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Hyperkalemia in non-crush traumatic cardiac arrest... how can we best mitigate the effects?
Bicarb?
Calcium?
How much? How fast? How often?

What would you consider and push and when?

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Next Generation Combat Medic Journal of Special Operations Medicine U.S. Army John F. Kennedy Special Warfare Center and School U.S. Army Special Operations Command U.S. Army Special Operations Aviation Command Special Forces Medics Ragged Edge Solutions

What is a topic you would like to be discussed further to better understand? Any and all I will go over starting with the most requested.

Second ETI Attempt vs Cricothyrotomy: When Should We Switch Gears?

Airway management is not just about skill, it is about decision timing and trajectory.

One of the most difficult calls in trauma or progressive airway compromise (burns, inhalation injury, worsening stridor) is not HOW to manage the airway, but WHEN continued intubation attempts stop helping and start hurting.

What the Evidence Shows

Endotracheal Intubation (ETI): Success Drops With Each Attempt

Prehospital and emergency department studies consistently show that first-pass success matters and outcomes worsen as attempts accumulate.

* After 1 failed intubation attempt, rescue success remains relatively high (81%)

* After 2 failed attempts, success drops to 71%
* After ≥3 attempts, success falls to 67%

(Sakles et al., 2015)

More importantly, complication rates increase dramatically with repeat attempts:

≤2 attempts cause9% major adverse events

≥3 attempts cause 35% major adverse events

* Multiple attempts are associated with a **4.5-fold increase** in complications, including:

* severe hypoxia
* hypotension
* dysrhythmias
* vomiting/aspiration
* need for emergency surgical airway

(Hasegawa et al., 2012; NEAR Registry)

Each attempt causes more airway trauma, edema, bleeding, and oxygen debt, particularly dangerous in trauma or swelling airways where anatomy is already deteriorating.

Pros of a second ETI attempt

* Familiar and widely practiced
* Definitive airway if successful
* Reasonable when oxygenation improves and anatomy remains stable

Cons

* Statistically decreasing success
* Exponentially increasing complications
* Repeated attempts worsen the airway you’re trying to save

Cricothyrotomy: Rare, but Highly Effective When Timed Correctly

While cricothyrotomy is infrequently performed in civilian EMS, outcomes are strong when it’s done early and deliberately, not as a last-ditch maneuver.

* Surgical cricothyrotomy success rates consistently reported between 82–100%
* Systematic reviews show a **pooled success rate 88%
* Needle cricothyrotomy success is significantly lower (40–60%), making surgical cric preferred

(Langvad et al., 2023)

Military medical systems, which encounter more destructive airway injuries, tend to perform earlier surgical airways, often avoiding the prolonged hypoxia seen with delayed civilian crics.

Pros of early cricothyrotomy

* High success despite upper airway obstruction
* Avoids repeated trauma from failed ETI attempts
* Definitive solution in a closing airway

Cons

* Rare procedure and skill fade without training
* Technically intimidating
* Outcomes worsen if delayed until cardiac arrest

The Real Question: Airway Trajectory

This is NOT an ETI vs cric debate, it is about recognizing WHEN the trend is failing.

Ask yourself:

* Is oxygenation improving or worsening?
* Is stridor static or progressing?
* Is anatomy stable or actively closing?

Worsening stridor + dropping SpO₂ + failed ETI = a shrinking window

Each additional attempt = lower success, higher harm

A second attempt can save a life, but so can recognizing when it’s time to stop trying.

Technique matters.
Timing matters.
Trajectory matters.

I’m interested to hear how others approach this decision across different systems and training environments.

References

Hasegawa, K., Shigemitsu, K., Hagiwara, Y., Chiba, T., Watase, H., Brown, C. A., & Japanese Emergency Airway Network. (2012). Association between repeated intubation attempts and adverse events in emergency departments: An analysis of a multicenter prospective observational study. *Annals of Emergency Medicine, 60*(6), 749–754. [https://doi.org/10.1016/j.annemergmed.2012.04.005](https://doi.org/10.1016/j.annemergmed.2012.04.005)

Langvad, S., Hyldmo, P. K., Nakstad, A. R., & Sandberg, M. (2023). Success rates and complications of prehospital cricothyrotomy: A systematic review. *Prehospital and Disaster Medicine, 38*(3), 305–313. [https://doi.org/10.1017/S1049023X23000261](https://doi.org/10.1017/S1049023X23000261)

Sakles, J. C., Mosier, J. M., Chiu, S., Keim, S. M., & Stolz, U. (2015). A comparison of outcomes between rescue intubations and successful primary intubations in the emergency department. *Academic Emergency Medicine, 22*(6), 674–683. [https://doi.org/10.1111/acem.12665](https://doi.org/10.1111/acem.12665)

Wang, H. E., Kupas, D. F., Hostler, D., Cooney, R., Yealy, D. M., & Lave, J. R. (2005). Procedural experience with out-of-hospital endotracheal intubation. *Critical Care Medicine, 33*(8), 1718–1721. [https://doi.org/10.1097/01.CCM.0000171530.61959.89](https://doi.org/10.1097/01.CCM.0000171530.61959.89)

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