Emergency cricothyrotomy--a systematic review

Prehospital Cricothyrotomy: A Narrative Review of Technical, Educational, and Operational Considerations for Procedure Optimization

BACKGROUND

Definitive airway management is a requisite skill in the prehospital setting, most often accomplished with either an endotracheal tube or supraglottic airway. When clinicians encounter a cannot oxygenate and cannot ventilate scenario, a patient's airway still must be secured. Prehospital cricothyrotomy is a high acuity, low frequency procedure used to secure the airway through the anterior neck. Patients who require cricothyrotomy often have significant comorbid conditions and mortality, and there can be a high rate of procedural complications. The ability to perform a cricothyrotomy is within the scope of practice for many prehospital clinicians and mastery of the procedure is crucial for patient outcomes. Despite this, initial training on the procedure is minimal, and paramedics report discomfort in their ability to perform the procedure.

OBJECTIVE

Review and summarize the best available evidence relating to the performance of cricothyrotomies and propose technical, educational, and operational considerations to minimize complications and optimize success of prehospital cricothyrotomies.

DISCUSSION

Technical considerations when performing cricothyrotomy in the prehospital setting can be used to mitigate airway misplacement, mainstem intubation, and hemorrhage. Educational consideration should include focus on a singular technique, use of established curriculum, spaced repetition with either simulation or mental practice, and a focus on intention training of when to perform the procedure. The preferred technique from the National Association of Emergency Medical Service (EMS) Physician guidelines is the surgical technique. Operational considerations to optimize a successful procedure should include checklists, preassembled kits, and robust quality improvement and insurance after a cricothyrotomy is performed.

CONCLUSIONS

By focusing on technical, educational, and operation considerations relating to prehospital cricothyrotomy, prehospital clinicians can optimize the chance for procedural success.

Randomized crossover trial comparing two open surgical cricothyrotomy techniques

Objective

Emergency cricothyrotomy is a life-saving procedure that is performed in "can't intubate can't oxygenate" scenario. A recent study comparing an open surgical technique using a bougie and endotracheal tube (ETT) with a Seldinger technique using the Cook Melker catheter showed that the open technique was quicker but suggested that the open technique could be quicker if using the Melker catheter instead of a bougie and ETT. The objective of this study was to compare the surgical technique using bougie and ETT with an open technique using the Melker catheter.

Methods

A randomized crossover trial was conducted involving emergency physicians (EPs) and trainees. Participants performed both techniques in succession on an airway model, with the technique performed first being randomized for each participant. The primary outcome was time to first insufflation of the artificial lung. Participants also indicated their comfort with each technique on a 5-point Likert scale and which technique they preferred.

Results

Seventeen EPs and 19 trainees participated. The Melker catheter technique was performed quicker with a mean time of 29.2 s versus 44.3 s for the bougie/ETT technique (difference 15.1 s, 95% confidence interval 10.8-19.4 s). The Melker catheter was most preferred by participants (61% vs. 39%). There was no significant difference in the comfort ratings between each technique. Time to model lung insufflation was not affected by training level or time since last performed a cricothyrotomy, either real or simulated.

Conclusions

The Melker catheter was quicker to perform and the most preferred by participants.

Cricothyroidotomy in out-of-hospital cardiac arrest: An observational study

Aim

To describe the incidence, characteristics, success rates, and outcomes of out-of-hospital cardiac arrest (OHCA) patients receiving cricothyroidotomy.

Methods

Over an 18-year period, we retrospectively analysed patient care records and cardiac arrest registry data for cricothyroidotomy cases. Multivariable logistic regression analysis was used to examine associations between study characteristics and cricothyroidotomy success.

Results

We identified 80 cricothyroidotomies, 56 of which occurred in OHCA. The incidence of cricothyroidotomy in OHCA was 1.1 per 1,000 attempted resuscitations and increased over the study period (incidence rate ratio [IRR] = 1.13, 95 % confidence interval [CI]: 1.02-1.25, p = 0.023). The overall success rate was 68.8 % (n = 55/80), with lower success in cardiac arrest (n = 33/56, 58.9 %) than non-cardiac arrest patients (n = 22/24, 91.7 %). In OHCA, success rates were higher for surgical compared to needle techniques (88.2 % vs. 54.6 %, p = 0.003). Cardiac arrest (odds ratio [OR] 0.09, 95 % CI 0.16-0.51) and needle techniques (OR 0.11, 95 % CI 0.02-0.56) were independently associated with lower odds of procedural success, while male sex (OR 10.06, 95 % CI 2.00-50.62) was associated with higher odds. Return of spontaneous circulation occurred in 44.6 % (n = 22/56), with 35.7 % (n = 20/56) surviving to hospital and 7.1 % (n = 4/56) surviving to hospital discharge. Procedural complications included cardiac arrest (n = 6/56, 10.7 %), minor bleeding (n = 5/56, 8.9 %), surgical emphysema (n = 3/56, 5.4 %), and major bleeding (n = 2/56, 3.6 %).

Conclusion

We found cricothyroidotomy in OHCA to be associated with low rates of procedural success and high mortality rates. Further studies are required to assess the role and potential benefits of cricothyroidotomy in cardiac arrest.

Comparison of Point-of-Care Ultrasound Guidance and the Traditional Approach in Performing Simulated Emergent Cricothyroidotomy Among Emergency Medicine Physicians, Residents, and Students

Objective  Emergency cricothyroidotomy (EC) is a rare procedure used to establish airway access when both endotracheal intubation and bag-mask ventilation have failed. Point-of-care ultrasound (POCUS) has been proposed as an adjunct to aid in identifying anatomical landmarks. However, its impact on emergency physicians when performing EC remains unclear. This study compared emergency physician and student confidence, preference, and procedure time between POCUS and traditional palpation for EC.  Methods  Our study utilized a randomized controlled crossover design. Emergency medicine providers attended a didactic lecture demonstrating traditional palpation and POCUS techniques for EC. The participants were randomly allocated to two simulation groups. One group started with the palpation of landmarks, while the other group started with POCUS landmark identification. A randomized crossover design was employed, and in a subsequent simulation, the reverse technique was utilized. Time to anatomic landmark identification was recorded. Participants completed a survey assessing their confidence and preference. Procedure times and confidence level differences were examined via Wilcoxon signed-rank tests.  Results  Sixteen participants completed the survey and were included in the final analysis. All participants successfully performed EC with the two landmark identification techniques. There was no significant difference in self-reported confidence between POCUS and palpation (p = 0.17). Landmark identification by palpation was significantly faster than POCUS (p = 0.001). A total of 10 (63%) participants preferred palpation over POCUS.  Conclusions  Both POCUS and traditional palpation were effective in identifying anatomical landmarks for EC. Although palpation was significantly quicker, confidence and preference between the two techniques were similar. The results suggest that both approaches can benefit clinical practice, depending on the context and provider familiarity. Further studies with larger cohorts and real-world scenarios are recommended to explore the effectiveness and safety of POCUS in EC.

Favour the best in case of emergency cricothyroidotomy-a randomized cross-over trial on manikin focused training and simulation of common devices

Background

Performing an emergency cricothyroidotomy (EC) is extremely challenging, the devices used should be easy to handle and the selected technique reliable. However, there is still an ongoing debate concerning the most superior technique.

Methods

Three different techniques were compared using a standardized, simulated scenario regarding handling, performing, training and decision making: The scalpel-bougie technique (SBT), the surgical anatomical preparation technique (SAPT) and the Seldinger technique (ST). First, anaesthesia residents and trainees, paramedics and medical students (each group n = 50) performed a cricothyroidotomy randomly assigned with each of the three devices on a simulator manikin. The time needed for successful cricothyroidotomy was the primary endpoint. Secondary endpoints included first-attempt success rate, number of attempts and user-satisfaction. The second part of the study investigated the impact of prior hands-on training on both material selection for EC and on time to decision-making in a simulated "cannot intubate cannot ventilate" situation.

Results

The simulated scenario revealed that SBT and SAPT were significantly faster than percutaneous EC with ST (p < 0.0001). Success rate was 100% for the first attempt with SBT and SAPT. Significant differences were found with regard to user-satisfaction between individual techniques (p < 0.0001). In terms of user-friendliness, SBT was predominantly assessed as easy (87%). Prior training had a large impact regarding choice of devises (p < 0.05), and time to decision making (p = 0.05; 180 s vs. 233 s).

Conclusion

This study supports the use of a surgical technique for EC and also a regular training to create familiarity with the materials and the process itself.The trial was registered before study start on 11.11.2018 at ClinicalTrials.gov (NCT: 2018-13819) with Nicole Didion as the principal investigator.

Front of neck airway in Finnish helicopter emergency medical services

INTRODUCTION

An emergent front of neck airway (FONA) is needed when a 'can't intubate, can't oxygenate' crisis occurs. A FONA may also in specific cases be the primary choice of airway management. Two techniques exist for FONA, with literature favouring the surgical technique over the percutaneous. The reported need for a prehospital FONA is fortunately rare as the mortality has been shown to be high. Due to the low incidence, literature on FONA is limited with regards to different settings, techniques and operators. As a foundation for future research and improvement of patient care, we aim to describe the frequency, indications, technique, success, and outcomes of FONA in the Finnish helicopter emergency medical services (HEMS).

MATERIALS AND METHODS

This retrospective descriptive study reviews FONA performed at the Finnish HEMS during 1.1.2012 to 8.9.2019. The Finnish HEMS consists of six units, staffed mainly by anaesthesiologists. Clinical data was gathered from a national HEMS database and trough chart reviews. Data on mortality was obtained from a population registry. Only descriptive statistics were performed.

RESULTS

A total of 22 FONA were performed during the study period, 7 were primary and 14 performed after failure to intubate (missing data regarding indication for one attempt). This equals a 0.13 % (14/10,813) need for a rescue FONA and a rate of 0.20 % (22/10,813) FONA out of all advanced airway management. All but one FONA was performed using a surgical approach (20/21, 95 %, missing data = 1) and all were successful (22/22, 100 %). Indications were mainly cardiac arrest (10/22, 45 %) and trauma (6/22, 27 %), and the most common reason for a need for a secondary FONA was obstruction of airway by food or fluids (7/14, 50 %). On-scene mortality was 36 % (8/22) and 30-day mortality 90 % (19/21, missing data = 1).

CONCLUSION

The need for FONA is scarce in a HEMS system with experienced airway providers. Even though the procedure is successfully performed, the mortality is markedly high.

Prehospital Surgical Cricothyrotomy in a Ground-Based 9-1-1 EMS System: A Retrospective Review

BACKGROUND

Airway management is a cornerstone in the prehospital care of critically ill or injured patients. Surgical cricothyrotomy offers a rapid and effective solution when oxygenation and ventilation fail using less-invasive techniques. However, the exact indications, incidence, and success of prehospital surgical cricothyrotomy are unknown, with variable rates reported in the literature. This study aimed to examine prehospital indications and success rates for surgical cricothyrotomy within a large, suburban, ground-based Emergency Medical Services (EMS) system.

METHODS

This is a retrospective analysis of 31 patients who underwent paramedic performed surgical cricothyrotomy from 2012 through 2022. Key demographic parameters were analyzed, including the incidence of cardiac arrest, call type (trauma versus medical), initial airway management attempts, number of endotracheal intubation (ETI) attempts before surgical airway, and average time to the establishment of a surgical airway in relation to the number of ETI attempts. Surgical cricothyrotomy success was defined as the acquisition of four-phase end-tidal capnography reading. The primary data sources were the EMS electronic medical records, and descriptive statistics were calculated.

RESULTS

A total of 31 patients were included in the final analysis. Of those who received a surgical cricothyrotomy, 42% (13/31) occurred in the trauma setting, while 58% (18/31) were medical calls. In all patients who underwent surgical cricothyrotomy, the median (IQR) time to the procedure was 17 minutes (IQR = 11-24). In trauma patients, the median time to surgical cricothyrotomy was 12 minutes (IQR = 9-19) versus 19 minutes (IQR = 14-33) in medical patients. End-tidal carbon dioxide (ETCO2) detection and placement success was confirmed in 94% (29/31) of patients. Endotracheal intubation was attempted in 55% (17/31) before subsequent surgical cricothyrotomy, with 29% (9/31) receiving more than one ETI attempt. The median time to surgical cricothyrotomy when multiple prior intubation attempts occurred was 33 minutes (IQR = 23-36) compared to 14.5 minutes (IQR = 6-19) in patients without a preceding intubation attempt.

CONCLUSION

Prehospital surgical airway can be performed by paramedics with a high degree of success. Identification of the need for surgical cricothyrotomy should be determined as soon as possible to allow for rapid securement of the airway and to ensure adequate oxygenation and ventilation.

Impact of airway devices and emergency airway techniques characteristics on airway adverse events in mainland China: a cross-sectional study

BACKGROUND

Novel airway devices are becoming widely available, yet it is unclear whether the techniques or preferences of airway practitioners for airway management have been impacted. Given these facts, a cross-sectional study of the current status of airway management in mainland China was conducted and compared with previous survey findings.

METHODS

The national survey was conducted from November 7th to November 28th, 2022. An electronic survey was sent to the New Youth Anesthesia Forum to examine the availability of airway devices, preference for front-of-neck access (FONA) techniques, the incidence of adverse airway events, and the status of airway management training.

RESULTS

Questionnaires were completed by 3783 respondents, with a response rate of 72.14%. So far, the availability of optical airway devices has improved dramatically, with the availability of videolaryngoscopes reaching 97.18%. When encountering "cannot intubate, cannot ventilate" (CICV) scenarios, the majority of respondents would prefer needle cricothyrotomy to establish FONA. However, less than a quarter of respondents had actually performed it. Moreover, the incidence of airway adverse events from 2016 to 2022 was 11.48%, of which 5.13% were brain damage or death. Multivariate logistic regression analysis revealed that the ability to perform FONA techniques (odds ratio [OR] 0.23, 95% CI: 0.16, 0.32; P<0.001) and the availability of difficult airway management carts or kits (OR 0.59, 95% CI 0.41, 0.85; P=0.005) were associated with a lower incidence of airway adverse events.

CONCLUSIONS

Optical airway devices can overcome some of the challenges posed by difficult airways, yet the CICV scenario remains a major obstacle. The future focus of airway management should be training, particularly for complicated emergency airway techniques.

Determination of the Cricothyroid Membrane Height by Age and Sex and Optimal Tracheal Tube Size

OBJECTIVES

The primary aim of this study was to determine the average cricothyroid membrane (CTM) height in healthy volunteers, and the secondary aim was to determine the hypothetical success rate for emergency cricothyrotomy with a tracheal tube with an 8.0 mm outer diameter.

METHODS

This study included healthy volunteers aged 18 years and older. The participants' clinical characteristics were recorded, and their CTM height was measured using ultrasound, with their necks placed sequentially in the neutral and extension positions. The relationship between the CTM height and sex, age, height, weight, body mass index, and sternomental distance was evaluated using linear regression analysis. An equation that could estimate the height of the CTM was obtained with the parameters found significant in this analysis.

RESULTS

Of the 340 participants, 208 (61.2%) were male. The mean (SD) height of the CTM in the extension position was 9.60 (1.54) mm, and it was significantly shorter in the women than in the men (8.72 [1.19] mm vs. 10.16 [1.48] mm, p < 0.001). Among the participants of short stature, the CTM was significantly shorter, regardless of sex. The hypothetical success rate for emergency cricothyrotomy was 93.3% for the males and 73.5% for the females. The equation for estimating the height of the CTM in the extension position was determined as -4.36 + 5.27 × height (m) + 0.32 × sternomental distance (cm).

CONCLUSIONS

Since the CTM height may differ according to age, sex, and height, cricothyrotomy sets should be available in various outer diameters.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1825-1830, 2024.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Prehospital Surgical Airway Management Skills in a Rural Emergency Medical Service System

BACKGROUND

The objective of this study is to describe the education, training, and use of prehospital surgical airways in a rural Emergency Medical Service (EMS) system.

MATERIALS AND METHODS

We conducted an internet-based survey instrument of all advanced life support (ALS) EMS agencies in a seven-county rural EMS system in Pennsylvania. ALS agencies were queried regarding basic demographic information as well as the number of surgical airways performed in the previous 10 years as well as the education and training of EMS providers in surgical airways.

RESULTS

The survey was completed by 11 of 20 ALS EMS agencies in our region (55% rate of return). The content and frequency of training varied considerably among EMS agencies. Only four prehospital surgical airways were performed during the study period. One patient survived to hospital discharge to home.

CONCLUSION

Surgical airways are an infrequently performed procedure in the rural prehospital setting. There is no universally accepted standard for teaching or evaluating the competency of this potentially life-saving procedure. Further efforts to establish a core educational curriculum appear warranted.

[The correct way to deal with the definitive surgical airway]

Dealing with a difficult airway is familiar to emergency care providers in both the prehospital and clinical settings. In anesthesiology and emergency medical care different algorithms almost equal in their wording have been introduced, indicating that an emergency front of neck airway access (eFONA) has to be established in the case of a cannot ventilate-cannot oxygenate situation. In a survey (Surveymonkey®) data concerning the level of experience with eFONA, devices required, previous training and complications were allocated among acute and emergency care providers of different backgrounds (doctors and paramedics). Furthermore, we asked about individual attitudes to and frequency of previous situations, in which an eFONA was not established despite strong indications. Of the respondents 15% (n = 63) answered that they had experienced this type of situation. eFONA had been performed by 28% of the interviewed (n = 117), reflecting the high number of military and EMT (emergency medical team) physicians participating in the survey. The number of experiences are rarely representative for the civilian setting. Different adjuncts may be helpful to detect the cricothyroid ligament. To use ultrasound seems obvious but it doubles the time for the detection of the cricothyroid ligament. Laryngeal masks can be employed as a supraglottic airway device (SAD) during "plan B". Stabilizing the airway with a SAD almost doubles the success of identifying laryngeal landmarks in females. The crew resource management (CRM) guidelines are more than essential in threatening situations demanding measures like eFONA. Providers should anticipate emerging problems and whenever feasible call for help and finally speak up. Naming a failed airway should be avoided as it implies a failure of the provider or of the entire airway team. In fact, the term non-accessible airway should be introduced. This might help to avoid the implication of a major failure. So far, an ideal simulator to train eFONA has not been introduced but it is mandatory to train procedures and algorithms on different types of simulators and manikins to achieve mastery.

Emergency Cricothyrotomy in a Harsh Environment: A Case Report of Complete Airway Obstruction Following a Lightning Strike

A lightning strike is an extreme event with the highest mortality rate among electrical injuries. Death from a lightning strike is caused by either cardiac arrest or respiratory arrest. It is rare for upper airway damage to occur, but in these cases, airway control is recommended. If transoral intubation is unsuccessful, an emergency cricothyrotomy should be considered. Our case report describes an emergency cricothyroidotomy performed in a harsh environment on a mountain 2300 m above sea level on a patient with extensive burns of his supraglottic structures, after being directly hit by a lightning strike.

Comparing the Scalpel-Bougie-Tube Emergency Front-of-Neck Airway (eFONA) Technique on Conventional Manikins and Ovine Larynges: Evaluating Cost, Realism, and Performance in Anaesthetic Trainees

Background Emergency front-of-neck airway (eFONA) is a crucial life-saving procedure in "cannot intubate, cannot oxygenate" (CICO) situations. It is essential to teach and maintain eFONA skills for healthcare providers, especially anesthesiologists. This study aims to assess the effectiveness of cost-effective ovine larynx models compared to conventional manikins in teaching eFONA using the scalpel-bougie-tube technique to a group of anaesthesia novices and newly appointed anaesthetic Fellows. Methods and study design The study was conducted at Walsall Manor Hospital, a district general hospital in the Midlands, UK. Participants underwent a pre-survey to assess familiarity with FONA and the ability to perform a laryngeal handshake. After a lecture and demonstration, participants performed two consecutive emergency cricothyrotomies on both ovine models and conventional manikins, followed by a post-survey to assess their confidence in performing eFONA and rate their experience using sheep larynges. Results The training session significantly improved the participants' ability to perform a laryngeal handshake and their confidence in performing eFONA. The majority of participants rated the ovine model higher in terms of realism, difficulty with penetration, difficulty in recognising landmarks, and difficulty in performing the procedure. Additionally, the ovine model was more cost-effective compared to conventional manikins. Conclusion Ovine models provide a more realistic and cost-effective alternative to conventional manikins for teaching eFONA using the scalpel-bougie-tube technique. The use of these models in routine airway teaching enhances the practical skill set of anaesthesia novices and newly appointed anaesthetists, better preparing them for CICO situations. However, further training with objective assessment methods and larger samples is needed to corroborate these findings.

[Cricothyrotomy : Data situation, guidelines and techniques for the definitive surgical airway]

Cricothyrotomy represents the final approach to secure the airway, in the course of which less invasive measures have failed. It can also primarily be carried out to establish a secure airway. This is essential to protect the patient from a significant hypoxia. This is a cannot ventilate-cannot oxygenate (CVCO) situation, which presumably all colleagues in emergency intensive care medicine and anesthesia have already been confronted with. Evidence-based algorithms for the management of a difficult airway and CVCO have been established. If oxygenation using an endotracheal tube, an extraglottic airway device or bag-valve mask ventilation all fail, the airway must be surgically secured, i.e. using cricothyrotomy. The prevalence of the CVCO situation in a prehospital setting is ca. 1%. No valid prospective randomized in vivo studies have been carried with respect to the question of the best method.

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.

Comparison of emergency surgical cricothyroidotomy and percutaneous cricothyroidotomy by experienced airway providers in an obese, in vivo porcine hemorrhage airway model

BACKGROUND

Emergency front-of-neck airway (eFONA) is a life-saving procedure in "cannot intubate, cannot oxygenate" (CICO). The fastest and most reliable method of eFONA has not been determined. We compared two of the most advocated approaches: surgical cricothyroidotomy and percutaneous cricothyroidotomy, in an obese, in vivo porcine hemorrhage model, designed to introduce real-time physiological feedback, relevant and high provider stress. The primary aim was to determine the fastest method to secure airway. Secondary aims were arterial saturation and partial pressure of oxygen, proxy survival and influence of experience.

METHODS

Twelve pigs, mean weight (standard deviation, SD) (60.3 ± 4.1) kg, were anesthetized and exposed to 25-35% total blood volume hemorrhage before extubation and randomization to Seldinger technique "percutaneous cricothyroidotomy" (n = 6) or scalpel-bougie-tube technique "surgical cricothyroidotomy" (n = 6). Specialists in anesthesia and intensive care in a tertiary referral hospital performed the eFONA, simulating an actual CICO-situation.

RESULTS

In surgical cricothyroidotomy vs. percutaneous cricothyroidotomy, the median (interquartile range, IQR) times to secure airway were 109 (IQR 71-130) s and 298 (IQR 128-360) s (P = 0.0152), arterial blood saturation (SaO₂) were 74.7 (IQR 46.6-84.2) % and 7.9 (IQR 4.1-15.6) % (P = 0.0167), pO₂ were 7.0 (IQR 4.7-7.7) kPa and 2.0 (IQR 1.1-2.9) kPa (P = 0.0667), and times of cardiac arrest (proxy survival) were 137-233 s, 190 (IQR 143-229), from CICO. All six animals survived surgical cricothyroidotomy, and two of six (33%) animals survived percutaneous cricothyroidotomy. Years in anesthesia, 13.5 (IQR 7.5-21.3), did not influence time to secure airway.

CONCLUSION

eFONA by surgical cricothyroidotomy was faster and had increased oxygenation and survival, when performed under stress by board certified anesthesiologists, and may be an indication of preferred method in situations with hemorrhage and CICO, in obese patients.

Needle Cricothyroidotomy by Intensive Care Paramedics

Objective:

Cricothyroidotomy is an advanced airway procedure for critically ill or injured patients. In Victoria, Australia, intensive care paramedics (ICPs) perform needle cricothyroidotomy utilizing the proprietary QuickTrach II (QTII) device. Recently, an Ambulance Victoria (AV) institutional change in workflow included pre-puncture surgical incision to assist in successful placement. This review aims to explore whether a surgical pre-incision prior to the insertion of the device improved overall procedural success rates of needle cricothyroidotomy using the QTII.

Methods:

This was a retrospective review of all patients who received a needle cricothyroidotomy by ICPs from May 1, 2015 through September 15, 2020. Data and patient care records were sourced from the AV data warehouse.

Results:

A total of 27 patients underwent a needle cricothyroidotomy with the mean age of patients being 50.2 years. Most cricothyroidotomies were performed using the QuickTrach II kit (92.6%). Prior to modification of the QTII procedure, front-of-neck access (FONA) success was 50.0%; however, this improved to 82.4% after the procedures recent update. The overall success rate of all paramedic-performed needle cricothyroidotomy during the study period was 74.1% (n = 20).

Conclusions:

This review demonstrates that propriety devices such as the QTII device achieve a low success rate for a FONA intervention. Despite the low frequency of this procedure, ICPs with extensive training and regular maintenance can perform needle cricothyroidotomy using scalpel assistance with a reasonable success rate. But when compared to the broader literature, success rate using a more straightforward technique such as a surgical cricothyroidotomy technique is likely going to be higher.

Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes

BACKGROUND

Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management.

OBJECTIVE

Our aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries.

METHODS

We performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center.

RESULTS

A total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia.

CONCLUSIONS

Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

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.

Training on a virtual reality cricothyroidotomy simulator improves skills and transfers to a simulated procedure

Objective

The virtual airway skills trainer (VAST) is a virtual reality simulator for training in cricothyroidotomy (CCT). The goal of the study is to test the effectiveness of training and transfer of skills of the VAST-CCT.

Methods

Two groups, control (no training) and simulation (2 weeks of proficiency-based training), participated in this study. Subjects in the control condition did not receive any training on the task whereas those in the simulation received a proficiency-based training on the task during a period of 2 weeks. Two weeks post-training, both groups performed CCT on the TraumaMan to demonstrate the transfer of skills.

Results

A total of (n=20) subjects participated in the study. The simulation group performed better than the control group at both the post-test (p<0.001) and retention test (p<0.001) on the simulator. The cumulative sum analysis showed that all subjects in the simulation group reached proficiency with acceptable failure rate within the 2 weeks of training. On the transfer test, the simulation group performed better on skin cut (p<0.001), intubation (p<0.001) and total score (p<0.001) than the control group.

Conclusions

The VAST-CCT is effective in training and skills transfer for the CCT procedure.

Level of evidence

Not applicable. Simulator validation study.

Review of Commercially Available Supraglottic Airway Devices for Prehospital Combat Casualty Care

Background

Airway obstruction is the second leading cause of potentially survivable death on the battlefield. The Committee on Tactical Combat Casualty Care lists airway optimization among the top 5 battlefield research and development priorities; however, studies show that combat medics lack access to the recommended supraglottic airway (SGA) devices. SGA devices are an alternative airway management technique to endotracheal tube intubation. Reports have shown SGA devices are easier to use and take fewer attempts to provide patent airflow to the patient when compared to endotracheal tube intubation. Military settings require a higher degree of skill to perform airway management on patients due to the environment, limited availability of equipment, and potential chaos of the battlefield. Finding the optimal SGA device for the military setting is an unmet need. The International Organization for Standardization describes basic functional requirements for SGA devices, as well as patient configurations and size limitations. Beyond that, no SGA device manufacturer states that their devices are intended for military settings.

Materials and Methods

We conducted a market review of 25 SGA devices that may meet inclusion into the medics’ aid bag. The company’s official “Instructions for Use” document, Google Scholar, and FDA reports were reviewed to obtain information for each SGA device.

Results

Twenty-five commercially available SGA devices are explored from manufacturer online sources. A commercially available device list is shown later in this paper, which provides the device’s features, indications, and contraindications based on the manufacturer’s product information documentation.

Conclusions

There are a variety of devices that require further testing to determine whether they should be included in sets, kits, and outfits.

High Success Rate of Prehospital and En Route Cricothyroidotomy Performed in the Israel Defense Forces: 20 Years of Experience

INTRODUCTION

Securing the airway is a crucial stage of trauma care. Cricothyroidotomy (CRIC) is often addressed as a salvage procedure in complicated cases or following a failed endotracheal intubation (ETI). Nevertheless, it is a very important skill in prehospital settings, such as on the battlefield.

HYPOTHESIS/PROBLEM

This study aimed to review the Israel Defense Forces (IDF) experience with CRIC over the past two decades.

METHODS

The IDF Trauma Registry (IDF-TR) holds data on all trauma casualties (civilian and military) cared for by military medical teams since 1997. Data of all casualties treated by IDF from 1998 through 2018 were extracted and analyzed to identify all patients who underwent CRIC procedures.Variables describing the incident scenario, patient's characteristics, injury pattern, treatment, and outcome were extracted. The success rate of the procedure was described, and selected variables were further analyzed and compared using the Fisher's-exact test to identify their effect on the success and failure rates. Odds Ratio (OR) was further calculated for the effect of different body part involvement on success and for the mortality after failed ETI.

RESULTS

One hundred fifty-three casualties on which a CRIC attempt was made were identified from the IDF-TR records. The overall success rate of CRIC was reported at 88%. In patients who underwent one or two attempts, the success rate was 86%. No difference was found across providers (physician versus paramedic). The CRIC success rates for casualties with and without head trauma were 80% and 92%, respectively (P = .06). Overall mortality was 33%.

CONCLUSIONS

This study shows that CRIC is of merit in airway management as it has shown to have consistently high success rates throughout different levels of training, injuries, and previous attempts with ETI. Care providers should be encouraged to retain and develop this skill as part of their tool box.

Emergency cricothyrotomy in morbid obesity: comparing the bougie-guided and traditional techniques in a live animal model

BACKGROUND

Cricothyrotomy is a rare, time sensitive procedure that is more challenging to perform when anatomical landmarks are not easily palpated before the initial incision. There is a paucity of literature describing the optimal technique for cricothyrotomy in patients with impalpable airway structures, such as in morbid obesity. In this study, we used a live sheep model of morbid obesity to compare the effectiveness of two common cricothyrotomy techniques.

METHODS

We randomly assigned emergency medicine residents to perform one of two cricothyrotomy techniques on a live anesthetized sheep. To simulate the anterior soft tissue neck thickness of an adult with morbid obesity we injected 120 mL of a mixture of autologous blood and saline into the anterior neck of the sheep. The traditional technique (as described in the New England Journal Video titled "Cricothyroidotomy") used a Shiley tracheostomy tube and no bougie, and the bougie-guided technique used a bougie and a standard endotracheal tube. The primary outcome was the total procedure time; the secondary outcome was first attempt success.

RESULTS

23 residents were included, 11 assigned to the bougie-guided technique and 12 to the traditional technique. After injection of blood and saline, the median depth from skin to cricothyroid membrane was 3.0 cm (IQR 2.5-3.4 cm). The median time for the bougie technique was 118 s (IQR 77-200 s) compared to 183 s (IQR 134-270 s) for the traditional technique (median difference 62 s, 95% CI 10-144 s). Success on the first attempt occurred in 7/11 (64%) in the bougie group and 6/12 (50%) in the traditional technique group.

CONCLUSION

In this study, which simulated morbid obesity on a living animal model complete with active hemorrhage and time pressure caused by extubation before the procedure, the bougie-guided technique was faster than the traditional technique using a tracheostomy tube without a bougie.

Randomized controlled trial comparing an open surgical technique and a Seldinger technique for cricothyrotomy performed on a simulated airway

OBJECTIVES

Emergency cricothyrotomy is a lifesaving procedure performed when intubation fails and oxygenation cannot occur. There are multiple techniques and kits to perform this procedure. However, current evidence does not provide a definitive answer as to which method is superior. Two techniques in common use are a surgical technique and a percutaneous Seldinger-based cricothyrotomy kit. The objective was to determine which of these two methods was quickest to perform and to determine which was most preferred by participants.

METHODS

A prospective randomized controlled crossover trial was conducted involving emergency physicians and trainees. Each participant performed both cricothyrotomy techniques in succession on an airway model, with the technique performed first being randomized for each participant. The primary outcome was time to first insufflation of the artificial lung. A survey was completed by participants asking their comfort with each technique on a 5-point scale from 1 (not at all comfortable) to 5 (very comfortable) and which technique they preferred.

RESULTS

Twenty-one emergency physicians and nine emergency medicine trainees were recruited. The surgical technique was performed the fastest, with a mean (±SD) time of 51.6 (±16.3) s versus 66.6 (±14.9) s for the Seldinger technique, with a statistically significant difference of 15.0 s (95% confidence interval = 8.5 to 21.5, p < 0.001). The surgical technique was rated the most comfortable to perform, with a median rating of 5 (interquartile range [IQR] = 4-5) versus 4 (IQR = 3-5) for the Seldinger technique. The surgical technique was most preferred by participants (80% vs 20%).

CONCLUSION

The surgical technique was the fastest to perform and was rated the most comfortable to perform and the most preferred technique.

A Novel Approach to Emergency Airway Simulation Using a 3D-printed Cricothyrotomy Task Trainer

BACKGROUND

Cricothyrotomy is a final recourse for salvaging a difficult airway, yet most anesthesiology providers have little training, exposure, or comfort with the procedure. Pig tracheas are frequently used for training, but are single use and require special handling and storage. Other simulation models, such as mannequins and cadavers, are costly. Advances in 3dimensional (3D) printing have improved accessibility and decreased costs. This research project sought to determine whether an inexpensive 3D-printed task trainer was noninferior to pig tracheas for teaching surgical cricothyrotomy skills.

METHODS

Anesthesiology residents were enrolled in an institutional review board-exempted, unblinded, randomized, controlled, single-institution, noninferiority trial. Participants were trained in the scalpel-finger-bougie technique for surgical cricothyrotomy. Participants were randomized to practice 5 repetitions on either a pig trachea or the 3D model and were assessed on time to cricothyrotomy completion on a pig trachea before and after practice.

RESULTS

Demographic characteristics of the 25 workshop attendees were similar between study arms. Overall mean (SD) improvement in speed was 9 (12) seconds (P = .001). Postpractice times were similar between groups (analysis of covariance estimated difference of -0.1 seconds [95% confidence interval, -9.4 to 9.2]; P = .55). The 3D model was noninferior to the pig trachea at the prespecified noninferiority margin of 10 seconds (P = .017).

CONCLUSIONS

The 3D model was noninferior to pig tracheas for improving the time to completion of a surgical cricothyrotomy. A 3D-printed model offers a viable alternative to pig tracheas for emergency airway simulation that is inexpensive, reusable, and readily modified to simulate challenging airway anatomy.

Emergent tracheostomy during the pandemic of COVID-19: Slovenian National Recommendations

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.

Improving Emergency Cricothyroidotomies: Simulation-Based Training for Critical Care Providers

This article discusses skill proficiency of providers related to emergency cricothyroidotomies. Various techniques to improve procedural skills were studied. Accurate identification of the cricothyroid membrane via palpation remained consistently inadequate. High-fidelity simulation including the use of human cadavers may be the preferred method of skill training for crisis management. The authors emphasize that additional research is needed regarding a method for rapid cricothyroid membrane identification as well as needle cricothyroidotomy versus surgical airway on cadavers. More consistent training will enable emergency care providers to perform this rare but lifesaving skill.

Simulation of Adult Surgical Cricothyrotomy for Anesthesiology and Emergency Medicine Residents: Adapted for COVID-19

INTRODUCTION

In a CICO (cannot intubate, cannot oxygenate) situation, anesthesiologists and acute care physicians must be able to perform an emergency surgical cricothyrotomy (front-of-neck airway procedure). CICOs are high-acuity situations with rare opportunities for safe practice. In COVID-19 airway management guidelines, bougie-assisted surgical cricothyrotomy is the recommended emergency strategy for CICO situations.

METHODS

We designed a 4-hour procedural simulation workshop on surgical cricothyrotomy to train 16 medical residents. We provided prerequisite readings, a lecture, and a videotaped demonstration. Two clinical scenarios introduced deliberate practice on partial-task neck simulators and fresh human cadavers. We segmented an evidence-based procedure and asked participants to verbalize the five steps of the procedure on multiple occasions.

RESULTS

Thirty-two residents who participated in the workshops were surveyed, with a 97% response rate (16 of 16 from anesthesiology, 15 of 16 from emergency medicine). Participants commented positively on the workshop's authenticity, its structure, the quality of the feedback provided, and its perceived impact on improving skills in surgical cricothyrotomy. We analyzed narrative comments related to three domains: preparation for the procedure, performing the procedure, and maintaining the skills. Participants highlighted the importance of performing the procedure many times and mentioned the representativeness of fresh cadavers.

DISCUSSION

We developed a surgical cricothyrotomy simulation workshop for anesthesiology and emergency medicine residents. Residents in the two specialities uniformly appreciated its format and content. We identified common pitfalls when executing the procedure and provided practical tips and material to facilitate implementation, in particular to face the COVID-19 pandemic.

Difficult Airway Management in Adult COVID-19 Patients: Statement by the Society of Airway Management

The COVID-19 disease, caused by Coronavirus SARS-CoV-2, often results in severe hypoxemia requiring airway management. Because SARS CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue the Society for Airway Management (SAM) created a task force to review existing literature and current Practice Guidelines for management of the difficult airway by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. SAM task force created recommendations for management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of AGREE Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. and difficult airway management often takes longer, may involve multiple procedures with aerosolization potential, strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When patient's airway risk assessment suggests awake tracheal intubation is an appropriate choice of technique, procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with tight seal facemask may be performed to reduce risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as first-line strategy for airway management. If emergent invasive airway access is indicated, we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.

Cricothyroidotomy competence and injuries using nonmedical equipment: A crossover noninferiority randomised controlled trial in a porcine cadaver model

BACKGROUND

International guidelines recommend cricothyroidotomy as a life-saving procedure for 'cannot intubate, cannot ventilate' situations. Although commercially available sets facilitate surgical cricothyroidotomy, regular training seems to be the key to success.

OBJECTIVES

The goal was to investigate if trained anaesthetists are able to transfer their skill in one surgical cricothyroidotomy technique to another. The primary hypothesis postulated that trained anaesthetists could perform an emergency cricothyroidotomy equally fast and successfully with a pocketknife compared with a surgical cricothyroidotomy set.

DESIGN

Crossover noninferiority randomised controlled trial.

SETTING

After written informed consent and ethics committee approval, this single-centre study was performed at the University Hospital of Bern, Bern, Switzerland.

PARTICIPANTS

Altogether, 61 study participants already familiar with surgical cricothyroidotomy were included.

INTERVENTION

The use of a commercially available cricothyroidotomy set was compared with a short-bladed pocketknife and ballpoint pen barrel. A pig-larynx cadaver model including trachea, with pig skin overlaid, was used. Participants underwent additional training sessions in both procedures.

MAIN OUTCOME MEASURES

The primary outcome was the time necessary to position the tracheal tube or pen barrel in the trachea. Other outcome parameters were success rate, tracheal and laryngeal injuries and preferred device.

RESULTS

Cricothyroidotomy with the pocketknife was performed significantly faster and equally successfully as compared with the cricothyroidotomy sets. Tracheal and laryngeal injuries were similar in both groups. Paratracheal or submucosal placement of the pen barrel occurred in 32%, compared with 29% for the tracheal tube. Sixty-six per cent of participants preferred the cricothyroidotomy set.

CONCLUSION

Regularly trained anaesthetists are able to accomplish cricothyroidotomy irrespective of the equipment used. A pocketknife with a ballpoint pen barrel was just as effective as a commercially available surgical set.

The Lost Airway

Management of the unanticipated difficult airway is one of the most relevant and challenging crisis management scenarios encountered in clinical anesthesia practice. Several guidelines and approaches have been developed to assist clinicians in navigating this high-acuity scenario. In the most serious cases, the clinician may encounter a failed airway that results from failure to ventilate an anesthetized patient via facemask or supraglottic airway or intubate the patient with an endotracheal tube. This dreaded cannot intubate, cannot oxygenate situation necessitates emergency invasive access. This article reviews the incidence, management, and complications of the failed airway and training issues related to its management.

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.

Developing Cricothyroidotomy Skills Using a Biomaterial-Covered Model

INTRODUCTION

Cricothyroidotomy is an advanced and life-saving technique, but it is also a rare and a difficult procedure. The purpose of the present study was to produce a low-cost simulation model with realistic anatomic features to investigate its effectiveness in developing cricothyroidotomy skills.

METHODS

This study was performed at a university simulation center with 57 second-year student paramedics and a cricothyroidotomy simulation model. Total scores were assessed using a checklist. This consisted of 13 steps and was scored as misapplication/omission=0, correct performance and timing with hesitation=1, and correct performance and timing without hesitation=2. One of these steps, local anesthesia of the area if time is available, was not performed owing to time limitations. The highest possible score was 24. Data are presented as mean±SD with range, as appropriate. Normal distribution was evaluated using the Kolmogorov-Smirnov test, Student t test, and Mann-Whitney U test, and correlation analysis was used for statistical analysis.

RESULTS

Students completed the cricothyroidotomy procedure steps in 116±46 (55-238) s. At performance assessment, the score achieved was 12±5 (2-24). The highest total score of 24 was achieved by 3 students (5%). Total scores exhibited negative and significant correlation with procedure time (r=-0.403, P=0.002).

CONCLUSIONS

The model developed in this study is an inexpensive and effective method that can be used in cricothyroidotomy training for student paramedics. We think that repeating the cricothyroidotomy procedure on the model will increase success levels.

Complications of cricothyroidotomy versus tracheostomy in emergency surgical airway management: a systematic review

Background

Airway guidelines recommend an emergency surgical airway as a potential life-saving treatment in a “Can’t Intubate, Can’t Oxygenate” (CICO) situation. Surgical airways can be achieved either through a cricothyroidotomy or tracheostomy. The current literature has limited data regarding complications of cricothyroidotomy and tracheostomy in an emergency situation. The objective of this systematic review is to analyze complications following cricothyroidotomy and tracheostomy in airway emergencies.

Methods

This synthesis of literature was exempt from ethics approval. Eight databases were searched from inception to October 2018, using a comprehensive search strategy. Studies were included if they were randomized controlled trials or observational studies reporting complications following emergency surgical airway. Complications were classified as minor (evolving to spontaneous remission or not requiring intervention or not persisting chronically), major (requiring intervention or persisting chronically), early (from the start of the procedure up to 7 days) and late (beyond 7 days of the procedure).

Results

We retrieved 2659 references from our search criteria. Following the removal of duplicates, title and abstract review, 33 articles were selected for full-text reading. Twenty-one articles were finally included in the systematic review. We found no differences in minor, major or early complications between the two techniques. However, late complications were significantly more frequent in the tracheostomy group [OR (95% CI) 0.21 (0.20–0.22), p < 0.0001].

Conclusions

Our results demonstrate that cricothyroidotomies performed in emergent situations resulted in fewer late complications than tracheostomies. This finding supports the recommendations from the latest Difficult Airway Society (DAS) guidelines regarding using cricothyroidotomy as the technique of choice for emergency surgical airway. However, emergency cricothyroidotomies should be converted to tracheostomies in a timely fashion as there is insufficient evidence to suggest that emergency cricothyrotomies are long term airways.

Surgeons With Five or More Actual Cricothyrotomies Perform Significantly Better on a Virtual Reality Simulator

BACKGROUND

Discriminating performance of learners with varying experience is essential to developing and validating a surgical simulator. For rare and emergent procedures such as cricothyrotomy (CCT), the criteria to establish such groups are unclear. This study is to investigate the impact of surgeons' actual CCT experience on their virtual reality simulator performance and to determine the minimum number of actual CCTs that significantly discriminates simulator scores. Our hypothesis is that surgeons who performed more actual CCT cases would perform better on a virtual reality CCT simulator.

METHODS

47 clinicians were recruited to participate in this study at the 2018 annual conference of the Society of American Gastrointestinal and Endoscopic Surgeons. We established groups based on three different experience thresholds, that is, the minimal number of CCT cases performed (1, 5, and 10), and compared simulator performance between these groups.

RESULTS

Participants who had performed more clinical cases manifested higher mean scores in completing CCT simulation tasks, and those reporting at least 5 actual CCTs had significantly higher (P = 0.014) simulator scores than those who had performed fewer cases. Another interesting finding was that classifying participants based on experience level, that is, attendings, fellows, and residents, did not yield statistically significant differences in skills related to CCT.

CONCLUSIONS

The simulator was sensitive to prior experience at a threshold of 5 actual CCTs performed.

Recommendations for the evaluation and management of the anticipated and non-anticipated difficult airway of the Societat Catalana d'Anestesiologia, Reanimació i Terapèutica del Dolor, based on the adaptation of clinical practice guidelines and expert consensus

The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines.

Rescue oxygenation success by cannula or scalpel-bougie emergency front-of-neck access in an anaesthetised porcine model

In the obese, the evidence for the choice of the optimal emergency front-of-neck access technique is very limited and conflicting. We compared cannula and scalpel-bougie emergency front-of-neck access techniques in an anaesthetised porcine model with thick pretracheal tissue. Cannula and scalpel-bougie cricothyroidotomy techniques were performed in 11 and 12 anaesthetised pigs, respectively. Following successful tracheal access, oxygenation was commenced and continued for 5 min using Rapid-O2 device for cannula and circle breathing system for scalpel-bougie study groups. The primary outcome was a successful rescue oxygenation determined by maintenance of arterial oxygen saturation >90% 5 min after the beginning of oxygenation. Secondary outcomes included success rate of airway device placement, time to successful airway device placement, and trauma to the neck and airway. The success rate of rescue oxygenation was 18% after cannula, and 83% after scalpel-bougie technique (P = 0.003). The success rate of airway device placement was 73% with cannula and 92% with scalpel-bougie technique (P = 0.317). Median (inter-quartile-range) times to successful airway device placement were 108 (30–256) and 90 (63–188) seconds (P = 0.762) for cannula and scalpel-bougie emergency front-of-neck access, respectively. Proportion of animals with iatrogenic trauma additional to the procedure itself was 27% for cannula and 75% for scalpel-bougie technique (P = 0.039). Thus, in the porcine model of obesity, the scalpel-bougie technique was more successful in establishing and maintaining rescue oxygenation than cannula-based technique; however, it was associated with a higher risk of severe trauma.

Multispecialty tracheostomy experience

INTRODUCTION

Tracheostomy is a common surgical procedure used to create a secure airway in patients, now performed by a variety of specialties, with a notable rise in critical care environments. It is unclear whether this rise is seen in units with large head and neck surgery departments, and how practice in such units compares with the rest of the UK.

METHODS

A three-year retrospective audit was carried out between anaesthetic, surgical and critical care departments. All tracheostomy procedures were recorded anonymously.

RESULTS

A total of 523 tracheostomies were performed, 66% of which were in men. The mean patient age was 60 years. The majority (83%) were elective, performed for various indications, while the remaining 17% were emergency tracheostomies performed for pending airway obstruction. A fifth of the tracheostomies were percutaneous procedures. Most emergency tracheostomies (78%) were performed by otolaryngology. Three cricothyroidotomies were performed within critical care and theatres. Complications related to tracheostomy occurred in 47 cases (9%), most commonly lower respiratory tract infection. The mean time to decannulation was 12.8 days.

CONCLUSIONS

This paper discusses the findings of a comprehensive, multispecialty audit of tracheostomy experience in a large health board, with over 150 tracheostomies performed annually. Elective cases form the majority although there is a significant case series of emergency tracheostomies performed for a range of pathologies. Around a quarter of those requiring tracheostomy ultimately died, mostly as a result of advanced cancer.

Percutaneous vs surgical emergency cricothyroidotomy: An experimental randomized crossover study on an animal-larynx model

BACKGROUND

Airway management is a paramount clinical skill for the anaesthesiologist. The Emergency Cricothyroidotomy (EC) constitutes the final step in difficult airway algorithms securing a patent airway via a front-of-neck access. The main distinction among available techniques is whether the procedure is surgical and scalpel-based or percutaneous and needle-based.

METHODS

In an experimental randomized crossover trial, using an animal larynx model, we compared two EC techniques; the Rapid Four Step Technique and the Melker Emergency Cricothyrotomy Kit®. We assessed time expenditure and success rates among 20 anaesthesiologists and related this to previous training, seniority and clinical experience with EC.

RESULTS

All participants achieved successful airway access with both methods. Average time to successful airway access for scalpel-based EC was 54 (±31) seconds and for percutaneous EC 89 (±38) seconds, with 35 (95% CI: 14-57) seconds time difference, P = .003. Doctors with recent (<12 months) EC training performed better compared to the non-training group (37 vs 61 seconds, P = .03 for scalpel-based EC, and 65 vs 99 seconds, P = .02 for percutaneous EC). We found no differences according to clinical seniority or previous real-life EC experience.

CONCLUSIONS

Our study demonstrated that anaesthesiologists achieved successful airway access on an animal experimental model with both EC methods within a reasonable time frame, but the scalpel-based EC is performed more promptly. Recent EC training affected the time expenditure positively, while seniority and clinical EC experience did not. EC procedures should be regularly trained for.

Management of patients with hereditary angio-oedema in dental, oral, and maxillofacial surgery: a review

Hereditary angio-oedema (HEA) is an autosomal dominant, life-threatening genetic disorder that is caused by insufficiency or dysfunction of the C1 esterase inhibitor that develops coincidentally with recurrent oedema in the skin, internal organs, and upper respiratory tract. Increased production of bradykinin secondary to increased plasma kallikrein activity is the primary cause of attacks. Dental procedures cause emotional stress and mechanical trauma and may also initiate attacks. The most feared complication is asphyxiation as a result of laryngeal oedema. Cases that resulted in death after tooth extraction have been reported, so dentists and oral and maxillofacial surgeons should take maximum care in the treatment of patients with HAO, consult with the patient's doctor, and ensure that prophylaxis is given before the procedure. They should work as atraumatically as possible and use procedures to minimise stress. In the event of an attack of HAO, despite all the correct measures having been taken, the procedure should be terminated immediately and treatment of the attack started as soon as possible. The first drugs for the treatment of acute attacks are C1-INH (C1 inhibitor), ecallantide, or icatibant.

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.

A pilot study evaluating the utility of a novel tube cricothyrotomy technique in providing ventilation in small animals using a live porcine model

Background

Tube cricothyrotomy has been suggested as a first-choice for emergency surgical airway access in small animals, rather than the more commonly accepted procedures of tracheotomy and needle cricothyrotomy.

Methods

A small pilot study of tube cricothyrotomy in a live porcine model was conducted to evaluate this method. The technique was modified to permit the use of commonly available equipment and ease of application. Following ethics approval, a tube cricothyrotomy was performed on 9 live pigs. The endpoints were the efficacy of ventilation through the tube as measured by end-tidal carbon dioxide, successful placement of the tube and the time taken for placement.

Results

Of the nine pigs, eight had a tube placed successfully, with the median procedure time being 111.5 seconds (range: 35–240 seconds). After 10 mins, the mean end-tidal carbon dioxide was 58.3 mmHg (95% CI: 55.2–61.3 mmHg), with a range of 54–64 mmHg. Tube cricothyrotomy holds promise as a means of rapidly obtaining tracheal access in small animals and temporarily sustaining ventilation in an emergency.

Conclusion

Further detailed investigation is warranted to assess the use of this technique in the small animal emergency setting.