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Seldinger Melker ; Cricothyrotomy Kit: 1. Attempt to clear the airway via conventional methods e.g. laryngoscopy, intubation, manual manoeuvres, epinephrine for anaphylaxis, etc. ; 2. If unsuccessful, place the patient in a supine position supporting the cervical spine if indicated. 3. Locate the cricothyroid membrane. Clean the area with alcohol and or iodine solution. 4. Stabilize the thyroid cartilage and insert the 14G 1 catheter-over-needle at a 45 inferior angle while assessing for free air in the attached syringe. 5. Remove the syringe and needle leaving the catheter in place. 6. Advance the soft flexible end of the wire guide through the catheter and into the airway several centimetres inferiorly. 7. Remove the catheter leaving the wire guide in place. 8. While stabilizing the wire guide, make a vertical stab into the midline of the cricothyroid membrane with a scalpel. 9. Advance the dilator over the wire and into the airway until the flange of the 15mm airway adapter is resting against the patient's neck. 10. Remove the dilator and secure the flange of the airway adapter. 11. Attach a BVM and attempt to ventilate the patient. Transport ventilators must not be used. 12. Ventilate the patient carefully, watching for complete chest excursion. 13. Initiate rapid transport to the closest hospital. 14. Patch to the Base Hospital if complications arise or further orders are required. Notify the Base Hospital at the earliest opportunity after the call.
Acknowledgments--We thank Drs. D Lautier, T. Levade and A. Bettaieb for stimulating discussions, Dr. H. Conjeaud for calcium experi ments, and A. Rousse for technical assistance. Note Added in proof--While this manuscript was being reviewed, another paper also demonstrated the mitochondrial complexe III origin of hydrogen peroxide generated by ceramide 62 ; . In concert, both studies underline the novel role of ceramide as an inducer of oxidative stress or perhaps more precisely of a reactive oxygen species-mediated signaling pathway.
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