Airway Skills 5:
Cricoid Pressure and the BURP Technique
Cricoid pressure, commonly called the Sellick maneuver,1 has many uses in emergency airway management. Although simple to perform, the Sellick maneuver requires explanation:
- Locate the cricoid cartilage, larynx, trachea, and the hyoid bone by palpation so that pressure is applied to the right structure. Hold the cricoid cartilage between the thumb and the middle finger. Place the index finger on the cricoid cartilage. Push the cricoid cartilage backward against the spine. Push with about 9 pounds of pressure (40 Newtons). Use common sense. If the patient is at risk for a cervical spine fracture, use less pressure.
- The primary purpose of this pressure is to collapse the esophagus
between the cricoid cartilage and the spine. This prevents
regurgitation of gastric contents.
a
It is not intended to prevent
vomiting. Patients who vomit have active gag reflexes. If you are
applying cricoid pressure and the patient vomits, let go and let the
patient cough out the vomitus. Log roll the patient to ease this
process and to suck out the vomitus with a suction tip.
- During orotracheal intubation, the person who performs cricoid pressure must maintain this pressure from the onset of the procedure until the ET tube has been inserted and tested for correct placement (esophageal intubation detector [EID], CO2 detection, breath sounds, etc.) and the cuff of the ET tube has been inflated.
- One can press too hard. If the intubator is having difficulty getting the endotracheal tube introducer (ETI) or the ET tube into the trachea, you may be obstructing the larynx with too much pressure. Ease up the pressure momentarily and let the tube in.
- If the intubator is having difficulty visualizing the larynx, move the cricoid cartilage from side to side. If the intubator is looking at the esophagus, it will not move.
- If the intubator inserts the laryngoscope blade too deeply, you will feel the larynx being lifted by the blade. If this occurs, inform him or her. As the blade backs out, you will feel the larynx fall back when it reaches its correct position.
- If the intubator uses an ETI, you will feel the tip of it run over the tracheal rings. This feels like a washboard sensation. If you feel this effect, it is positive confirmation of correct placement of the ETI. Inform the intubator.
- Another important use for cricoid pressure is to prevent filling of the esophagus and stomach with air during use of a bag-valve-mask.
BURP stands for Backward, Upward, Rightward Pressure
When the trachea is located in an anterior anatomic position, PEDS as in small children, using this modification of cricoid pressure greatly facilitates the intubator’s viewing of the larynx.7
Apply your fingers to the thyroid or cricoid cartilage as described. Apply backward pressure and push the cartilage toward the chin. Move it to the patient's right. This BURP technique may bring the larynx into view. It may work in adults also, so if the intubator is having difficulty visualizing the larynx, it is worth trying this maneuver.
References
-
Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia. Lancet. 1961;2:404-406.
-
Miller, RD, editor. Miller’s Anesthesia, 6th ed. Philadelphia, Pa: Churchill Livingstone, 2005.
-
Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007;50:653-665.
-
Shirley P. Cricoid pressure for emergency airway management. Emerg Med Australas. 2006;18:99.
-
Morris J, Cook TM. Rapid sequence intubation: a national survey of practice. Anaesthesia. 2001;56:1090-1097.
-
Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia. 2000;55:208-211.
-
Takahata O, Kubota M, Mamiya K, et al. The efficacy of the "BURP" maneuver during a difficult laryngoscopy. Anesth Analg. 1997;84:419-421.