a needle than a knife’. I think if I had to do one on small child, say 5 years or less, I would do what I would do in any crike where the anatomy was hard to feel:

    Grab a knife not a needle

    Make a significant vertical midline incision

    Ignore the bleeding and keep cutting until I found air (the US call this the ‘cut to air’ technique)

    Deal with any bleeding afterwards with direct pressure

    I would caution, however, in getting too concerned about these sort of ‘what ifs’ when the great majority of crikes are adults with easy anatomy and the biggest hurdle to overcome is simply getting on and doing it, not agonising over technique or difficulties.

    (regarding teaching method)
    As noted above, in most cases crikes are not technically difficult to do, but they must be done swiftly and often unexpectedly. Far and away the biggest thing to teach our people is that they just have to pick up a knife and do it when required. I regularly ambush my registrars by walking into their ORs, plonking down a very simple ‘plastic water-pipe’ neck and starting a 60 second timer. I am testing their ability to decide to do a crike, and to find the required equipment to do it (scalpel and tube) rather than their technical ability with the procedure itself. Most fail the test the first time, none fail the second time. I am unconvinced that animal wet labs are really worth the cost and I find them desperately sad and cadavers, like manikins, always suffer from the loss of fidelity that death brings.



  5. Minh Le Cong

    thanks Bruce for the prompt replies to my questions!

    I disagree that the notion that paediatric surgical airways are rare so dont worry too much about them. thats like saying police dont need to worry about using their firearm cause they are unlikely to ever use one in anger in their career!

    what you describe is called a slash tracheostomy as described by ENT folks I have asked.
    I think ENT have a lot to teach us non ENT folks on this issue and in fact my question around training was in relation to whether we should be looking to train in other areas like ENT to gain surgical skills for the neck, rather than practising on pieces of plastic and duct tape and hoping that some Zen mantra repetitive practice will improve critical decision making.

    its clear that given your prehosp XP and numbers of successful surgical airways in the field that you are more confident to make the decision to do it. Can not doing surgical training in ENT to some degree, reproduce the same level of XP and confidence?

    Why must we just keep training the old ways if in fact you say they are not going to prepare you adequately?

    Should all anaesthetists and critical care folks undergoe training in prehospital care and get XP in that area? If thats where you and Bill got the most XP in surgical airway?

  6. Scott


    Fantastic! Though I believe there are still some points of rebuttal to be made and I’d love to come on and raise them.

  7. Jonathan Begley

    Thanks Drs Perry and Paix for the podcast!

    Drs Paix states that none of the [surviving] patients had any long-term complications from their surgical airways. I’m curious, was this with active followup or passive reporting? In other words, did they get seen on or after discharge and specifically asked about vocal changes and reduced exercise tolerance, or investigated for stenosis?

    “The surgical airway with a knife will get you out of problems every time you try it.” If only that were true! Published success rates are about 90%, which isn’t bad but there’s still 10% of patients who are by implication going to die due to procedural failure. I know it was a casual comment and probably not meant to be taken literally but it underplays the importance of recognising that any procedure carries with it a failure rate.

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