Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple ‘scalpel-finger-tube’ method

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

A case of telehealth-directed emergency front-of-neck access (FONA)

In this case, we describe the completion of emergency front-of-neck access by a novice provider facilitated by specialist telehealth support. A facility with limited advanced airway skills requested telehealth support for a critically unwell patient with severe hypoxic respiratory failure and acute delirium. Attempts to temporise his physiology with ketamine-facilitated non-invasive ventilation were unsuccessful, and he proceeded to rapid sequence intubation. Ultimately, intubation was unsuccessful and attempts at ventilation by laryngeal mask also failed. A Cannot Intubate, Cannot Oxygenate scenario was identified. The referring team had significant anxiety about performing a surgical front-of-neck access procedure. However, with telehealth support, this was ultimately completed by a novice provider, and the patient stabilised. The key issue identified was the need for the telehealth provider to take clinical governance of the procedure. The referring team also required assistance in completing an adequate neck incision, responding to bleeding, and determining the preferred technique.

Emergency front-of-neck access in cardiac arrest: A scoping review

BACKGROUND

Airway management is a core component of the treatment of cardiac arrest. Where a rescuer cannot establish a patent airway to provide oxygenation and ventilation using standard basic and advanced airway techniques, there may be a need to consider emergency front-of-neck airway access (eFONA, e.g., cricothyroidotomy), but there is limited evidence to inform this approach.

OBJECTIVES

This scoping review aims to identify the evidence for the use of eFONA techniques in patients with cardiac arrest.

METHODS

In November 2023, we searched Medline, Embase, and Cochrane Central to identify studies on eFONA in adults. We included randomised controlled trials, non-randomised studies, and case series with at least five cases that described any use of eFONA. We extracted data, including study setting, population characteristics, intervention characteristics, and outcomes. Our analysis focused on four key areas: incidence of eFONA, eFONA success rates, clinical outcomes, and complications.

RESULTS

The search identified 21,565 papers, of which 18,934 remained after de-duplication. After screening, we included 69 studies (53 reported incidence, 40 reported success rate, 38 reported clinical outcomes; 36 studies reported complications). We identified only one randomised controlled trial. Across studies, there was a total of 4,457 eFONA attempts, with a median of 31 attempts (interquartile range 16-56.5) per study. There was marked heterogeneity across studies that precluded any pooling of data. There were no studies that included only patients in cardiac arrest.

CONCLUSION

The available evidence for eFONA is extremely heterogeneous, with no studies specifically focusing on its use in adults with cardiac arrest.

Cricothyrotomy - In Unanticipated Difficult Intubation Cases with Respiratory Compromise

Introduction  Cricothyrotomy, percutaneous dilation tracheostomy, and tracheostomy are all cost-effective and safe techniques used in the management of critically ill patients who need an artificial airway other than endotracheal tube ventilation. The present study focused on enlightening on elective and emergency procedures performed on conditions present with difficult airways and also attempts to shed light on the aspects of securing an airway in anticipated and unanticipated difficult intubation. Objective  The objective of the study was to compare the three procedures conducted during difficult airway/failed intubation situations. Methods  The present retrospective observational study was conducted collecting data from patient files obtained at a tertiary healthcare center from 2013 to 2018. The difficult intubation cases were managed by ear, nose, and throat (ENT) surgeons. The study compared three methods: Cricothyrotomy, percutaneous dilation tracheostomy, and tracheostomy based on factors such as procedure duration, complications, and the instruments required for each procedure. Results  The study enrolled 85 patients, 61 males and 24 females, aged between 30 and 70 years old. To perform cricothyrotomy, only a simple blade was required. Cricothyrotomy had the shortest operating time (4.1±3.1 minutes) and the shortest time of full oxygen saturation (3 min). Percutaneous tracheostomy had the least amount of bleeding (1%). Cricothyrotomy significantly showed the least intraoperative bleeding than percutaneous dilation, tracheostomy, and tracheostomy ( p  = 0.001). Conclusion  Cricothyrotomy is preferable as it takes less time to perform, causes less bleeding, and takes the least time for full oxygen saturation than tracheostomy and percutaneous dilatational tracheostomy in "can't intubate, can't oxygenate" patients.

Evaluation of the Educational Value of Low-Cost Training Model for Emergency Cricothyrotomy

BACKGROUND

In this study, we aimed to evaluate the educational value and students' satisfaction with the hand-made low-cost cricothyrotomy simulation model.

MATERIALS AND METHODS

A low-cost and hand-made model and a high-fidelity model were used to assess the students. The students' knowledge and satisfaction were evaluated using a 10-item checklist and a satisfaction questionnaire, respectively. Medical interns in the present study participated in a two-hour briefing and debriefing session held in the Clinical Skills Training Center by an emergency attending doctor.

RESULTS

Based on the results of data analysis, no significant differences were found between the two groups in terms of gender, age, the month of internship, and last semester's grade (P = .628, .356, .847, and .421, respectively). We also found no significant differences between our groups in terms of the median score of each item in the assessment checklist (P = .838, .736, .805, .172, .439, .823, .243, .950, .812, and .756, respectively). The study groups had no significant difference in the median total scores of the checklist as well (P = .504). Regarding the students' satisfaction, our results showed that interns evaluated their experience of the model as positive (median scores of 4 and 5 out of 5). They also gave the hand-made model a median score of 7 in comparison with the high-fidelity model and 8 out of 10 for its usability.

CONCLUSION

The study results showed that a low-cost model could be as effective as an expensive high-fidelity model for teaching the necessary knowledge of cricothyrotomy techniques to medical trainees.

Success rate of prehospital emergency front-of-neck access (FONA): a systematic review and meta-analysis

BACKGROUND

Front-of-neck access (FONA) is an emergency procedure used as a last resort to achieve a patent airway in the prehospital environment. In this systematic review with meta-analysis, we aimed to evaluate the number and success rate of FONA procedures in the prehospital setting, including changes since 2017, when a surgical technique was outlined as the first-line prehospital method.

METHODS

A systematic literature search (PROSPERO CRD42022348975) was performed from inception of databases to July 2022 to identify studies in patients of any age undergoing prehospital FONA, followed by data extraction. Meta-analysis was used to derive pooled success rates. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

From 909 studies, 69 studies were included (33 low quality; 36 very low quality) with 3292 prehospital FONA attempts described (1229 available for analysis). The crude median success rate increased from 99.2% before 2017 to 100.0% after 2017. Meta-analysis revealed a pooled overall FONA success rate of 88.0% (95% confidence interval [CI], 85.0-91.0%). Surgical techniques had the highest success rate at a median of 100.0% (pooled rate=92.0%; 95% CI, 88.0-95.0%) vs 50.0% for needle techniques (pooled rate=52.0%; 95% CI, 28.0-76.0%).

CONCLUSIONS

Despite being a relatively rare procedure in the prehospital setting, the success rate for FONA is high. A surgical technique for FONA appears more successful than needle techniques, and supports existing UK prehospital guidelines.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022348975.

Successful surgical cricothyroidotomy following an obstetric "can't oxygenate" scenario: a narrative of enabling factors

The airway management of a patient requiring emergency caesarean delivery for fetal distress and pre-eclampsia with severe features is described. A difficult obstetric airway was anticipated prior to induction and managed with the use of decision-support guidelines and cognitive aids. Failed tracheal intubation later progressed to a "can't oxygenate" scenario necessitating front-of-neck-access via surgical cricothyroidotomy. We discuss the factors which facilitated the preparation and implementation of interventions required to successfully execute this high-acuity task.

Comparison of emergency airway management techniques in the performance of emergent Cricothyrotomy

Introduction

Emergent cricothyrotomy (EC) is a rare and lifesaving procedure to secure a difficult airway when other methods have failed. Many techniques have been discussed in the literature. This study aimed to identify major techniques used to perform EC in a regional trauma center and evaluate outcomes associated with the techniques.

Methods

Patients who underwent EC at Arrowhead Regional Medical Center between 1-1-2009 and 1-1-2019 were reviewed for eligibility for this study. Patients’ data were extracted from the trauma database. Chi-square tests were conducted to assess the difference on variables between the techniques.

Results

A total of 51 (0.17%) of these patients required EC and were included in the database. The two most prevalent techniques were the scalpel-bougie-tube (SBT) and the surgical cricothyrotomy technique (SCT). More than half (n = 27, 52.9%) of the cohort received the SBT. There was no statistically significant difference between the two techniques with regards to demographic variables, including age (p = 0.7528), injury severity score (ISS, p = 0.896), gender (p = 0.3709), and race (p = 0.8935). However, the SCT group had a statistically higher Glasgow Coma Scale (GCS) than the SBT group (p = 0.0036). There was no statistically significant difference in mortality or complications between these two groups (p = 0.2172 for mortality).

Discussion

Two techniques of EC were identified as preferred techniques. Both procedures were successful in securing an emergency airway, noting a difference in the time to completion of the two techniques. Given the rarity of the procedure, practitioners may choose the method based on their training and the availability of appropriate instruments.

A Proposed Guideline for Performance of Emergency Surgical Airways in Small Animals: Analysis of Five Unsuccessfully Managed Cannot Intubate, Cannot Oxygenate Cases

Objective—To describe three dogs and two cats diagnosed with a cannot intubate, cannot oxygenate (CICO) condition, and discuss the appropriateness and timing of emergency front-of-neck airway access (eFONA). The authors aim to increase awareness of CICO events and effective management strategies, which may result in faster airway access and improve patient outcomes. Case series summary—Three dogs and two cats could not be easily intubated resulting in the inability to deliver oxygen and contributing to their death. Emergency front-of-neck airway access was attempted in three cases, it could not be performed in one when indicated, and it was not considered in managing another. Conclusions—This is the first report of small animals suffering CICO emergencies and tracheostomy attempts without a concurrently secured airway. Cannot intubate, cannot oxygenate events and eFONA attempts were managed sub-optimally in all cases, which likely contributed to the poor outcomes. Rapid diagnosis of CICO and early eFONA using appropriate techniques has the potential to improve the management of difficult airways in small animals.

Development of a Simulation Surgical Cricothyroidotomy Curriculum for Novice Providers: A Learning Curve Study

INTRODUCTION

Airway obstruction is the third most common cause of preventable death on the battlefield, accounting for 1%-2% of total combat fatalities. No previous surgical cricothyroidotomy (SC) studies have analyzed the learning curve required to obtain proficiency despite being studied in numerous other surgical technique training experiments. The aims of this study were to establish expert SC performance criteria, develop a novel standardized SC curriculum, and determine the necessary number of practice iterations required by a novice to reach this pre-determined performance goal.

MATERIALS AND METHODS

A standardized checklist and SC performance standards were established based on the performance of 12 board certified Military Health System surgeons with prior experience on performing a SC using a simulated trauma mannequin. Expert-level criteria were defined as a SC time to completion of 40 s or less and checklist score of at least 9/10, including all critical steps. Study subjects included 89 novice providers (54 active-duty first- and second-year medical students and 35 Navy corpsmen). Subjects received instruction on performing a SC using the principles of mastery learning and performed a final test of SC proficiency on a trauma mannequin within a realistic simulated MEDEVAC helicopter. The total number of subject practice attempts, checklist scores, and time to completion were measured and/or blindly scored. Learning curve and exponential plateau equations were used to characterize their improvement in mean time to SC completion and checklist scores.

RESULTS

Mean pre-test knowledge scores for the entire group were 11.8 ± 3.1 out of 24 points. Total mean practice learning plateaued at checklist scores of 9.9/10 after 7 iterations and at a mean completion time of 30.4 s after 10 iterations. During the final test performance in the helicopter, 67.4% of subjects achieved expert-level performance on the first attempt. All subjects achieved expert-level performance by the end of two additional attempts. While a significantly larger proportion of medical students (79.9%) successfully completed the helicopter test on the first attempt compared to corpsmen (54.3%), there were no statistically significant differences in mean SC completion times and checklist scores between both groups (P > 0.05). Medical students performed a SC only 1.3 s faster and scored only 0.16 points higher than corpsmen. The effect size for differences were small to negligible (Cohen's d range 0.18-0.33 for SC completion time; Cohen's d range 0.45-0.46 for checklist scores).

CONCLUSION

This study successfully defined SC checklist scores and completion times based on the performance of experienced surgeons on a simulator. Using these criteria and the principles of mastery learning, novices with little knowledge and experience in SC were successfully trained to the level of experienced providers. All subjects met performance targets after training and overall performance plateaued after approximately seven iterations. Over two-thirds of subjects achieved the performance target on the first testing attempt in a simulated helicopter environment. Performance was comparable between medical student and corpsmen subgroups. Further research will assess the durability of maintaining SC skills and the timing for introducing refresher courses after initial skill acquisition.

Prehospital Emergency Cricothyrotomy in Dogs Part 1: Experiences With Commercial Cricothyrotomy Kits

The surgical cricothyrotomy (CTT) has been recommended for emergency front of neck airway access (eFONA) during a cannot intubate, cannot oxygenate scenario for military working dogs (MWD) and civilian law enforcement working dogs (operational K9s). In prehospital and austere environments, combat medics and emergency medical service providers are expected to administer emergency medical care to working dogs and may only have emergency airway kits designed for humans at their disposal. The objective of this article is to provide a detailed description of the application of such devices in cadaver dogs and highlight potential alterations to manufacturer guidelines required for successful tube placement. The kits evaluated included the Portex® PCK, Melker universal cricothyrotomy kit and H&H® emergency cricothyrotomy kit. A novel technique for awake cricothyrotomy in the dog is also described, which can also be considered for in-hospital use, together with the open surgical method described for the H&H® kit. To the authors' knowledge, this is the first publication documenting and providing instruction on the application of commercial cricothyrotomy kits in dogs.

Case series and review of emergency front-of-neck surgical airways from The Australian and New Zealand Emergency Department Airway Registry

BACKGROUND

An emergency front-of-neck access (eFONA), also called can't intubate, can't oxygenate (CICO) rescue, is a rare event. Little is known about the performance of surgical or percutaneous airways in EDs across Australia and New Zealand.

OBJECTIVE

To describe the management of cases resulting in an eFONA, and recorded in The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR).

METHODS

A retrospective case series and review of ED patients undergoing surgical or percutaneous airways. Data were collected prospectively over 60 months between 2010 and 2015 from 44 participating EDs.

RESULTS

An eFONA/CICO rescue airway was performed on 15 adult patients: 14 cricothyroidotomies (0.3% of registry intubations) and one tracheostomy. The indication for intubation was 60% trauma and 40% medical aetiologies. The intubator specialty was emergency medicine in eight (53.3%) episodes. Thirteen (86.7%) cricothyroidotomies and the sole tracheostomy (6.7%) were performed at major referral hospitals with 12 (80%) surgical airways out of hours. In four (26.7%) cases, cricothyroidotomy was performed as the primary intubation method. Pre-oxygenation techniques were used in 14 (93.3%) episodes; apnoeic oxygenation in four (26.7%).

CONCLUSIONS

Most cases demonstrated deviations from standard difficult airway practice, which may have increased the likelihood of performance of a surgical airway, and its increased likelihood out of hours. Our findings may inform training strategies to improve care for ED patients requiring this critical intervention. We recommend further discussion of proposed standard terminology for emergency surgical or percutaneous airways, to facilitate clear crisis communication.

Cricothyrotomy Is Faster Than Tracheostomy for Emergency Front-of-Neck Airway Access in Dogs

Objectives: In novice final year veterinary students, we sought to: (1) compare the procedure time between a novel cricothyrotomy (CTT) technique and an abbreviated tracheostomy (TT) technique in canine cadavers, (2) assess the success rate of each procedure, (3) assess the complication rate of each procedure via a damage score, (4) evaluate the technical difficulty of each procedure and (5) determine the preferred procedure of study participants for emergency front-of-neck access.

Materials and Methods: A prospective, cross-over, block randomised trial was performed, where veterinary students completed CTT and TT procedures on cadaver dogs. Eight students were recruited and performed 32 procedures on 16 dogs. A generalised estimating equation approach to modelling the procedure times was used.

Results: The procedure time was significantly faster for the CTT than the TT technique, on average (p < 0.001). The mean time taken to complete the CTT technique was 49.6 s (95% CI: 29.5–69.6) faster on average, with a mean CTT time of less than half that of the TT. When taking into account the attempt number, the procedure time for a CTT was 66.4 s (95% CI: 38.9–93.9) faster than TT for the first attempt, and for the second attempt, this was 32.7 s (95% CI: 15.2–50.2) faster, on average. The success rate for both procedures was 100% and there was no difference detected in the damage or difficulty scores (P = 0.13 and 0.08, respectively). Seven of eight participants preferred the CTT.

Clinical Significance: CTT warrants consideration as the primary option for emergency front-of-neck airway access for dogs.

Effectiveness of Surgical Airway Training Laboratory and Assessment of Skill and Knowledge Fade in Surgical Airway Establishment Among Prehospital Providers

OBJECTIVE

This study aimed to evaluate the effectiveness of surgical airway education composed of training using cadavers. The secondary aim was to evaluate the presence and degree of knowledge and skill fade 3 months after training.

METHODS

Thirteen participants were recruited from a helicopter emergency medical services program. Participants were assessed at multiple points during training using a multiple-choice examination and a timed evaluation of the ability to establish a surgical airway.

RESULTS

Training was effective at increasing knowledge and skill, with a mean increase in multiple-choice examination scores of 14.6 percentage points after training (P < .01) and a mean decrease in time to airway establishment of 26 seconds (P < .01). The training was not associated with the ability to establish a surgical airway in less than 40 seconds, with only 46% of participants able to do so. There was no evidence of knowledge or skill fade at 3 months after training.

CONCLUSION

Surgical airway training that includes both didactic and clinical learning using human cadavers is effective at increasing both knowledge and skill. Additional training is needed to establish competency in consistently performing surgical airways in less than 40 seconds. No knowledge or skill fade was present at 3 months after training.

Impact of Succinct Training on Open Cricothyrotomy Performance: A Randomized, Prospective, Observational Study of U.S. Army First Responders

INTRODUCTION

Primary airway failure has become the second most common cause of potentially survivable battlefield fatality. Cricothyrotomy is taught to all U.S. military providers as a means of securing an airway in extremis. However, retrospective studies show that cricothyrotomy failure rates for U.S. military first responders performing the procedure in combat is 33%. Our hypothesis was that these rates could be improved.

MATERIALS AND METHODS

We conducted a randomized, prospective, observational study to evaluate the effects of inexpensive, succinct training on open cricothyrotomy performance by studying two unique U.S. Army First Responder participant groups. One participant group consisted of regular U.S. Army Medics (68 Ws). The second group was Special Operations Combat Medics. We evaluated both groups' baseline ability to correctly perform a cricothyrotomy and then randomly assigned individuals within each group to either a training or practice group.

RESULTS

The training group had a higher proportion of success and performed the cricothyrotomy faster than the practice group with 68 Ws group appearing to benefit most from training: their procedural success rates increased by an average of 23%, and their average time-to-correct-placement decreased by 21 seconds-a 33% improvement over baseline.

CONCLUSION

With one manikin, a qualified trainer, and $35 worth of expendable supplies, 10 medics could be trained in the procedure in just 2-3 hours. Our study suggests that this simple intervention has the potential to significantly improve U.S. Army First Responders' ability to correctly perform an open cricothyrotomy and drastically decrease the time needed to perform this lifesaving procedure correctly, possibly saving one in four potentially survivable combat casualties suffering from airway compromise.

Guidelines for Tracheostomy From the Korean Bronchoesophagological Society

The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.

Emergency Airways After Himalayan Black Bear Attacks in Bhutan

INTRODUCTION

Although bear attacks on humans are uncommon, the incidence has slowly risen as human populations increasingly encroach on wilderness habitat. In the Kingdom of Bhutan, Himalayan black bear attacks occur regularly. Bears preferentially attack the face, often causing injuries that require surgical airway management. We sought to determine how often patients injured by Himalayan black bears required airway management during initial resuscitation.

METHODS

We conducted a retrospective review of emergency department and admission records of the 3 referral hospitals in Bhutan. We identified all victims of bear attacks in Bhutan who received emergency airway management, including surgical airway management during the period from August 2013 to December 2017.

RESULTS

There were 21 patients who were treated for injuries from bear attacks during the study period. Of these, 12 required emergency airway management. Three patients who required emergency airways (2 intubations, 1 surgical airway) were attacked near a regional referral hospital and received care at that hospital. The remaining 9 patients received care from the helicopter emergency medical services (HEMS) retrieval team (1 intubation, 8 surgical airways).

CONCLUSIONS

The use of highly trained HEMS critical care retrieval teams may improve outcomes in critically injured patients who require time-critical airway management in remote areas. Countries such as Bhutan with populations far from emergency and critical care might benefit from the establishment of HEMS critical care retrieval services. HEMS teams providing care while retrieving patients from austere environments should be expert in emergency airway management.

Incidence and outcomes of cricothyrotomy in the "cannot intubate, cannot oxygenate" situation

Few data are available regarding factors that impact cricothyrotomy use and outcome in general hospital setting. The aim of the present study was to determine the incidence and outcomes of the patients underwent cricothyrotomy in a "cannot intubate, cannot oxygenate" (CICO) situation at university hospitals in Korea.This was a retrospective review of the electronic medical records of consecutive patients who underwent cricothyrotomy during a CICO situation between March, 2007, and October, 2018, at 2 university hospitals in Korea. Data regarding patient characteristics and outcomes were analyzed using descriptive statistics.During the study period, a total of 10,187 tracheal intubations were attempted and 23 patients received cricothyrotomy. Hospitalwide incidence of cricothyrotomy was 2.3 per 1000 tracheal intubations (0.23%). The majority of cricothyrotomy procedures (22 cases, 95.7%) were performed in the emergency department (ED); 1 cricothyrotomy was attempted in the endoscopy room. In the ED, 5663 intubations were attempted and the incidence of cricothyrotomy was 3.9 per 1000 tracheal intubations (0.39%). Survival rate at hospital discharge was 47.8% (11 of 23 cases). Except for cardiac arrest at admission, survival rate was 62.5% (10 of 16 cases). Successful cricothyrotomy was performed in 17 patients (73.9%) and 9 patients (52.9%) were survived. Among 6 patients of failed cricothyrotomy (26.1%), 2 patients (33.3%) were survived. After failure of cricothyrotomy, various methods of securing airway were established: 3 tracheal intubations, 1 nasotracheal intubation, and 1 tracheostomy.The success rate of cricothyrotomy and survival rate in the CICO situation were not high. After failure of cricothyrotomy, various methods of securing airway were performed.

Emergency front of neck airway: What do trainers in the UK teach? A national survey

Background and Aims:

Front of neck airway (FONA) is the final step to deliver oxygen in the difficult airway management algorithms. The Difficult Airway Society 2015 guidelines have recommended a standardized scalpel cricothyroidotomy technique for an emergency FONA. There is a wide variability in the FONA techniques with disparate approaches and training. We conducted a national postal survey to evaluate current teaching, availability of equipment, experienced surgical help and prevalent attitudes in the face of a can’t intubate, can’t oxygenate situation.

Material and Methods:

The postal survey was addressed to airway leads across National Health Service hospitals in the United Kingdom (UK). In the anesthetic departments with no designated airway leads, the survey was addressed to the respective college tutors. A total of 259 survey questionnaires were posted.

Results:

We received 209 survey replies with an overall response rate of 81%. Although 75% of respondents preferred scalpel cricothyroidotomy, only 28% of the anesthetic departments considered in-house FONA training as mandatory for all grades of anesthetists. Scalpel-bougie-tube kits were available in 95% of the anesthetic departments, either solely or in combination with other FONA devices.

Conclusion:

The survey has demonstrated that a majority of the airway trainers in the UK would prefer scalpel cricothyroidotomy as emergency FONA. There is a significant variation and deficiency in the current levels of FONA training. Hence, it is important that emergency FONA training is standardized and imparted at a multidisciplinary level.

Cricothyrotomy in Helicopter Emergency Medical Service Transport

OBJECTIVE

Airway management is a requisite skill set for helicopter emergency medical service (HEMS) providers. Cricothyrotomy is a potentially lifesaving skill that is used when other airway maneuvers fail. The authors reviewed all transports by a helicopter program in which cricothyrotomy was performed to assess the frequency, success, and technique.

METHODS

This was a retrospective chart review of air medical patient records from an electronic medical record system over a 112-month period.

RESULTS

During the study period, 22,434 patients were transported, 13 (.057%) of whom underwent cricothyrotomy. The typical patient was a male trauma victim with a mean Glasgow Coma Score of 5 transported from an accident scene with a mean age of 34.3 years. Six (46%) of the patients were alive at 24 hours. All patients (13/100%) received attempted endotracheal intubation; the mean number of attempts per patient was 2. The success rate was 100% with all patients ventilated via cricothyrotomy.

CONCLUSION

This study shows cricothyrotomy is a rarely performed skill but that HEMS providers are able to successfully learn the skill with proper training and oversight.

Emergency Cricothyrotomy Performed by Surgical Airway-naive Medical Personnel: A Randomized Crossover Study in Cadavers Comparing Three Commonly Used Techniques

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.

Management of pregnancy and obstetric complications in prehospital trauma care: faculty of prehospital care consensus guidelines

This consensus statement seeks to provide clear guidance for the management of pregnant trauma patients in the prehospital setting. Pregnant patients sustaining trauma injuries have certain clinical management priorities beyond that of the non-pregnant trauma patients and that if overlooked may be detrimental to maternal and fetal outcomes.

Emergency Surgical Airways Following Activation of a Difficult Airway Management Team in Hospitalized Critically Ill Patients: A Case Series

INTRODUCTION

An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments.

METHODS

We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT).

RESULTS

Of 207 DAMT activations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event.

CONCLUSION

An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.

A hierarchical task analysis of cricothyroidotomy procedure for a virtual airway skills trainer simulator

BACKGROUND

Despite the critical importance of cricothyroidotomy (CCT) for patient in extremis, clinical experience with CCT is infrequent, and current training tools are inadequate. The long-term goal is to develop a virtual airway skills trainer that requires a thorough task analysis to determine the critical procedural steps, learning metrics, and parameters for assessment.

METHODS

Hierarchical task analysis is performed to describe major tasks and subtasks for CCT. A rubric for performance scoring for each task was derived, and possible operative errors were identified.

RESULTS

Time series analyses for 7 CCT videos were performed with 3 different observers. According to Pearson's correlation tests, 3 of the 7 major tasks had a strong correlation between their task times and performance scores.

CONCLUSIONS

The task analysis forms the core of a proposed virtual CCT simulator, and highlights links between performance time and accuracy when teaching individual surgical steps of the procedure.

Every surgical resident should know how to perform a cricothyrotomy: an inexpensive cricothyrotomy task trainer for teaching and assessing surgical trainees

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.

Development of a standard operating procedure and checklist for rapid sequence induction in the critically ill

INTRODUCTION

Rapid sequence induction (RSI) of critically ill patients outside of theatres is associated with a higher risk of hypoxia, cardiovascular collapse and death. In the prehospital and military environments, there is an increasing awareness of the benefits of standardised practice and checklists.

METHODS

We conducted a non-systematic review of literature pertaining to key components of RSI preparation and management. A standard operating procedure (SOP) for in-hospital RSI was developed based on this and experience from large teaching hospital anaesthesia and critical care departments.

RESULTS

The SOP consists of a RSI equipment set-up sheet, pre-RSI checklist and failed airway algorithm. The SOP should improve RSI preparation, crew resource management and first pass intubation success while minimising adverse events.

CONCLUSION

Based on the presented literature, we believe the evidence is sufficient to recommend adoption of the core components in the suggested SOP. This standardised approach to RSI in the critically ill may reduce the current high incidence of adverse events and hopefully improve patient outcomes.

Emergency cricothyrotomy--a systematic review

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.

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.