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Morand S, Gleizal A. Cricothyroidotomy in extreme emergency: A case report of a real-life experience in three steps and less than 30 s using a single blade. Int J Surg Case Rep 2024; 117:109526. [PMID: 38503163 PMCID: PMC10963650 DOI: 10.1016/j.ijscr.2024.109526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 03/21/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Cricothyroidotomy is often the last resort when conventional ventilation devices prove ineffective. The conventional procedure that involves several steps and requires the completion of a preoperative checklist. This report describes a novel approach to cricothyroidotomy, allowing quick access to the cricothyroid membrane in fewer steps. CASE PRESENTATION We present the case of a 26-year-old male with Schimmelpenning syndrome, exhibiting significant anatomical deformity. Following surgery for temporomandibular joint replacement, the patient developed a hematoma requiring urgent intervention. During nasotracheal intubation, the patient experienced a significant drop in oxygen saturation, which required prompt cricothyroidotomy. The procedure was performed in less than 30 s using a single blade for incising the tissues and the surgeon's hands for dissection and retraction. The procedure resulted in immediate recovery of the patient's oxygen saturation. CLINICAL DISCUSSION In contrast to previously reported multi-step procedures, this study reports a simpler three-step cricothyroidotomy. The technique involves a vertical skin incision, blunt dissection using the surgeon's fingers, and a horizontal incision on the cricothyroid membrane. The procedure was executed with the patient in a semi-reclined position, optimizing time efficiency. CONCLUSION This case highlights the efficacy of a rapid cricothyroidotomy technique in extreme emergencies. The presented technique requires minimal instrumentation and can be completed quickly in an emergency situation, even in the presence of anatomical variations.
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Affiliation(s)
- S Morand
- Maxillofacial Surgery Department, Lyon Croix Rousse Hospital, 103 Grande rue de la Croix Rousse, 69004 Lyon, France.
| | - A Gleizal
- Maxillofacial Surgery Department, Lyon Croix Rousse Hospital, 103 Grande rue de la Croix Rousse, 69004 Lyon, France
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Suzuki K, Yambe N, Hojo K, Komatsu Y, Serikawa M, Usami A. Anatomical morphometry for Cricothyrotomy puncture and incision. BMC Surg 2023; 23:198. [PMID: 37438728 DOI: 10.1186/s12893-023-02100-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/07/2023] [Indexed: 07/14/2023] Open
Abstract
PURPOSE Emergency surgical airway securing techniques include cricothyrotomy, puncture, and incision. While the instruments used for these methods vary in size, no index of laryngeal morphology exists to guide instrument selection. Therefore, we measured the morphology of the cricothyroid ligament in Japanese individuals and assessed its correlations with height. METHODS This retrospective study used 61 anatomical practice specimens. The cricothyroid ligament of the laryngeal area was dissected, and a frontal image was recorded. Next, images of the midsagittal sections of the larynx and trachea were recorded. The width and height of the cricothyroid ligament were measured from the frontal images, and the depth of the larynx and the angle to the lower edge of the cricothyroid plate were measured from the mid-sagittal cross-sectional images. The height was estimated from the tibial lengths of the specimens and statistically analyzed for correlations. RESULTS: The width and depth were significantly greater in males. Overall, there was a slight correlation between the results of each laryngeal measurement and estimated height for all items. CONCLUSION The morphology of cricothyrotomy revealed that the width and depth of the laryngeal area varied according to sex. Moreover, the results also showed a correlation with the estimated height. Thus, it is important to predict the morphology of the laryngeal area and cricothyroid ligament by considering factors such as patient sex, weight, and height.
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Affiliation(s)
- Kaiji Suzuki
- Department of Oral Functional Anatomy, Graduate School of Dentistry, Ohu University, Koriyama, Japan
| | - Naohito Yambe
- Community Medicine Support Dentistry, Ohu University Hospital, Koriyama, Japan
| | - Kentaro Hojo
- Department of Oral Anesthesia, School of Dentistry, Ohu University, Koriyama, Japan
| | - Yasunori Komatsu
- Department of Oral Anesthesia, School of Dentistry, Ohu University, Koriyama, Japan
| | - Masamitsu Serikawa
- Department of Morphological Biology, School of Dentistry, Ohu University, Koriyama, Japan
| | - Akinobu Usami
- Department of Morphological Biology, School of Dentistry, Ohu University, Koriyama, Japan.
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Zagona-Prizio C, Pascoe MA, Corbisiero MF, Simon VC, Mann SE, Mayer KA, Maloney JP. Cadaveric emergency cricothyrotomy training for non-surgeons using a bronchoscopy-enhanced curriculum. PLoS One 2023; 18:e0282403. [PMID: 36952528 PMCID: PMC10035915 DOI: 10.1371/journal.pone.0282403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 02/07/2023] [Indexed: 03/25/2023] Open
Abstract
Background Emergency cricothyrotomy training for non-surgeons is important as rare “cannot intubate or oxygenate events” may occur multiple times in a provider’s career when surgical expertise is not immediately available. However, such training is highly variable and often infrequent, therefore, enhancing these experiences is important. Research question Is bronchoscopy-enhanced cricothyrotomy training in cadavers feasible, and what are the potential benefits provided by this innovation for trainees? Methods This study was performed during implementation of a new program to train non-surgeon providers on cadaveric donors on our campus. Standard training with an instructional video and live coaching was enhanced by bronchoscopic visualization of the trachea allowing participants to review their technique after performing scalpel and Seldinger-technique procedures, and to review their colleagues’ technique on live video. Feasibility was measured through assessing helpfulness for trainees, cost, setup time, quality of images, and operator needs. Footage from the bronchoscopy recordings was analyzed to assess puncture-to-tube time, safety errors, and evidence for a training effect within groups. Participants submitted pre- and post-session surveys assessing their levels of experience and gauging their confidence and anxiety with cricothyrotomies. Results The training program met feasibility criteria for low costs (<200 USD/donor), setup time (<30 minutes/donor), and operator needs (1/donor). Furthermore, all participants rated the cadaveric session as helpful. Participants demonstrated efficient technique, with a median puncture-to-tube time of 48.5 seconds. Bronchoscopy recordings from 24 analyzed videos revealed eight instances of sharp instruments puncturing the posterior tracheal wall (33% rate), and two instances of improper tube placement (8% rate). Sharp instruments reached potentially dangerous insertion depths beyond the midpoint of the anterior-posterior diameter of the trachea in 58.3% of videos. Bronchoscopic enhancement was rated as quite or extremely helpful for visualizing the trachea (83.3%) and to assess depth of instrumentation (91.7%). There was a significant average increase in confidence (64.4%, P<0.001) and average decrease in performance anxiety (-11.6%, P = 0.0328) after the session. A training effect was seem wherein the last trainee in each group had no posterior tracheal wall injuries. Interpretation Supplementing cadaveric emergent cricothyrotomy training programs with tracheal bronchoscopy is feasible, helpful to trainees, and meets prior documented times for efficient technique. Furthermore, it was successful in detecting technical errors that would have been missed in a standard training program. Bronchoscopic enhancement is a valuable addition to cricothyrotomy cadaveric training programs and may help avoid real-life complications.
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Affiliation(s)
- Caterina Zagona-Prizio
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Michael A. Pascoe
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | | | - Violette C. Simon
- School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Scott E. Mann
- Department of Otolaryngology Head and Neck Surgery, University of Colorado, Aurora, CO, United States of America
- Department of Surgery, Denver Health Medical Center, Denver, CO, United States of America
| | - Katherine A. Mayer
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - James P. Maloney
- Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
- * E-mail:
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Hock SM, Martin JJ, Stanfield SC, Alcorn TR, Binstadt ES. Novel cricothyrotomy assessment tool for attending physicians: A multicenter study of an error avoidance checklist. AEM EDUCATION AND TRAINING 2021; 5:e10687. [PMID: 34589660 PMCID: PMC8457693 DOI: 10.1002/aet2.10687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/24/2021] [Accepted: 08/03/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND This study used existing literature and expert feedback to develop and pilot a novel error-avoidance checklist tool for cricothyrotomy in attending physicians. Prior literature has not focused on expert cricothyrotomy performance. While published checklists teach a specific procedural method, ideal for novice learners, this may hinder expert learners. OBJECTIVES We endeavored to create a succinct error-avoidance checklist for cricothyrotomy. We hypothesized that such a checklist would prove feasible and acceptable to attending physicians. METHODS This is a multicenter prospective checklist creation, evaluation, and feasibility study. Multiple experts pursued an iterative process to reach consensus on a 7-item error-avoidance checklist. The checklist was trialed for feasibility in pilot sessions at two sites by 45 attending emergency physicians who used the checklist for peer performance assessment and provided feedback. RESULTS During the pilot implementation, 94% of respondents completed the procedure within the allotted 120 s. Greater than 85% of respondents agreed that four of the five procedural errors on the checklist were very or somewhat critical to avoid, including cutting >2 cm from midline, creating a false passage, failing to continuously maintain an object in the trachea, and injuring oneself during the procedure. Only 66% of participants felt severing the cricoid cartilage was critical. Successful breath administration and time under 120 s were critical for 100% and 95% of participants, respectively. The checklist was rated "easy" or "very easy" to use by 93% of participants, and 95% found this checklist reasonable for evaluating attending physicians. CONCLUSIONS We present the multicenter development and implementation of a novel error-avoidance checklist tool for use in expert cricothyrotomy performance. Attending emergency medicine (EM) physicians rated our tool easy to use and agreed that most of the proposed errors were critical. Participants overwhelmingly agreed this tool would be reasonable for evaluation of cricothyrotomy performance among attending EM physicians.
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Affiliation(s)
- Sara M. Hock
- Emergency DepartmentRush University Medical CenterChicagoIllinoisUSA
| | - Jerome J. Martin
- Emergency DepartmentRush University Medical CenterChicagoIllinoisUSA
| | | | - Thomas R. Alcorn
- Emergency DepartmentRush University Medical CenterChicagoIllinoisUSA
| | - Emily S. Binstadt
- Emergency DepartmentRegions HospitalHealth PartnersSt PaulMinnesotaUSA
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Šifrer R, Urbančič J, Piazza C, van Weert S, García-Purriños F, Benedik J, Tancer I, Aničin A. Emergent tracheostomy during the pandemic of COVID-19: Slovenian National Recommendations. Eur Arch Otorhinolaryngol 2021; 278:2209-2217. [PMID: 32889621 PMCID: PMC7473826 DOI: 10.1007/s00405-020-06318-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/21/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Emergent tracheostomy under local anaesthesia is a reliable method of airway management when orotracheal intubation is not possible. COVID-19 is spread through aerosol making the emergent tracheostomy a high-risk procedure for surgeons. The surgical establishment of the air conduit in emergency scenarios must be adjusted for safety reasons. METHODS To establish the Slovenian National Guidelines for airway management in cannot intubate-cannot ventilate situations in COVID-19 positive patients. RESULTS Good communication and coordination between surgeon and anaesthesiologist is absolutely necessary. Deep general anaesthesia, full muscle relaxation and adequate preoxygenation without intubation are initial steps. The surgical cricothyrotomy is performed quickly, the thin orotracheal tube is inserted, the cuff is inflated and ventilation begins. Following patient stabilisation, the conversion to the tracheostomy is undertaken with the following features: skin infiltration with vasoconstrictor, a vertical incision, avoidance of electrical devices in favour of classical manners of haemostasis, the advancement of the tube towards the carina, performing the tracheal window in complete apnoea following adequate oxygenation, the insertion of non-fenestrated canulla attached to a heat and moisture exchanger, the fixation of canulla with stitches and tapes, and the cricothyrotomy entrance closure. Appropriate safety equipment is equally important. CONCLUSION The goal of the guidelines is to make the procedure safer for medical teams, without harming the patients. Further improvements of the guidelines will surely appear as COVID-19 is a new entity and there is not yet much experience in handling it.
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Affiliation(s)
- Robert Šifrer
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia.
| | - Jure Urbančič
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
| | - Cesare Piazza
- Department of Otorhinolaryngology, Maxillofacial and Thyroid Surgery, National Cancer Institute of Milan, Via Giacomo Venezian 1, Milan, Italy
- Department of Oncology and Oncohematology, University of Milan, Via Festa del Perdono 7, Milan, Italy
| | - Stijn van Weert
- Department of Otolaryngology - Head and Neck Surgery, Amsterdam UMC, Locatie VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Francisco García-Purriños
- Servicio de Otorrinolaringología, Hospital Universitario Los Arcos del Mar Menor, Paraje Torre Octavio 54, 30739, Pozo Aledo, Murcia, Spain
| | - Janez Benedik
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
- Department of Anaesthesiology and Surgical Intensive Therapy, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Ivana Tancer
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Aleksandar Aničin
- University Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1104, Ljubljana, Slovenia
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Giacomino K, Caliesch R, Sattelmayer KM. The effectiveness of the Peyton's 4-step teaching approach on skill acquisition of procedures in health professions education: A systematic review and meta-analysis with integrated meta-regression. PeerJ 2020; 8:e10129. [PMID: 33083149 PMCID: PMC7549471 DOI: 10.7717/peerj.10129] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/17/2020] [Indexed: 01/14/2023] Open
Abstract
Background Acquisition of procedures is an important element in health professions education. Traditionally procedures are taught using a "see one - do one" approach. That is a teacher demonstrates and describes a procedure and afterwards the students practice the procedure. A more recent teaching approach for the acquisition of procedural skills was presented by Walker and Peyton. Peyton's teaching approach is a stepwise teaching approach and consists of the following four steps: demonstration, deconstruction, comprehension and performance. The aims of this study were (i) to systematically evaluate the effectiveness of Peyton's 4-step teaching approach on the acquisition of procedural skills in health professions education and (ii) to evaluate whether studies with fewer students per teacher showed a larger between group difference than studies with more students per teacher. Methods We searched in Medline, PsycInfo, Embase and ERIC for eligible studies. Records were screened by two independent reviewers. A random effects meta-analysis was performed to evaluate skill acquisition and time needed to perform the procedures at post-acquisition and retention tests. A meta-regression was used to explore the effect of the number of students per teacher on the estimated effect of the educational interventions. Results An effect size of 0.45 SMD (95% CI [0.15; 0.75]) at post-acquisition and 0.7 SMD (95% CI [-0.09; 1.49]) at retention testing were in favour of Peyton's teaching approach for skill acquisition. The groups using Peyton's teaching approach needed considerably less time to perform the procedure at post-acquisition (SMD: -0.8; 95% [CI -2.13 to 1.62]) and retention (SMD: -2.65; 95% CI [-7.77 to 2.47]) testing. The effectiveness of Peyton's teaching approach was less clear in subgroup analyses using peer teachers. Meta-regression showed that the number of students per teacher was an important moderator variable. Conclusion Peyton's teaching approach is an effective teaching approach for skill acquisition of procedural skills in health professions education. When peer students or student tutors are used as teachers the effectiveness of Peyton's teaching approach is less clear. Peyton's teaching approach is more effective when small groups with few students per teacher are used.
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Affiliation(s)
- Katia Giacomino
- School of Health Sciences, HES-SO Valais-Wallis, Leukerbad, Switzerland
| | - Rahel Caliesch
- School of Health Sciences, HES-SO Valais-Wallis, Leukerbad, Switzerland
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Onrubia X, Frova G, Sorbello M. Front of neck access to the airway: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.06.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Emergency Cricothyrotomy Performed by Surgical Airway-naive Medical Personnel: A Randomized Crossover Study in Cadavers Comparing Three Commonly Used Techniques. Anesthesiology 2017; 125:295-303. [PMID: 27275669 DOI: 10.1097/aln.0000000000001196] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND When conventional approaches to obtain effective ventilation and return of effective spontaneous breathing fail, surgical airway is the last rescue option. Most physicians have a limited lifetime experience with cricothyrotomy, and it is unclear what method should be taught for this lifesaving procedure. The aim of this study is to compare the performance of medical personnel, naive to surgical airway techniques, in establishing an emergency surgical airway in cadavers using three commonly used cricothyrotomy techniques. METHODS Twenty medical students, without previous knowledge of surgical airway techniques, were randomly selected from their class. After training, they performed cricothyrotomy by three techniques (surgical, Melker, and QuickTrach II) in a random order on 60 cadavers with comparable biometrics. The time to complete the procedure, rate of success, and number of complications were recorded. A success was defined as the correct placement of the cannula within the trachea in 3 min. RESULTS The success rates were 95, 55, and 50% for surgical cricothyrotomy, QuickTrach, and Melker, respectively (P = 0.025). The majority of failures were due to cannula misplacement (15 of 20). In successful procedures, the mean procedure time was 94 ± 35 s in the surgical group, 77 ± 34 in the QuickTrach II group, and 149 ± 24 in the Melker group (P < 0.001). Few significant complications were found in successful procedures. No cadaver biometric parameters were correlated with success of the procedure. CONCLUSION Surgical airway-naive medical personnel establish emergency cricothyrotomy more efficiently and safely with the surgical procedure than with the other two commonly used techniques.
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Ono Y, Kunii M, Miura T, Shinohara K. "Cannot ventilate, cannot intubate" situation after penetration of the tongue root through to the epipharynx by a surfboard: a case report. J Med Case Rep 2017; 11:121. [PMID: 28460647 PMCID: PMC5412042 DOI: 10.1186/s13256-017-1284-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 04/05/2017] [Indexed: 12/29/2022] Open
Abstract
Background Surfing is an increasingly popular activity and surfing-related injuries have increased accordingly. However, to the best of our knowledge, there are no reports of penetrating upper airway injuries in surfers. We present a “cannot ventilate, cannot intubate” situation following penetrating neck injury by a surfboard fin. Case presentation A previously healthy 29-year-old Japanese man was swept off his board by a large wave and his left mandible, tongue root, and right epipharynx were penetrated by the surfboard fin. He presented with severe hypovolemic shock because of copious bleeding from his mouth. Direct laryngoscopy failed, as did manual ventilation, because of the exacerbated upper airway bleeding and distorted upper airway anatomy. Open cricothyrotomy was immediately performed, followed by surgical exploration, which revealed extensive ablation of his tongue root and laceration of his lingual artery. After definitive hemostasis and intensive care, he returned home with no sequelae. Conclusions The long, semi-sharp surfboard fin created both extensive crushing upper airway lesions and a sharp vascular injury, resulting in a difficult airway. This case illustrates that surfing injuries can prompt a life-threatening airway emergency and serves as a caution for both surfers and health care professionals.
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Affiliation(s)
- Yuko Ono
- Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan. .,Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Fukushima, Fukushima, 963-8558, Japan.
| | - Miha Kunii
- Department of Otolaryngology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan
| | - Tomohiro Miura
- Department of Otolaryngology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Fukushima, 960-1295, Japan.,Department of Head and Neck Surgery, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Fukushima, Fukushima, 963-8558, Japan
| | - Kazuaki Shinohara
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Fukushima, Fukushima, 963-8558, Japan
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Andersson ML, Møller AM, Pace NL. Emergency cricothyroidotomy for airway management. Hippokratia 2017. [DOI: 10.1002/14651858.cd010921.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Mette Legaard Andersson
- Herlev University Hospital; Department of Anaesthesiology; Herlev Ringvej 75 Herlev Denmark 2730
| | - Ann Merete Møller
- Herlev and Gentofte Hospital, University of Copenhagen; The Cochrane Anaesthesia, Critical and Emergency Care Group; Herlev Ringvej Herlev Denmark 2730
| | - Nathan Leon Pace
- University of Utah; Department of Anesthesiology; 3C444 SOM 30 North 1900 East Salt Lake City UT USA 84132-2304
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Abstract
Tracheal intubation remains a life-saving procedure that is typically not difficult for experienced providers in routine conditions. Unfortunately, difficult intubation remains challenging to predict and intubation conditions may make the event life threatening. Recent technological advances aim to further improve the ease, speed, safety, and success of intubation but have not been fully investigated. Video laryngoscopy, though proven effective in the difficult airway, may result in different intubation success rates in various settings and in different providers’ hands. The rescue surgical airway remains a rarely used but critical skill, and research continues to investigate optimal techniques. This review highlights some of the new thoughts and research on these important topics.
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Affiliation(s)
- Joelle Karlik
- Oregon Health & Science University, Portland, OR, USA
| | - Michael Aziz
- Oregon Health & Science University, Portland, OR, USA
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12
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Küßner T, Popp E. A – Atemweg. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0271-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Sabato SC, Long E. An institutional approach to the management of the 'Can't Intubate, Can't Oxygenate' emergency in children. Paediatr Anaesth 2016; 26:784-93. [PMID: 27277897 DOI: 10.1111/pan.12926] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2016] [Indexed: 12/15/2022]
Abstract
The 'Can't Intubate Can't Oxygenate' emergency is rare in children. Nevertheless, airway clinicians involved in pediatric airway management must be able to rescue the airway percutaneously through the front of the neck should this situation be encountered. Little evidence exists in children to guide rescue techniques, and extrapolation of adult evidence may be problematic due to anatomical differences. This document reviews the currently available evidence, and presents a practical approach to standardizing equipment, techniques, and training for managing the 'Can't Intubate Can't Oxygenate' emergency in children.
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Affiliation(s)
- Stefano C Sabato
- Department of Anaesthesia and Pain Management, The Royal Children's Hospital Melbourne, Parkville, Vic., Australia.,Murdoch Children's Research Institute, Parkville, Vic., Australia
| | - Elliot Long
- Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.,Department of Pediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, Vic., Australia
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Chrisman L, King W, Wimble K, Cartwright S, Mohammed K, Patel B. Surgicric 2: A comparative bench study with two established emergency cricothyroidotomy techniques in a porcine model. Br J Anaesth 2016; 117:236-42. [DOI: 10.1093/bja/aew174] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2016] [Indexed: 12/13/2022] Open
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Melchiors J, Todsen T, Konge L, Charabi B, von Buchwald C. Cricothyroidotomy - The emergency surgical airway. Head Neck 2016; 38:1129-31. [DOI: 10.1002/hed.24392] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 09/22/2015] [Accepted: 12/17/2015] [Indexed: 11/07/2022] Open
Affiliation(s)
- Jacob Melchiors
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre of Head and Orthopedics, Rigshospitalet; University Hospital of Copenhagen; Denmark
| | - Tobias Todsen
- Copenhagen Academy for Medical Education and Simulation Capital Region of Denmark; Copenhagen Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation Capital Region of Denmark; Copenhagen Denmark
| | - Birgitte Charabi
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre of Head and Orthopedics, Rigshospitalet; University Hospital of Copenhagen; Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre of Head and Orthopedics, Rigshospitalet; University Hospital of Copenhagen; Denmark
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Browne GA. Quick Response Tracheotomy: A Novel Surgical Procedure. J Intensive Care Med 2016; 31:276-84. [PMID: 26905541 DOI: 10.1177/0885066615627141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/23/2015] [Indexed: 11/16/2022]
Abstract
Quick response tracheostomy (QRT) is a novel open surgical technique to emergently establish an airway. The method is simple; the skills necessary to perform this procedure are rapidly acquired; and it is expedient, minimally traumatic, and remarkably devoid of complications often encountered with percutaneous dilatational tracheotomies, including those complications seen with cricothyroidotomies. Unlike all other tracheotomies in which considerable blunt dissection is required, QRT avoids tissue crushing because sharp dissection alone is used to acquire surgical access to the trachea. The QRT does not entail inserting a guidewire into the trachea, a standard feature for percutaneous tracheal access; it avoids any risk of unintended laceration of the posterior tracheal wall and proximal subjacent esophagus. The technique averts tracheal ring fracture and tracheoesophageal fistula complications. The QRT has a uniquely low incidence of inducing hemorrhage, and it requires no steps that cause temporary tracheal occlusion and will therefore not facilitate hypoxia. The QRT contributes minimally to conditions favorable for generating subglottic stenosis, and the procedure is swiftly executed with very low probability for external tracheal placement of the tracheostomy tube. The QRT is not a blind procedure. No special instruments are required for its execution nor is concurrent tracheoscopy required at any stage while performing a QRT as is specified for percutaneous tracheotomies.
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Affiliation(s)
- Graeme A Browne
- Department Emergency Medicine, Mayo Health Care System Austin, Austin, MN, USA
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Akulian JA, Yarmus L, Feller-Kopman D. The role of cricothyrotomy, tracheostomy, and percutaneous tracheostomy in airway management. Anesthesiol Clin 2016; 33:357-67. [PMID: 25999008 DOI: 10.1016/j.anclin.2015.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cricothyrotomy, percutaneous dilation tracheostomy, and surgical tracheostomy are cost-effective and safe techniques employed in the management of critically ill patients requiring insertion of an artificial airway. These procedures have been well characterized and studied in the surgical, emergency medicine, and critical care literature. This article focuses on the role of each of these modalities in airway management, specifically comparing the data for each procedure in regard to procedural outcomes. The authors discuss the techniques available and the relevant background data regarding choice of each method and its integration into clinical practice.
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Affiliation(s)
- Jason A Akulian
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, 8007 Burnett Womack, CB 7219, Chapel Hill, NC 27599-7219, USA
| | - Lonny Yarmus
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Suite 7125, Baltimore, MD 21287, USA
| | - David Feller-Kopman
- Bronchoscopy and Interventional Pulmonology, Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, MD 21287, USA.
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King W, Teare J, Vandrevala T, Cartwright S, Mohammed KB, Patel B. Evaluation of a novel Surgicric® cricothyroidotomy device for emergency tracheal access in a porcine model. Anaesthesia 2015; 71:177-84. [PMID: 26572240 DOI: 10.1111/anae.13275] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 12/21/2022]
Abstract
A can't intubate, can't ventilate scenario can result in morbidity and death. Although a rare occurrence (1:50 000 general anaesthetics), it is crucial that anaesthetists maintain the skills necessary to perform cricothyroidotomy, and are well-equipped with appropriate tools. We undertook a bench study comparing a new device, Surgicric(®) , with two established techniques; the Melker Emergency Cricothyroidotomy, and a surgical technique. Twenty-five anaesthetists performed simulated emergency cricothyroidotomy on a porcine model, with the primary outcome measure being insertion time. Secondary outcomes included success rate, tracheal trauma and ease of use. The surgical technique was fastest. The median (IQR [range]) was 81 (62-126 [37-300]) s, followed by the Melker 124 (100-217 [71-300]) s, and the Surgicric 127 (68-171 [43-300]), p = 0.003. The Surgicric device was the most traumatic, as evaluated by a blinded Ear, Nose and Throat surgeon. Subsequently, the authors contacted the device manufacturer, who has now modified the kit in the hope that its clinical application might be improved. Further studies are required to evaluate the revised model.
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Affiliation(s)
- W King
- Surrey Peri-operative Anaesthesia Critical Care Collaborative Research Group, Anaesthetic Department, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - J Teare
- Surrey Peri-operative Anaesthesia Critical Care Collaborative Research Group, Anaesthetic Department, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - T Vandrevala
- Research Design Service, Kingston Hospital, Surrey, UK
| | - S Cartwright
- ENT Department, Guy's and St Thomas' Hospitals, London, UK
| | - K B Mohammed
- Research and Development Department, The Royal Marsden Hospital, London, UK
| | - B Patel
- Surrey Peri-operative Anaesthesia Critical Care Collaborative Research Group, Anaesthetic Department, Royal Surrey County Hospital, Guildford, Surrey, UK
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Bair AE, Chima R. The inaccuracy of using landmark techniques for cricothyroid membrane identification: a comparison of three techniques. Acad Emerg Med 2015. [PMID: 26198864 DOI: 10.1111/acem.12732] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Successful cricothyrotomy is predicated on accurate identification of the cricothyroid membrane (CTM) by palpation of superficial anatomy. However, recent research has indicated that accuracy of the identification of the CTM can be as low as 30%, even in the hands of skilled providers. To date, there are very little data to suggest how to best identify this critical landmark. The objective was to compare three different methods of identifying the CTM. METHODS A convenience sample of patients and physician volunteers who met inclusion criteria was consented. The patients were assessed by physician volunteers who were randomized to one of three methods for identifying the CTM (general palpation of landmarks vs. an approximation based on four finger widths vs. an estimation based on overlying skin creases of the neck). Volunteers would then mark the skin with an invisible but florescent pen. A single expert evaluator used ultrasound to identify the superior and inferior borders of the CTM. The variably colored florescent marks were then visualized with ultraviolet light and the accuracy of the various methods was recorded as the primary outcome. Additionally, the time it took to perform each technique was measured. Descriptive statistics and report 95% confidence intervals (CIs) are reported. RESULTS Fifty adult patients were enrolled, 52% were female, and mean body mass index was 28 kg/m(2) (95% CI = 26 to 29 kg/m(2) ). The general palpation method was successful 62% of the time (95% CI = 48% to 76%) and took an average of 14 seconds to perform (range = 5 to 45 seconds). In contrast, the four-finger technique was successful 46% of the time (95% CI = 32% to 60%) and took an average of 12 seconds to perform (range = 6 to 40 seconds). Finally, the neck crease method was successful 50% of the time (95% CI = 36% to 64%) and took an average of 11 seconds to perform (range = 5 to 15 seconds). CONCLUSIONS All three methods performed poorly overall. All three techniques might potentially be even less accurate in instances where the superficial anatomy is not palpable due to body habitus. These findings should alert clinicians to the significant risk of a misplaced cricothyrotomy and highlight the critical need for future research.
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Affiliation(s)
- Aaron E. Bair
- Department of Emergency Medicine; University of California; Davis Health System; Sacramento CA
| | - Rupinder Chima
- Department of Emergency Medicine; University of California; Davis Health System; Sacramento CA
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Aho JM, Thiels CA, AlJamal YN, Ruparel RK, Rowse PG, Heller SF, Farley DR. Every surgical resident should know how to perform a cricothyrotomy: an inexpensive cricothyrotomy task trainer for teaching and assessing surgical trainees. JOURNAL OF SURGICAL EDUCATION 2015; 72:658-661. [PMID: 25703738 DOI: 10.1016/j.jsurg.2014.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/26/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Emergency cricothyrotomy is a rare but potentially lifesaving procedure. Training opportunities for surgical residents to learn this skill are limited, and many graduating residents have never performed one during their training. We aimed to develop and validate a novel and inexpensive cricothyrotomy task trainer that can be constructed from household items. DESIGN A model was constructed using a toilet paper roll (trachea and larynx), Styrofoam (soft tissue), cardboard (thyroid cartilage), zip tie (cricoid), and fabric (skin). Participants were asked to complete a simulated cricothyrotomy procedure using the model. They were then evaluated using a 10-point checklist (5 points total) devised by 6 general surgeons. Participants were also asked to complete an anonymous survey rating the educational value and the degree of enjoyment regarding the model. SETTING A tertiary care teaching hospital. PARTICIPANTS A total of 54 students and general surgery residents (11 medical students, 32 interns, and 11 postgraduate year 3 residents). RESULTS All 54 participants completed the training and assessment. The scores ranged from 0 to 5. The mean (range) scores were 1.8 (1-4) for medical students, 3.5 (1-5) for junior residents, and 4.9 (4-5) for senior-level residents. Medical students were significantly outperformed by junior- and senior-level residents (p < 0.001). Trainees felt that the model was educational (4.5) and enjoyable (4.0). CONCLUSIONS A low-fidelity, low-cost cricothyrotomy simulator distinguished the performance of emergency cricothyrotomy between medical students and junior- and senior-level general surgery residents. This task trainer may be ideally suited to providing basic skills to all physicians in training, especially in settings with limited resources and clinical opportunities.
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Affiliation(s)
| | | | | | - Raaj K Ruparel
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - David R Farley
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Uehara M, Kokuryo S, Sasaguri M, Tominaga K. Emergency Cricothyroidotomy for Difficult Airway Management After Asynchronous Bilateral Neck Dissections: A Case Report and Literature Review. J Oral Maxillofac Surg 2015; 73:2066.e1-7. [PMID: 26126919 DOI: 10.1016/j.joms.2015.06.152] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/06/2015] [Accepted: 06/07/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE This report describes a case that required emergency cricothyroidotomy for an upper airway obstruction owing to laryngeal edema after asynchronous bilateral neck dissections. PATIENT AND METHODS A 57-year-old man was diagnosed with multicentric squamous cell carcinoma of the tongue (T1 and 2N0M0), and partial glossectomy with primary closure was performed. Three months after surgery, secondary metastases in the right cervical lymph nodes were detected, and a right radical neck dissection was performed. Contrast-enhanced computed tomographic (CT) scan taken 2 weeks after the right neck dissection visualized a possible third metastasis in the left cervical lymph node. Four weeks after the right radical neck dissection, left supraomohyoid neck dissection was carried out. In this surgery, the left internal jugular vein (IJV) was preserved. Nine hours after surgery, severe swelling of the face and pharynx was recognized, resulting in a stoppage of respiration and then an emergency cricothyroidotomy. RESULTS The patient's life was saved without any encephalopathy or airway trouble. Contrast-enhanced CT scan taken the next day confirmed the preserved left IJV patency. CONCLUSION Oral and maxillofacial surgeons should be aware of the possibility of life-threatening laryngeal edema associated with bilateral neck dissections even if the unilateral IJV is preserved and should know the procedure for emergency cricothyroidotomy.
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Affiliation(s)
- Masataka Uehara
- Lecturer, Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Fukuoka, Japan.
| | - Shinya Kokuryo
- Lecturer, Division of Oral Medicine, Department of Science of Physical Functions, Kyushu Dental University, Fukuoka, Japan
| | - Masaaki Sasaguri
- Associate Professor, Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Fukuoka, Japan
| | - Kazuhiro Tominaga
- Professor and Chairman, Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Fukuoka, Japan
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Kristensen M, Teoh W, Baker P. Percutaneous emergency airway access; prevention, preparation, technique and training. Br J Anaesth 2015; 114:357-61. [DOI: 10.1093/bja/aev029] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Melchiors J, Todsen T, Nilsson P, Wennervaldt K, Charabi B, Bøttger M, Konge L, von Buchwald C. Preparing for Emergency. Otolaryngol Head Neck Surg 2014; 152:260-5. [DOI: 10.1177/0194599814556722] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Emergency cricothyrodotomy (EC) is a lifesaving procedure. Evidence-based assessment of training effects and competency levels is relevant to all departments involved in emergency airway management. As most training uses low-fidelity models, the predictive value of good performance on such a model becomes relevant with regard to performance on a high-fidelity model (cadaver). This requires a valid assessment tool for EC performance. Study Design Psychometric study on low-fidelity models and human cadavers. Setting University hospital. Subjects and Methods An assessment tool was created. Sixteen physicians (7 experienced surgeons and 9 novice physicians) performed an EC on a low-fidelity model and a cadaver. Two blinded raters assessed video recordings of performances using the assessment tool. Results We found a high interrater reliability, based on a Pearson’s r (0.81), and good evidence for validity, based on successfully distinguishing the 2 groups, using an independent samples t test ( P < .001). We found a good correlation between performance on a low-fidelity model and the cadaver with an R2 = 0.78. Conclusion The tool for assessing EC competence proved reliable and valid. Performance on a low-fidelity model measured this way is a good predictor of performance in a more lifelike situation.
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Affiliation(s)
- Jacob Melchiors
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre of Head and Orthopedics, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - Tobias Todsen
- Centre for Clinical Education, University of Copenhagen and the Capital Region of Denmark, Copenhagen, Denmark
- Department of Surgery, Queen Ingrid's Hospital, Nuuk, Greenland
| | - Philip Nilsson
- Centre for Clinical Education, University of Copenhagen and the Capital Region of Denmark, Copenhagen, Denmark
| | - Kasper Wennervaldt
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre of Head and Orthopedics, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - Birgitte Charabi
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre of Head and Orthopedics, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - Morten Bøttger
- Department of Anesthesia, Centre of Head and Orthopedics, Rigshospitalet, University Hospital of Copenhagen, Denmark
| | - Lars Konge
- Centre for Clinical Education, University of Copenhagen and the Capital Region of Denmark, Copenhagen, Denmark
| | - Christian von Buchwald
- Department of Otorhinolaryngology, Head and Neck Surgery, Centre of Head and Orthopedics, Rigshospitalet, University Hospital of Copenhagen, Denmark
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Emergent Surgical Airway: Comparison of the Three-Step Method and Conventional Cricothyroidotomy Utilizing High-Fidelity Simulation. J Emerg Med 2014; 46:304-7. [DOI: 10.1016/j.jemermed.2013.08.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 06/15/2013] [Accepted: 08/15/2013] [Indexed: 11/16/2022]
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Nakstad AR, Bredmose PP, Sandberg M. Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scand J Trauma Resusc Emerg Med 2013; 21:59. [PMID: 23890359 PMCID: PMC3727957 DOI: 10.1186/1757-7241-21-59] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 06/30/2013] [Indexed: 12/05/2022] Open
Abstract
Background A large number of techniques and devices for cricothyroidotomy have been developed. In this study, the Portex™ Cricothyroidotomy Kit (PCK, Smiths Medical Ltd, Hythe, UK) was compared with the bougie assisted emergency surgical cricothyrotomy technique (BACT). Methods Twenty air ambulance anaesthesiologists performed emergency cricothyrotomy on a cadaveric porcine airway model using both PCK and BACT. Baseline performance and performance after the intensive training package were recorded. Success rate, time to secured airway and tracheal damage were the primary endpoints, and confidence rating was a secondary endpoint. Results During baseline testing, success rates for PCK and BACT were 60% and 95%, respectively. Tracheal injury rate with PCK was 60% while no such injury was found in BACT. A lecture was given and skills were trained until the participants were able to perform five consecutive successful procedures with both techniques. In the post-training test, all participants were successful with either technique. The mean time to successful insertion was reduced by 15.7 seconds (from 36.3 seconds to 20.6 seconds, p< 0.001) for PCK and by 7.8 seconds (from 44.9 seconds to 37.1 seconds, p=0.021) for BACT. In the post-training scenario, securing the airway with PCK was significantly faster than with BACT (p<0.001). Post-training tracheal laceration occurred in six (30%) of the PCK procedures and in none of the BACT procedures (p=0.028). The self-evaluated confidence level was measured both pre- and post-training using a confidence scale with 10 indicating maximum amount of confidence. The median values increased from 4 to 8 for PCK and from 6.5 to 9.5 for BACT. All participants reported that BACT was their preferred technique. Conclusions Testing the base-line PCK skills of prehospital anaesthesiologists revealed low confidence, sub-optimal performance and a very high failure rate. The BACT technique demonstrated a significantly higher success rate and no tracheal damage. In spite of PCK being a significantly faster technique in the post-training test, the anaesthesiologists still reported a higher confidence in BACT. Limitations of the cadaveric porcine airway may have influenced this study because the airway did not challenge the clinicians with realistic tissue bleeding.
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Langvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy--a systematic review. Scand J Trauma Resusc Emerg Med 2013; 21:43. [PMID: 23725520 PMCID: PMC3704966 DOI: 10.1186/1757-7241-21-43] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 05/26/2013] [Indexed: 01/28/2023] Open
Abstract
Background An emergency cricothyrotomy is the last-resort in most airway management protocols and is performed when it is not possible to intubate or ventilate a patient. This situation can rapidly prove fatal, making it important to identify the best method to establish a secure airway. We conducted a systematic review to identify whether there exists superiority between available commercial kits versus traditional surgical and needle techniques. Methods Medline, EMBASE and other databases were searched for pertinent studies. The inclusion criteria included manikin, animal and human studies and there were no restrictions regarding the professional background of the person performing the procedure. Results In total, 1,405 unique references were identified; 108 full text articles were retrieved; and 24 studies were included in the review. Studies comparing kits with one another or with various surgical and needle techniques were identified. The outcome measures included in this systematic review were success rate and time consumption. The investigators performing the studies had chosen unique combinations of starting and stopping points for time measurements, making comparisons between studies difficult and leading to many conflicting results. No single method was shown to be better than the others, but the size of the studies makes it impossible to draw firm conclusions. Conclusions The large majority of the studies were too small to demonstrate statistically significant differences, and the limited available evidence was of low or very low quality. That none of the techniques in these studies demonstrated better results than the others does not necessarily indicate that each is equally good, and these conclusions will likely change as new evidence becomes available.
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Affiliation(s)
- Sofie Langvad
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Optimizing Emergent Surgical Cricothyrotomy for use in Austere Environments. Wilderness Environ Med 2013; 24:53-66. [DOI: 10.1016/j.wem.2012.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 06/23/2012] [Accepted: 07/03/2012] [Indexed: 11/23/2022]
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Falcon-Chevere JL, Mercado J, Mathew D, Uzcategui-Corder M, Almodovar A, Richards E. Critical Trauma Skills and Procedures in the Emergency Department. Emerg Med Clin North Am 2013. [DOI: 10.1016/j.emc.2012.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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BAKER PA, FERNANDEZ TMA, HAMAEKERS AE, THOMPSON JMD. Parker Flex-Tip or standard tracheal tube for percutaneous emergency airway access? Acta Anaesthesiol Scand 2013; 57:165-70. [PMID: 23252832 DOI: 10.1111/aas.12042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Percutaneous emergency airway access (PEAA) can be established utilising a scalpel, bougie and cuffed tracheal tube. The study compared the Parker Flex-Tip tracheal tube with a standard tracheal tube for PEAA in cadavers. We hypothesised that a standard tracheal tube would be more likely to advance over a bougie into the trachea during a PEAA procedure than a Parker Flex-Tip tracheal tube. METHODS Three anaesthetists performed a PEAA with a scalpel, bougie and cuffed tracheal tube, 12 times each. Recorded times included: loading the tracheal tube onto the bougie and advancing the tube over the bougie to the skin, advancing the tube through the skin into the trachea and completion of the whole procedure. Subjective opinion regarding the ease of tube insertion was recorded by visual analogue scoring. RESULTS Subjective opinion, overall time and time to complete each component of the procedure were not significantly affected by the type of tube used. The mean time for three novice anaesthetists to complete PEAA on a cadaver was 37.5 (8.8) s, after 1 h of training. In two of the 12 cadavers, the cricothyroid membrane could not be palpated or located with the scalpel. CONCLUSION The Parker Flex-Tip tube and a standard tracheal tube perform equally well during PEAA procedures on adult cadavers.
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Affiliation(s)
| | - T. M. A. FERNANDEZ
- Department of Anaesthesia; Auckland City Hospital; Auckland; New Zealand
| | - A. E. HAMAEKERS
- Department of Anaesthesia; Maastricht University Medical Centre; Maastricht; The Netherlands
| | - J. M. D. THOMPSON
- Department of Paediatrics; The University of Auckland; Auckland; New Zealand
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Use of Cadaver Models in Point-of-care Emergency Ultrasound Education for Diagnostic Applications. J Emerg Med 2012; 43:683-91. [DOI: 10.1016/j.jemermed.2012.01.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 12/01/2011] [Accepted: 01/22/2012] [Indexed: 11/23/2022]
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Donat A, Petitjeans F, Précloux P, Puidupin M, Escarment J. La cricothyrotomie : données actuelles et intérêt de cette technique en médecine de guerre. ACTA ACUST UNITED AC 2012; 31:141-51. [DOI: 10.1016/j.annfar.2011.10.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Accepted: 10/26/2011] [Indexed: 11/25/2022]
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Paix BR, Griggs WM. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel-finger-tube’ method. Emerg Med Australas 2011; 24:23-30. [DOI: 10.1111/j.1742-6723.2011.01510.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hamaekers AE, Henderson JJ. Equipment and strategies for emergency tracheal access in the adult patient. Anaesthesia 2011; 66 Suppl 2:65-80. [DOI: 10.1111/j.1365-2044.2011.06936.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Hill C, Reardon R, Joing S, Falvey D, Miner J. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med 2010; 17:666-9. [PMID: 20491685 DOI: 10.1111/j.1553-2712.2010.00753.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to compare time to completion, failure rate, and subjective difficulty of a new cricothyrotomy technique to the standard technique. The new bougie-assisted cricothyrotomy technique (BACT) is similar to the rapid four-step technique (RFST), but a bougie and endotracheal tube are inserted rather than a Shiley tracheostomy tube. METHODS This was a randomized controlled trail conducted on domestic sheep. During a 3-month period inexperienced residents or students were randomized to perform cricothyrotomy on anesthetized sheep using either the standard technique or the BACT. Operators were trained with an educational video before the procedure. Time to successful cricothyrotomy was recorded. The resident or student was then asked to rate the difficulty of the procedure on a five-point scale from 1 (very easy) to 5 (very difficult). RESULTS Twenty-one residents and students were included in the study: 11 in the standard group and 10 in the BACT group. Compared to the standard technique, the BACT was significantly faster with a median time of 67 seconds (interquartile range [IQR] = 55-82) versus 149 seconds (IQR = 111-201) for the standard technique (p = 0.002). The BACT was also rated easier to perform (median = 2, IQR = 1-3) than the standard technique (median = 3, IQR = 2-4; p = 0.04). The failure rate was 1/10 for the BACT compared to 3/11 for the standard method (p = NS). CONCLUSIONS This study demonstrates that the BACT is faster than the standard technique and has a similar failure rate when performed by inexperienced providers on anesthetized sheep.
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Affiliation(s)
- Chandler Hill
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis MN, USA.
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Braude D, Webb H, Stafford J, Stulce P, Montanez L, Kennedy G, Grimsley D. The bougie-aided cricothyrotomy. Air Med J 2010; 28:191-4. [PMID: 19573767 DOI: 10.1016/j.amj.2009.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 02/03/2009] [Accepted: 02/04/2009] [Indexed: 11/15/2022]
Affiliation(s)
- Darren Braude
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM 87131-0001, USA.
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Keane MF, Brinsfield KH, Dyer KS, Roy S, White D. A LABORATORYCOMPARISON OFEMERGENCYPERCUTANEOUS ANDSURGICALCRICOTHYROTOMY BYPREHOSPITALPERSONNEL. PREHOSP EMERG CARE 2009. [DOI: 10.1080/312704001194] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Soulsby CR, Kessell G. Teaching lifesaving procedures: the impact of model fidelity on acquisition and transfer of cricothyrotomy skills to performance on cadavers. Anesth Analg 2009; 108:1992; author reply 1992-3. [PMID: 19448241 DOI: 10.1213/ane.0b013e3181a1f892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Schober P, Hegemann MC, Schwarte LA, Loer SA, Noetges P. Emergency cricothyrotomy—A comparative study of different techniques in human cadavers. Resuscitation 2009; 80:204-9. [DOI: 10.1016/j.resuscitation.2008.10.023] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 09/18/2008] [Accepted: 10/03/2008] [Indexed: 10/21/2022]
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Abstract
Cricothyrotomy is considered an integral procedure in the practice of emergency medicine. The Accreditation Council for Graduate Medical Education requires residents in emergency medicine to demonstrate proficiency in this skill, but because cricothyrotomy is rarely encountered in the clinical setting, alternative methods to teach this high-stakes procedure become an important curricular component in residency training. We present an innovative and inexpensive method for teaching cricothyrotomy using animal trachea and synthetic skin.
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Friedman Z, You-Ten KE, Bould MD, Naik V. Teaching lifesaving procedures: the impact of model fidelity on acquisition and transfer of cricothyrotomy skills to performance on cadavers. Anesth Analg 2008; 107:1663-9. [PMID: 18931230 DOI: 10.1213/ane.0b013e3181841efe] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A decline in emergency surgical airway procedures in recent years has resulted in a decreased exposure to cricothyrotomy. Consequently, residents have very little experience or confidence in performing this intervention. In this study, we compared cricothyrotomy skills acquired on a simple inexpensive model to those learned on a high fidelity simulator using valid evaluation instruments and testing on cadavers. METHODS First and second year anesthesiology residents were recruited. All subjects performed a videotaped pretest cricothyrotomy on cadavers. Subjects were randomized into two groups: The high fidelity group (n = 11) performed two cricothyrotomies on a full-scale simulator with an anatomically accurate larynx. The low fidelity group (n = 11) performed two cricothyrotomies on a low fidelity model constructed from corrugated tubing. Within 2 wk all subjects performed a posttest. Two blinded examiners graded and timed the performances using a checklist and a global rating scale. RESULTS There was no significant difference in the change from pretest to posttest performance between the model groups as evaluated by all three measures (all: P = NS). Training on both models significantly improved performance on all measures (all: P < 0.001). Inter-rater reliability was strong (checklist: r = 0.90; global rating scale: r = 0.89). CONCLUSIONS Our study shows that a simple inexpensive model achieved the same effect on objectively rated skill acquisition as did an expensive simulator. The skills acquired on both models transferred effectively to cadavers. Training for this life-saving skill does not need to be limited by simulator accessibility or cost.
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Affiliation(s)
- Zeev Friedman
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, 600 University Ave., Toronto M5G1X5, ON, Canada.
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Wang EE, Quinones J, Fitch MT, Dooley-Hash S, Griswold-Theodorson S, Medzon R, Korley F, Laack T, Robinett A, Clay L. Developing technical expertise in emergency medicine--the role of simulation in procedural skill acquisition. Acad Emerg Med 2008; 15:1046-57. [PMID: 18785939 DOI: 10.1111/j.1553-2712.2008.00218.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Developing technical expertise in medical procedures is an integral component of emergency medicine (EM) practice and training. This article is the work of an expert panel composed of members from the Society for Academic Emergency Medicine (SAEM) Interest Group, the SAEM Technology in Medical Education Committee, and opinions derived from the May 2008 Academic Emergency Medicine Consensus Conference, "The Science of Simulation in Healthcare." The writing group reviewed the simulation literature on procedures germane to EM training, virtual reality training, and instructional learning theory as it pertains to skill acquisition and procedural skills decay. The authors discuss the role of simulation in teaching technical expertise, identify training conditions that lead to effective learning, and provide recommendations for future foci of research.
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Affiliation(s)
- Ernest E Wang
- Division of Emergency Medicine, Evanston Northwestern Healthcare, Evanston, IL, USA.
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Abstract
This article reviews the more recent theoretic and practical information that pertains to airway management in the trauma setting. This is followed by a presentation of the newer airway devices that may be advantageous in the management of the airway in trauma as well as a discussion of other devices, techniques, or maneuvers that are useful in the trauma setting but may be underused. Each clinician needs to be knowledgeable about the various airway options and then, based on one's own particular skills and resources, construct an airway management algorithm that works best for him or her. Each clinician needs to be knowledgeable about the various airway options, and then, based on the clinician's particular skills and resources, construct an airway management algorithm that works best.
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Affiliation(s)
- John McGill
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue North, Minneapolis, MN 55415, USA.
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Helm M, Gries A, Mutzbauer T. Surgical approach in difficult airway management. Best Pract Res Clin Anaesthesiol 2006; 19:623-40. [PMID: 16408538 DOI: 10.1016/j.bpa.2005.06.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In all difficult airway algorithms, cricothyroidotomy is the life-saving procedure and is the final 'cannot ventilate, cannot intubate' option, whether in pre-hospital, emergency department, intensive care unit, or operating room patients. Cricothyroidotomy is a relatively safe and rapid means of securing an emergency airway. As with all other critical procedures in emergency medicine, a thorough knowledge of the technique and adequate practice prior to attempting to perform an emergency cricothyroidotomy are essential.
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Affiliation(s)
- Matthias Helm
- Department of Anaesthesiology and Intensive Care, Federal Armed Forces Medical Center, Ulm, Germany.
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Engelbrecht D. Cricothyroidotomy in emergency practice: Two case reports. S Afr Fam Pract (2004) 2005. [DOI: 10.1080/20786204.2005.10873246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Abstract
Cricothyrotomy is a very invasive technique to secure the airway in an emergency but is irreplacable when less invasive techniques fail or cannot be instigated under the prevailing circumstances. Various techniques have been reported which can be subdivided into anatomical-surgical preparation or puncture techniques. The preferred strategy is mostly oriented towards the departmental standard procedure which will be decided by the clinical situation. Training for each procedure can be carried out in intensive care departments, and using autopsy material or a manekin. Various methods of cricothyrotomy will be discussed here, and additionally an anatomical preparation and two puncture techniques will be demonstrated in detail.
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Affiliation(s)
- T S Mutzbauer
- Klinik für Kiefer- und Gesichtschirurgie, Universitätsspital, Zürich, Schweiz.
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Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59:675-94. [PMID: 15200543 DOI: 10.1111/j.1365-2044.2004.03831.x] [Citation(s) in RCA: 786] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Problems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flow-charts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS. DISCLAIMER It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.
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Affiliation(s)
- J J Henderson
- Anaesthetic Department, Gartnavel General Hospital, 1053 Great Western Road, Glasgow G12 0YN, UK.
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