Airflow efficacy of ballpoint pen tubes as surgical airways

[SOWMAS]

We've all heard about using a ballpoint pen to perform an "emergency trach." It seems that a few docs actually looked at the procedure and found that all pens are not created equal. My apologies if this has been posted before, I couldn't find it when I did a forum search.

http://www.ncbi.nlm.nih.gov/pubmed/20385693

Emerg Med J. 2010 Apr;27(4):317-20.
Airflow efficacy of ballpoint pen tubes: a consideration for use in bystander cricothyrotomy.
Owens D, Greenwood B, Galley A, Tomkinson A, Woolley S.
SourcePrincess of Wales Hospital, Bridgend, Wales CF31 1RQ, UK.

Abstract
OBJECTIVE: To examine the suitability of commonly available ballpoint pens as a substitute emergency tracheostomy tube.

METHODS: Commonly available ballpoint pens were examined and compared against two standard cricothyroidotomy sets. The pens were evaluated for dimensions, speed of construction of a temporary tracheostomy tube and airway resistance with differing flow rates.

RESULTS: Internal diameters of the pens varied considerably. Time taken to construct a temporary tube ranged from 3 to 170 s, and in the majority of pens the airway resistance increased dramatically as the airflow rate increased.

CONCLUSION: Contrary to popular belief, the majority of ballpoint pens appear unsuitable for use as a substitute tracheostomy tube. In this study only two pens fulfilled the criteria for use: the Baron retractable ballpoint and the BIC soft feel Jumbo.

[Vicarious_Lee]

Hi and welcome to ZS! You probably don't know me yet, but sometime last year I proposed we start a ZS First Aid Journal Club HERE.

It never got off the ground because I got busy and lazy, but I feel like this is EXACTLY the kind of off-the-wall shit I was thinking about reviewing. Do you mind if I try out some ideas on this article for what I was thinking with ZSFAJC, namely, sharing my perspective and experience and everyone else in the fields doing the same?

Also, I don't suppose there's a way to view and review the whole article that's free (and legal) is there?


DISCLAIMER: No one ever do this to anyone or anything ever. Not even to a houseplant.



So that's the procedure there. It's not something I've ever done, though I do have a lot of experience with long-term tracheostomy care, which is really pretty simple stuff.



It's one of those things where if it's obstructed, suction it, clear it. If if falls out, put it back in quickly and make sure it's not in the fascia between the surface and larynx. When changing them, do it quickly. Don't put a one-way speaking valve over it with the cuff inflated. That sort of thing.

As far as emergency cricothyroidotomy, I actually purchased and reviewed (Nutnfancy Bench Review, I didn't cric anyone) it a few years ago, and got some opinions on it from professional airway-ologist.

viewtopic.php?f=43&t=48365&hilit=cricothyroidotomy

I'd love to hear an expansion or anyone else's thoughts/experience with this sort of thing from different perspectives.

OP, you cool with this? It seems like a fun article and fun topic.

[SOWMAS]

I'd love to hear an expansion or anyone else's thoughts/experience with this sort of thing from different perspectives.

OP, you cool with this? It seems like a fun article and fun topic.

Sounds good to me. I don't think there is a way to view the full article without paying for it though.

I'd certainly be interested in your idea to review journal articles. Medicine in resource-poor environments is one of my favorite subjects. Would this post then be moved to a different place in the forum?

[Vicarious_Lee]

I think this is the perfect place for it. I've already PM-ed a couple ZS First Aid folks to see if they'll wade in here and get discussion going. Thanks for sharing this article. I wanted to get ZSJC started but just couldn't find the right subject to discuss.

Emergency Cric with a ballpoint pen is just fantastic.

[SOWMAS]

Do you mind if I chime in during the discussion?

By way of medical background, I've been a WI licensed Paramedic for 10+ years, have critical care and tactical medicine endorsements, NREMT-P, CCEMT-P, FP-C, teach a variety of subjects, and I'm about 90% done with a degree in nursing. Also, 4 years in the USMC infantry. Not medical, I know, but it influenced my way of thinking quit a bit.

[Vicarious_Lee]

Do you mind if I chime in during the discussion?

By way of medical background, I've been a WI licensed Paramedic for 10+ years, have critical care and tactical medicine endorsements, NREMT-P, CCEMT-P, FP-C, teach a variety of subjects, and I'm about 90% done with a degree in nursing. Also, 4 years in the USMC infantry. Not medical, I know, but it influenced my way of thinking quit a bit.

Oh hell no, I absolutely want everyone to chime in, ESPECIALLY the field guys. In fact, in my original ZSJC proposal thread, I said that because I was buried so deep in the post-injury, long-term, institutional-based care of patients that I probably wouldn't be the best to lead-off a journal club to begin with.

I'd like to hear from all the medics, ER folks, first-line people, veterinarians, and laymen who just have questions.

[Makarov]

Interesting stuff. I've got fulltext rights from BMJ, so I actually read the whole article. I'll see what I can do to help you boys out on that.

[duodecima]

Interesting stuff. I've got fulltext rights from BMJ, so I actually read the whole article. I'll see what I can do to help you boys out on that.

If this were a real journal club, copying the article and handing out paper copies ahead of time for folks to read would be considered "fair use" legally. Anybody know if emailing the file to interested participants in the discussion would be fair use? I have full text access or paper access to a lot of stuff, (this article is not cooperating, I'm going to try again whenI'm not on a mobile...).

[SOWMAS]

I think the biggest point to take away from this article is that you can't stick any ole tube into somebody's neck and expect it to work. In the few instances that I've been involved in and where surgical airways were needed, it's always been due to massive facial trauma. I've never had the need to use a surgical airway to bypass an obstruction, but that is the scenario that many people associate with jabbing a pen into somebody's throat. Even if you were successful in placing the pen barrel into the trachea, the diameter of a pen is too small to allow for spontaneous breathing. I'll need to confirm this tomorrow, but I remember reading that an adult needs an airway diameter of around 6.0mm to breathe effectively.

I can't tell you how many times that people have asked about "traching" someone with a pen during class. These are not stupid people mind you, they come from various backgrounds and have various levels of education, but rarely have much medical training. So, they rely on what they have seen on TV or in some movie.

[LowKey]

Just a regular old uneducated layman here, and this might sound silly, but wouldn't a simple test of something you might use as an improvised surgical airway be to simply put it in your mouth and try to breathe deeply through it for a few minutes?
I mean, IDK about you folks but I sure as hell wouldn't be able to get enough air through the tube of a ballpoint pen.

Maybe the tube of a fat marker......

[SOWMAS]

Just a regular old uneducated layman here, and this might sound silly, but wouldn't a simple test of something you might use as an improvised surgical airway be to simply put it in your mouth and try to breathe deeply through it for a few minutes?
I mean, IDK about you folks but I sure as hell wouldn't be able to get enough air through the tube of a ballpoint pen.

Maybe the tube of a fat marker......

You'd certainly get to see how airway diameter affects airflow resistance. This is the reason that many people with asthma describe an asthma attack as being like trying to breathe through a coffee straw.

As for the marker, bigger would be better in terms of airflow, but the size of the cricothyroid membrane (average 10mm x 22mm or so) limits the size of what you can stick through there into the trachea.

[Manliest]

Pretty much any pen (or a Sharpie) is a larger lumen than would be available with a needle cric. I haven't seen a 10ga on an ambulance in....a long time. I think some tactical medic types carry them, and I have a couple (cause I'm a whacker with sticky fingers), but the few needle jobs I've seen in the field have been a standard 14ga.
Not that I'd choose surgical cric with expedient materials over the much more common and protocol authorized procedure, but it's food for thought about the respective airway diameter. I've had nightmares (or wet dreams, take your pick) about having to do a surgical cric without proper equipment. It's not something I'm looking forward to.

And now I'm getting the hell away from discussing school/work-related things on ZS, because this is supposed to be recreation.

Sent from my SCH-I800 using Tapatalk 2

[SOWMAS]

Pretty much any pen (or a Sharpie) is a larger lumen than would be available with a needle cric. Not that I'd choose surgical cric with expedient materials over the much more common (and protocol authorized) procedure, but it's food for thought.

And now I'm getting the hell away from discussing school/work-related things on ZS, because this is supposed to be recreation.

Sent from my SCH-I800 using Tapatalk 2

That's true, but we're talking about spontaneous breathing in this case.

[AZMedic]

Even a 14 is super tiny to breathe through. And also if doing it properly your have to use a BVM for pressure or a special 100% o2 high pressure device. "

A pen would work if ya carried one with a large enough cavity. Most have a tapered attached end.

[Vicarious_Lee]

Just a regular old uneducated layman here, and this might sound silly, but wouldn't a simple test of something you might use as an improvised surgical airway be to simply put it in your mouth and try to breathe deeply through it for a few minutes?
I mean, IDK about you folks but I sure as hell wouldn't be able to get enough air through the tube of a ballpoint pen.

Maybe the tube of a fat marker......

That's what my wife and I did when I bought her THIS THING.

Other thoughts: We both put this in our mouths and breathed through it. The C02 builds up rapidly, and chemoreceptor-driven air hunger sets in pretty quickly. It's a shitty airway, no doubt. You'd need to get an ambu-bag attached fairly quickly, and apply aggressive pressure ventilation immediately to overcome the small lumen. If using this with the bag, you're gonna have to jam down on the bag hard, deep, and fast to overcome the insufficiencies of the lumen. Also, maybe pack the mouth with gauze so you don't lose any pressure.

She carried it in her purse for awhile, and doesn't anymore. The lumen looks 14 gauge, but I'm used to sizing trachs by "Shiley" sizing.

http://160.109.101.132/respcare/conversi.htm

The smallest of which (for chronic patients not in any kind of respiratory distress) is a Shiley "4", which has a 5mm internal diameter.

I'm reading the article that Makarov "handed out" to me via PM to discuss, and the first thing I notice is that the "needle cric" ostomy requires high-pressure jet ventilation to be effective, because the lumens are so damn small.

Failure to establish a patent upper airway is rare in critical care, and, therefore, emergency cricothyroidotomy is performed infrequently.

That's an understatement.

Rapid, definitive airway management is vital in many critically ill and injured patients. If endotracheal intubation cannot be established orally or nasally, cricothyroidotomy is indicated. In the prehospital setting, standard medical equipment may not be immediately available and, therefore, an airway may need to be provided with commonly available objects. Essential requirements include a good knife and a hollow device as a substitute for the tracheostomy tube. Some medical texts recommend the barrel of a ballpoint pen.12–14 However, a study in military medicine,11 based on a case report, suggests that the barrel of a ballpoint pen is not adequate in this setting and advocates the use of sports bottle straws.

Sports bottle straws......

This study suggests that many commercially available ballpoint pens are not suitable for use as temporary tracheostomy tubes because of either the time taken to construct the temporary tube or the marked increase in resistance as airflow increases. Two commercially available ballpoint pens appear to fulfil the criteria: the Baron retractable ballpoint and the BIC soft feel Jumbo.

Conclusion

This study examines the widespread belief that ballpoint pens can be used as substitute tracheostomy tubes in the emergency setting. This belief appears to be only partially founded. Many commercially available ballpoint pens have increased resistance to airflow at the higher flow rates necessary to produce effective ventilation. It is, therefore, essential to ensure that any object used as a temporary tracheostomy tube has the ability to perform well in comparison to commercially available cricothyroidotomy tubes. Studies on other commonly available objects may be appropriate.

So, that's copy and paste of a few parts of the article that I hope doesn't violate anything. One of the parts I didn't post mentioned that the Bic Soft Feel Jumbo took less time to assemble into a trocar, and also was big enough to provide adequate ventilation.

So that seems to be the top choice for a movie-style, unrealistic, an unbelievably rare field cricothyroidotomy for airway ventilation.

Take home messages:

1. Don't ever do this.
2. Don't ever learn to do this.
3. You will never need to do this. Like, you're more likely to need to know how to react in a water-landing airplane crash.
4. Shit's for movies and stuff only.
5. If you had to do this, I guess you should use the Bic Soft Feel Jumbo pen barrel.

[acestor]

As far as I know reproducing medical articles for a medical journal club is legal (any lawyers out there chime in). I have access to virtually all medical articles in pdf format and can send them out if you start a journal club. Do not do emergency medicine myself (worked an emergency room years ago but not in past couple of decades) but have something to contribute. Do not have time to organize and run a journal club but could supply the articles. Could also survey a given topic and review and send the latest and best articles. Let me know as I think it is worthwhile. For instance, what is the best treatment for snake bites, do the snake bite kits work? Do we need to suture or are the tape closures sufficient for minor wounds? Should everyone carry an epipen in their first aid kit? How do you use them? What is the first aid treatment for a heart attack? How do you recognize it? What is the first aid treatment for burns? You could include sanitary topics such as purifying water, food sanitation etc. The goal would be to put together a consensus document from ZS that would be the latest and best recommendations. This is done in medicine all the time - usually by a consensus conference - with a "white paper" giving their recommendations. This would need to be a sticky, available to all. IIf you want to put together a medical journal club, count me in.

[Vicarious_Lee]

As far as I know reproducing medical articles for a medical journal club is legal (any lawyers out there chime in). I have access to virtually all medical articles in pdf format and can send them out if you start a journal club. Do not do emergency medicine myself (worked an emergency room years ago but not in past couple of decades) but have something to contribute. Do not have time to organize and run a journal club but could supply the articles. Could also survey a given topic and review and send the latest and best articles. Let me know as I think it is worthwhile. For instance, what is the best treatment for snake bites, do the snake bite kits work? Do we need to suture or are the tape closures sufficient for minor wounds? Should everyone carry an epipen in their first aid kit? How do you use them? What is the first aid treatment for a heart attack? How do you recognize it? What is the first aid treatment for burns? You could include sanitary topics such as purifying water, food sanitation etc. The goal would be to put together a consensus document from ZS that would be the latest and best recommendations. This is done in medicine all the time - usually by a consensus conference - with a "white paper" giving their recommendations. This would need to be a sticky, available to all. IIf you want to put together a medical journal club, count me in.

Aww shit I like you.

In ZSOT CHAT thread I'm already hitting up Krustofski, a German parasitologist, for the next bi-monthly ZSJC concerning louses.

You keep talking like that and I'm going to hammer you to turn out for like the next 5 consecutive Journal Clubs.

[Makarov]

Never been in any journal club before, but I'm in. I've got access to a lot of articles due to being a nursing student(albeit on my last year, so I dunno how much access I'll have 12 months from now...)

[SOWMAS]

I'd be down for putting together some ZS medical white papers. Sounds like fun.

[IANMCDEVITT]

I'd help how I can guys. I got a new book coming out finally in the late winter so as long as I don't screw that info or release date up, I'm in.

[Vicarious_Lee]

Never been in any journal club before, but I'm in. I've got access to a lot of articles due to being a nursing student(albeit on my last year, so I dunno how much access I'll have 12 months from now...)

Sure, let's say we'll post the next one September 1. We'll do a free-for-all or some brainstorming, and be on the lookout for something practical, preferably weird, and wilderness or limited-resource based that could be applicable to a SHTF or a PAW.

I'll start looking into immobilized patients in a disaster like a hurricane, because where I work has extensive preps and experience in that area, but I won't be able to find anything or put anything together by Sept 1. I'm moving like, next week.

[Sochr000]

If this is open to anyone, count me in. Especially if you're headed toward wilderness medicine, as I'm a Red Cross Wilderness and Remote Area First Aid instructor. I have little hands-on experience, but I'm interested in learning!

[LowKey]

I just had to say this-
Thanks for this new course of discussion in FA.
You folks are fantastic!

[Manliest]

Dupe