Cricothyrotomy technique: standard versus the rapid four step technique

An overview of complications associated with open and percutaneous tracheostomy procedures

Tracheostomy, whether open or percutaneous, is a commonly performed procedure and is intended to provide long-term surgical airway for patients who are dependent on mechanical ventilatory support or require (for various reasons) an alternative airway conduit. Due to its invasive and physiologically critical nature, tracheostomy placement can be associated with significant morbidity and even mortality. This article provides a comprehensive overview of commonly encountered complications that may occur during and after the tracheal airway placement, including both short- and long-term postoperative morbidity.

Parker Flex-Tip or standard tracheal tube for percutaneous emergency airway access?

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.

Emergency cricothyrotomy in infants--evaluation of a novel device in an animal model

BACKGROUND

According to different algorithms of airway management, emergency cricothyrotomy is the final step in managing an otherwise not accessible airway. As an alternative to an open surgical procedure, minimally invasive approaches exist. Quicktrach baby™ is a commercially available set for a minimal invasive cricothyrotomy in infants. The set consists of a plastic cannula over a metal needle for direct placement in the trachea. So far, this device has not been evaluated for its intended use.

OBJECTIVES

We hypothesize that Quicktrach baby™ allows the establishment of an emergency airway. The aim was to prove that the device is easy to handle and the cricothyrotomy fast to perform.

METHODS

After approval of the local ethics committee, the study was performed on the cadavers of 10 adult rabbits. Cricothyrotomy was performed with Quicktrach baby™. Successful placement, performance time, and complication rate were documented. Possible ventilation with a breathing bag was evaluated. Data are reported as mean and interquartile range.

RESULTS

Successful placement of Quicktrach baby™ was possible in all attempts. The placement took 31 [23-43] s. In two cases, a fracture of the cricoid's cartilage was seen. In one animal, damage to the posterior wall mucosa was observed. In all cases, sufficient ventilation was possible.

CONCLUSIONS

Quicktrach™ baby proved to be a reliable technique. In the animal model, it is easy and fast to perform. Only a few minor complications occurred. Sufficient ventilation was possible in all attempts.

Retrograde intubation

Airway management in the emergency department is a critical skill that must be mastered by emergency physicians. When rapid-sequence induction with oral-tracheal intubation performed by way of direct laryngoscopy is difficult or impossible due to a variety of circumstances, an alternative method or device must be used for a rescue airway. Retrograde intubation requires little equipment and has few contraindications. This technique is easy to learn and has a high level of skill retention. Familiarity with this technique is a valuable addition to the airway-management armamentarium of emergency physicians caring for ill or injured patients. Variations of the technique have been described, and their use depends on the individual circumstances.

Developing technical expertise in emergency medicine--the role of simulation in procedural skill acquisition

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.

Emergency cricothyrotomy: a randomised crossover trial comparing the wire-guided and catheter-over-needle techniques

In a randomised crossover trial, we compared a wire-guided cricothyrotomy technique (Minitrach) with a catheter-over-needle technique (Quicktrach). Performance time, ease of method, accuracy in placement and complication rate were compared. Ten anaesthesiology and 10 ENT residents performed cricothyrotomies with both techniques on prepared pig larynxes. The catheter-over-needle technique was faster than the wire-guided (48 compared to 150 s, p < 0.001) and subjectively easier to perform (VAS-score 2.1 vs. 5.6, p < 0.001). Correct positioning of the cannula could be achieved in 95% and 85%, respectively (NS). There was one complication in the catheter-over-needle group compared to five in the wire-guided group. We conclude that the wire-guided minitracheotomy kit is unsuitable for emergency cricothyrotomies performed by inexperienced practitioners. On the other hand, the catheter-over-needle technique appears to be quick, safe and reliable.