More than 5 minutes until intubation
Every Emergency Department and Pre-Hospital service must be able to provide safe "planned" emergency intubation where there is time to employ all available safety enablers.
LESS than 5 minutes
until intubation
Every intubating critical care team must provide a safe "time critical intubation" where a basic checklist or regular airway team drills enables safety in the face of hypoxia, or impending hypoxia, and the need for a definitive endotracheal tube within 5 minutes
CICO
Every intubating critical care team must be able to deliver a safe scalpel-finger-bougie FONA (>8 years) before hypoxic brain injury occurs.
Hypoxic brain injury occurs within 4 minutes of the hypoxic bradycardic response.
CRIC-ALOT HIGH REPETITION TRAINER
Repetition and practice is an easy way to reduce anxiety about decision making knowing that you can do a simple but critical procedure safely and successfully
The CRIC-ALOT part trainer is a robust injection moulded model that allows high volume repetition of the scalpel-finger-bougie technique.
Designed and created by Professor Richard Levitan from the United States, these trainers are perfect for both training and skills maintenance.
Features
- Both male and female models. The female models are smaller and have an anatomically correct thyroid cartilage.
- Lateral movement of the larynx
- A soft trachea to practice palpating and localising the cricoid ring from below
- Anatomically correct tracheal length to practice tube depth placement and ensure it
- Allows disposible skin and soft tissue to be purchased anywhere.
Whats in the case?
x1 Female model trainer
x 1 Male model trainer
- Some sample neck pads, materials to replace the neck pads (plastic pockets and plaster padding),
- A zip pocket to store your scalpel, bougie and size 6 tube (these latter 3 items are not included).
What are the neck pads?
The pads are plastic pockets with 2 or 3 layers of cotton plaster padding inserted inside the pocket. The first layer of plastic represents skin (we find more realistic skin does not add to fidelity or repetition practice), the subutanous tissue is the plaster padding, and the plastic with paper backing of the doculope is the cricothyroid membrane. Feel free to improvise other options.
How do I put the neck pads on?
Remove paper backing on the right and left edges only to stick to the blue case edges. Dont remove the paper backing in the middle so the larynx is free to slide laterally without being stuck to the pocket.
Where do I get more plastic pockets from?
The pockets are doculope invoice pockets plain white 115 x 150mm and can be purchased from any packaging store - eg 1000 pockets (PDE1000) cost $46 (5 cents a pocket) at surepak.com.au.
Can I fill the pockets with red fluid to simulate blood?
Smaller pockets that arent too sticky can be used vertically and stuck directly on the larynx if you want to fluid fill the pockets to simulate blood.
Where do I get plaster padding from?
If your work place does not supply the right 10cm plaster padding rolls for training with the models, plaster padding can be bought from any medical supply shop. We prefer Defries industries DEF257 10cm x 2.75m multilayered absorbant undercast padding. 48 rolls cost $220 ($4.50 a roll) - email them at sales@defries.com.au
Can I reuse the plaster padding to save the environment?
Absolutely. But if the padding gets too fluffy eg after more than 5 uses, it can start to catch on your ETT cuff and make it harder to insert detracting from the experience.
TIPS FOR USE
Orientation
Always orientate the person to the model before you start. Identify for them/yourself:
-the chin part of the blue case
-the sternum & the suprasternal notch
- the compressible, squishy trachea
- the end of the trachea and that this represents the carina
- the overlap between thyroid and cricoid cartilage.
- the biggest space is between the hyoid and thyroid and can be erroneously used when spatial orientation is lost under pressure.
Identifying the CTM
Before the vertical skin incision, teach both localisation from above and below. Below using the soft/squishy trachea and the first hard bump above being the cricoid ring. Above by identifying the thyroid cartilage.
Teach that the vertical skin incision is essential under pressure and palpation with the index finger of the stabilising non dominant hand is much easier once the skin is incised. Teach that you are less likely to lose the hole in the CTM with a vertical incision if there is head extension/flexion. Teach that for a person with lots of soft tissue the incision is longer/bigger than someone where the landmarks are obvious and a smaller vertical incision can be used.
The finger
The finger is the most important part of the procedure. It ensures the bougie goes into the trachea - both by tactile localisation of the inside of the larynx through the CTM and feeling the bougie slide smoothly next to the finger while in that space. The analogy of the tactile finger and the pleural space in thoracostomy should be made and the danger of subcutanous tube placement highlighted. The feel of the CTM space with the hard smooth back of the cricoid posterior is characteristic. Even better is a finger tip inferiorly into the cricoid ring which gives the feeling of a characteristic hard smooth complete ring to directs bougie placement within.
Depth of tube placement
For the first cricothyroidotomy it is common to push the tube too far in. If the tube is inserted in the model further than the cuff "just disapperaing" through the CTM, take the cover off to show the tube beyond the tracheal end (and in a main bronchus).
Zoe Kennedy
Zoe Kennedy was 13 years old when she had a respiratory arrest from asthma at the front door of the Emergency Department. She died from hypoxic brain injury.
The Zoe Kennedy Foundation is supporting research and education for time critical intubation and AMAX4 concepts in asthma and anaphylaxis.
