The MacGuyver Cric – SOF Medical Magic

Next time you are hanging out, happen to have spare airway tubes and IV sets sitting around, and want to impress your medical geek friends with some SOF Medical Magic, throw together a Macguyver Cric.  It’s a great conversation starter if not a great airway…..

The following story highlights a bit of SOF medical gadgetry that may or may not be real.  Lots of folks have heard of this bit of medical coolness, few have actually used it.

The usual disclaimers apply – this is not medical advice.  As configured, the equipment demonstrated in this article isn’t approved by any medical authority, is not FDA approved, and has not been studied in any controlled manner.  Suffice to say, this is off-the-record, no shit hasty and temporary.

This is graphic……and, oh by the way, this never happened.

A long time ago, in a galaxy far far away……I was part of a medical team that treated an adult male after he attempted to kill himself with his personal weapon.  He did the typical hollywood drama shot, with the pistol pointing vertically while he held it under his chin.  He fired one round that shredded his jawbone and lower face.  Sadly, he missed his brain entirely and survived.  (Its tragic that he tried to kill himself in the first place, it just got worse when he missed…)

Without any bony structure, his lower face and blood kept falling back into his throat, choking him.  He was terrified, in severe pain, and desperate to die.  Worse yet, every time we tried to lay him down to put in a breathing tube, he’d choke more and start swinging and kicking us.  We couldn’t get close to the guy’s neck to perform a surgical airway without getting kicked and punched.  Not knowing where the bullet had traveled, we decided that a blind insertion of any kind of tube through his face could possibly penetrate his brain.  Fortunately, the patient could sit up, lean forward, and hold the shreds of his face out of the way to get a short breath on his own. (Its amazing how a person will protect their own airway if allowed).

This guy was in a bad way and we were in a bind.  There are only a couple airway maneuvers you can use when you can’t lay a person flat.  They require a very cooperative patient, an anatomically intact airway, and no risk of riding a bullet tract into the brain.  We had to “cric” the guy but we couldn’t get close to his neck and no one wanted to be punched while holding a scalpel.

The challenge – perform a cricothyroidotomy while the patient is sitting up and swinging his fists at you.

Normally, to perform a cricothyroidotomy you make an incision in the skin of the neck and put a tube into the trachea through a little membrane that stretches between the cricoid cartilage and the big thyroid (voice box) cartilages.  I usually do this on severely sick or injured people with massive facial trauma or airway swelling when standard airway techniques fail.  These folks are almost always lying down and unconscious.  It wasn’t gonna be easy or safe to use a scalpel to make a small incision and insert tiny instruments into the neck of an arm swinging, blood slinging, desperate and dying man.

THIS PART IS OFF THE RECORD. IT NEVER HAPPENED AND WILL BE DENIED BY ALL WHO WERE PRESENT

We wanted to be able to shield the patient from the sharp end of the airway device while we got up nice and close to his neck without getting hit.  We needed something other than a scalpel or long needle to punch a hole in his neck, get air moving into his lungs and give us the time we to sedate him and place a proper airway.

Enter the “Macguyver Cric”…….

This is not an approved airway by any measure but it does provide one alternative for when you don’t want to wrestle a guy while holding a scalpel and you need the control of a short poker with the airflow capacity of a standard airway device.

To make the  “macguyver cric” we used a standard 7.0 endotracheal tube and a macro-drip IV tubing set. (10 gtt/ml).   We assembled our equipment including the bag valve mask and standard surgical cric kit.  We then explained our plan to the patient who agreed to hold as still as possible.  We involved him in the plan and that helped to calm him down.  We had two strong guys hold his hands and keep his legs on the table.  Once things were set I got right up to his neck with my fist and quickly inserted the pointy end of the IV set into his neck.   The effect was dramatic.  His breathing became more controlled and he calmed down.   Once he had a functioning (temporary) airway, we could safely sedate him and control his pain.  Once he was asleep, we changed the Macguyver cric to a standard cric by using a wire-guided technique similar to other tube changing maneuvers.  Once the approved airway was secure we initiated his evac and sat down to write our notes…..together….in a coordinated kinda way…..ya dig?

To make a “Macguyver Cric”  –

• Step 1  Cut the 7.0 Endotracheal tube at a right angle to its long axis at the 20 cm mark.  Keep the short end with the adapter, get rid of the end with the balloon on it.  You don’t need it.
• Step 2.   Cut the IV Extension set drip chamber at a right angle halfway between the puncture set and the IV tubing.  Keep the pointy end, get rid of the IV tubing.
• Step 3.  Jam the cut end of the endotracheal tube into the sleeve created by the cut end of the drip chamber.  The internal diameter of the 7.0 airway tube makes a tight fit over the external diameter of the internal drip cap.
• Step 4.  Place the “needle end” hasty cric into the same place YOU were TRAINED to place a cricothyroidotomy.  (the small soft space under the adam’s apple, above the cricoid cartilage and below the thyroid cartilage)

Caution: When you perform a cricothyroidotomy of any type, you are pushing a sharp object into the neck of another human being.  The risk of puncturing big arteries, big veins, the back wall of the trachea, the esophagus, the soft tissue spaces around the neck and other disasters is quite likely.  Don’t do this unless….

Juliet 2

This article is courtesy of Juliet 2 from The Loadout Room.