#note/rubric | #on/airway | #on/emergencymedicine | #on/emergencymanual **Granular Rubric for Observing a Surgical Cricothyroidotomy** **Scale:** • **1 = Needs Improvement** (Incorrect technique, delays, excessive movement) • **2 = Developing Competency** (Mostly correct but with inefficiencies) • **3 = Mastery** (Efficient, minimal movement, precise execution) **Rubric for Surgical Cricothyroidotomy** | **Category** | **1 - Needs Improvement** | **2 - Developing Competency** | **3 - Mastery** | **Score (1-3)** | | ------------------------------------------------------------ | ------------------------------------------------------------------------- | ------------------------------------------------------------------------------ | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------- | | **1. Recognizing the Indication & Mental Preparation** | Hesitates, delays, or considers other options too long. | Identifies need but lacks confidence or delays in committing. | **Immediately recognizes need, justifies decision with positive self-talk, verbalizes a personal enabling mantra.** Example: _“I’ve trained for this. I will not let this patient die from an obstructed airway.”_ | | | **2. Declaring the Emergency** | Does not verbalize or delays clear communication. | States urgency but does not use standardized language. | **Clearly names the emergency: “Cannot intubate, cannot oxygenate, converting to front of neck access.” Claims roles, "I'm going to get us organized and I need your help." Aims team" I need you to get the equipment on the patient's right on a table, someone continuing to try oxygenating from above, someone to document, meds ... what am I missing? ** | | | **3. Equipment Readiness** | Does not organize or retrieve equipment in a timely manner. | Gathers equipment but placement is suboptimal. | **Ensures betadine, gloves, #10 blade scalpel, bougie, 6.0 ETT (or premade device) are on the dominant side, within easy reach. Rest of the team continues efforts to oxygenate from above.** | | | **4. Hand Placement During Landmark Identification** | Uses incorrect or inconsistent technique, excessive hand movement. | Identifies landmarks but readjusts hands frequently. | **Non-dominant hand stabilizes larynx with thumb and long finger; dominant hand rests on the sternum. Non-dominant index finger locates the cricothyroid membrane, marching down midline structures.** | | | **5. Blade Grip and Incision Execution** | Holds the blade incorrectly or makes an imprecise incision. | Holds blade near the tip but hesitates or repositions. | **Holds a #10 (wide) blade like a pencil near the tip. Makes a decisive 5-8 cm vertical incision with minimal movement.** | | | **6. Minimal Hand Movement During Incision** | Hands shift position frequently, causing inefficiency. | Some unnecessary repositioning but does not significantly delay the procedure. | **Non-dominant hand remains on larynx, dominant hand stabilizes on sternum. Blade control is precise, incision is efficient.** | | | **7. Horizontal Incision Through the Cricothyroid Membrane** | Multiple small cuts, slicing motion, or failure to make adequate opening. | Uses tip of blade but does not make a full-width opening. | **Performs a decisive plunge cut through the CTM, feeling the back wall of the cricoid. Saws in one direction, turns the blade, then saws back to create a full-width opening.** | | | **8. Post-Incision Hand Positioning** | Does not confirm opening with index finger or inefficient hand use. | Uses index finger but hesitates or repositions excessively. | **Immediately inserts non-dominant index finger into the opening to confirm placement.** | | | **9. Bougie or ETT Introduction** | Places device at wrong angle or struggles with insertion. | Inserts correctly but with unnecessary movement. | **Positions the angled tip of the 6.0 ETT or bougie toward the patient’s side closest to the operator, smoothly sneaks it into the opening.** | | | **10. Confirmation Feedback (if using a bougie)** | Skips feedback step or delays confirmation. | Confirms placement but inefficiently. | **Obtains tactile feedback (tracheal rings) and slight resistance at the carina before advancing the ETT.** | | | **11. Endotracheal Tube Placement Depth & Inflation** | Places tube too deep or fails to confirm placement. | Places tube correctly but takes longer to adjust. | **Advances ETT only until the entire balloon is inside the airway, then inflates. Avoids deep placement.** | | | **12. Initial Ventilation** | Does not ventilate immediately or ventilates incorrectly. | Provides ventilation but does not optimize technique. | **Uses BVM with PEEP valve to provide initial breaths, avoids over-ventilation.** | | | **13. Final Placement Confirmation** | Does not confirm placement or takes too long. | Confirms but with some delay. | **Quickly confirms placement with auscultation, CO₂ detection, and visible chest rise.** | | | **14. Securing the Airway** | Unstructured approach, excessive movement securing tube. | Secures tube but takes longer than necessary. | **Efficiently sutures or uses a securement device with minimal movement.** | | | **15. Post-Procedure Care** | Forgets post-procedure considerations (sedation, analgesia, pressors). | Provides sedation and analgesia but not systematically. | **Administers sedation and analgesia. Provides pressors if needed to maintain vitals. If patient decompensates, assesses for pneumothorax.** | | **Total Score: ____ / 45** **Performance Levels** • **40-45 = Mastery**: Minimal movement, optimal efficiency, confident execution. • **30-39 = Competent**: Mostly correct technique but some inefficiencies. • **20-29 = Developing**: Needs refinement in movement efficiency, hand positioning, or procedural flow. • **<20 = Needs Improvement**: Major inefficiencies, hesitation, or errors. **Key Updates & Enhancements:** ✅ **Clear verbalization of the emergency (“Cannot intubate, cannot oxygenate, converting to front of neck access”).** ✅ **Equipment placement standardized (dominant side, within easy reach).** ✅ **Rest of team continues oxygenation efforts above while the provider works.** ✅ **Post-procedure care includes sedation, analgesia, pressors, and ventilation strategy (BVM with PEEP valve, avoiding over-ventilation).** ✅ **Explicit mention to check for pneumothorax if patient decompensates.** This version ensures a **precise, structured, and minimal-movement approach** while incorporating essential team coordination and post-procedure care. Let me know if you’d like any further refinements! 🚀