Case Report

Use of a Gum elastic bougie during surgical crichothyrotomy

Abstract

We describe the novel use of a gum elastic bougie to facilitate caudad placement of an endotracheal tube during a field surgical crichothyrotomy. The gum elastic bougie was placed into the surgical incision of the crichothyroid membrane and successfully aided passage of the bougie into the correct position. Based on our review, this has not previously been reported in the literature.

Our critical care helicopter service was dispatched to the scene of a high-speed motor vehicle rollover in a rural area. The driver had been ejected from the vehicle and thrown face-first into a boulder and was found by emer- gency medical service to be in Traumatic cardiac arrest with pulseless electrical activity. They were unable to intubate the patient despite several attempts presumably due to the patient’s injuries and significant obesity. On our arrival, intubation attempts by both the critical care team’s flight nurse specialist and flight physician were unsuccessful via the orotracheal route. The decision was made immediately to perform a surgical crichothyrotomy while continuing standard trauma resuscitation. The initial skin incision and subsequent crichothyroid membrane puncture were made easily with a scalpel and a direct tract was easily palpable. On passing a small endotracheal tube, however, the tube would be felt curling aberrantly toward the patient’s mouth. The flight physician was able to introduce a bougie into the surgical incision and use this to pass the endo- tracheal tube in the caudad directly correctly. Review of the literature shows no mention of the use of a gum elastic bougie to aid the placement of an endotracheal tube during surgical crichothyrotomy.

The gum elastic bougie (Eschmann tracheal tube introducer) remains a useful, cheap, and effective device for securing a definitive airway by orotracheal intubation. Descriptions in the anesthesiology literature date back

approximately 20 years [1]. Early mention of the bougie appears in the emergency medicine literature in the mid 1990s [2]. Use of the bougie is also mentioned in emergency and emergency medical service literature for use by Prehospital care providers [3]. The typical use of the bougie is to pass it with the curved end up as close under the epiglottis as possible while maintaining traction with the laryngoscope. Classically, palpation of “clicks” from the tracheal ring indicates success, but we have found that meeting resistance at the level of the carina instead of continuing to pass as in esophageal placement is also a useful indicator. Anecdotally we have used the gum elastic bougie as a Rescue device successfully and suspect this has decreased the need for emergent crichothyrotomy.

However, review of the literature does not indicate a prior mention of using the gum elastic bougie during surgical crichothyrotomy. We wanted to raise awareness for another potential use of this effective life-saving device.

Michael D. Smith MD

Department of Emergency Medicine BG3-73

Cleveland, OH 44109, USA E-mail address: [email protected]

Joseph Katrinchak RN, BSN Cleveland Metro Life Flight Cleveland, OH 44109, USA

doi:10.1016/j.ajem.2007.11.035

References

1. Kidd JF, et al. Successful difficult intubation: use of the gum elastic bougie. Anaesthesia 1988;43(6):437-8.
2. Nocera A. A flexible solution for emergency intubation difficulties. Ann

Emerg Med 1996;27(5):665-7.

1. Jabre P, et al. Use of a gum elastic bougie for prehospital difficult intubation. Am J Emerg Med 2005;23(4):552-5.

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