The reason you’ve been carrying that scalpel in your scrub pocket…

As ED physicians, we fear the patient we can’t intubate, can’t ventilate. We’ve had a rash of emergency cricothyrotomies in our ED recently. Though rare, you never know when you might need to perform this life saving procedure. Review the brief overview of the steps of the procedure below so you’ll be ready to step up to the plate:

There 3 methods for the procedure, the most common is the knife – finger – bougie approach (described below)


  • Scalpel 10 blade ideal
  • Bougie
  • Size 6-0 ETT or tracheostomy tube (shiley at Sinai, Portex at EHC)
  • PPE especially eye protection!

The Procedure:

  1. Identify your anatomy – cricothyroid membrane is between the thyroid (superior) and cricoid (inferior) cartilages.
  2. Use non dominant hand to stabilize thyroid cartilage. If time, betadine/chloroprep site
  3. Make vertical midline incision, 3-5 cm with low threshold to extend incision
  4. Palpate cricothyroid membrane
  5. Make horizontal incision in cricothyroid membrane
  6. Insert finger, then pass bougie
  7. Place ET tube or tracheostomy tube over bougie

Watch this incredible video of an actual cricothyrotomy performed by our very own Ram Parekh and Reuben Strayer, published on EmCrit

To learn more, check out theses resources:


Expressing Empathy in the ED

Have you spent the past week wondering how you could express empathy more successfully? Don’t re-invent the wheel, use a tool from palliative care — NURSE statements!

Name the emotion: “Many people would feel angry if that happened to them, I wonder if you have felt that way?”

Understand the emotion: “Although I personally have never gone through what you are going through, I do understand this must be hard for you”

Respect the patient: “I am so impressed with the strength you displayed while getting chemotherapy”

Support the patient: “I will continue to be here for you”

Explore the emotion: “Tell me more about what the chemo means to you”

Good luck!!

What to do with a metabolic kid

Ornithine transcarbamylase deficiency, citrullinemia, methylmalonic acidemia, tyrosinemia, phenylketonuria, Galactosemia… did I lose you yet? These words bring me back to the dark place of step one studying. So take a deep breath, don’t worry about the big words and here are a couple of tips next time you have a “metabolic kid” in the peds ED.

Four Tests to Rember:

  • Lactate — can indicate metabolic crisis
  • Respiratory alkalosis — suggests an exogenous drive for hyperpnea, that can be caused by toxic levels ammonia which directly stimulate the respiratory center
  • UA for ketones — high when in metabolic crisis or absence in the setting of hypoglycemia
  • Ammonia — greater than 200 = yikesville!

Manifestations of metabolic crisis:

  • Neurologic: irritability/lethargy, vomiting, hypotonia, seizures. 
  • Tachypnea from metabolic acidosis and hyperventilation from hyperammonia
  • Vomiting

Comprehensive diagnostic testing options:

  • Venous blood gas
  • Blood sugar
  • Comprehensive metabolic panel
  • Clotting studies
  • Ammonia level (heparinized tube on ice)
  • Urinalysis
  • Plasma amino acids (heparinized tube on dry ice)
  • Urine organic acids, orotic acids, and amino acids (on ice)
  • Plasma-free and acylcarnitines (heparinized tube)
  • Urine-reducing substances (on ice)


  • Provide energy while shutting down catabolism
    • hypoglycemia can cause irreversible neurologic damage
  • Correcting electrolyte and/or acid base imbalances
  • Remove toxic metabolites
    • sodium benzoate, sodium phenylacetate (Ammonul), arginine hydrochloride –> ammonia elimination in the urine
    • if ammonia >500 –> hemodialysis


MacNeill, EC et al. Inborn Errors of Metabolism in the Emergency Department (Undiagnosed and Management of the Known) Emergency Medicine Clinics of North America, 2018-05-01, Volume 36, Issue 2, Pages 369-385.