Evaluation of Seldinger technique emergency cricothyroidotomy versus standard surgical cricothyroidotomy in 200 cadavers

BACKGROUND: Percutaneous cricothyroidotomy is a lifesaving procedure for airway obstruction in trauma victims who need airway establishment and cannot be intubated or in whom intubation has failed. METHODS: The purpose of this study was to examine whether there is a training effect using Seldinger technique emergency cricothyroidotomy (group 1; Arndt Emergency Cricothyroidotomy Catheter Set; Cook Critical Care, Bloomington, IN) versus standard surgical cricothyroidotomy (group 2). Twenty emergency physicians performed five cricothyroidotomies with each method in a total of 200 human cadavers, comparing efficacy and safety (speed, success rate, and injuries). RESULTS: Seven attempts in group 1 and six in group 2 had to be aborted. Time intervals from the start of the procedure to location of the cricothyroid membrane were not significantly different between the groups. However, time to tracheal puncture (P < 0.01) and time to first ventilation (P < 0.001) were significantly longer in group 2. No time effect could be observed in both groups. The airway was accurately placed into the trachea through the cricothyroid membrane in 88.2% (82 of 93) of the cadavers in group 1 and in 84.0% (79 of 94) in group 2 (not significant). No injuries were observed in group 1, whereas there were six punctures of the thyroid vessels in group 2 (P < 0.05). CONCLUSIONS: With respect to time needed for the procedure, the participants performed Seldinger technique emergency cricothyroidotomy significantly faster as compared with standard surgical cricothyroidotomy. Even if no training effect had been observed, the authors believe that it is important to train residents in different methods of cricothyroidotomy in cadavers in addition to training in mannequins to achieve a higher level of efficacy in real-life situations. The shorter time to first ventilation and the fact that no injuries could be observed favor the Seldinger technique.     

Evaluation of Seldinger Technique Emergency Cricothyroidotomy versus Standard Surgical Cricothyroidotomy in 200 Cadavers

Background: Percutaneous cricothyroidotomy is a lifesaving procedure for airway obstruction in trauma victims who need airway establishment and cannot be intubated or in whom intubation has failed.

Methods: The purpose of this study was to examine whether there is a training effect using Seldinger technique emergency cricothyroidotomy (group 1; Arndt Emergency Cricothyroidotomy Catheter Set; Cook Critical Care, Bloomington, IN) versus standard surgical cricothyroidotomy (group 2). Twenty emergency physicians performed five cricothyroidotomies with each method in a total of 200 human cadavers, comparing efficacy and safety (speed, success rate, and injuries).

Results: Seven attempts in group 1 and six in group 2 had to be aborted. Time intervals from the start of the procedure to location of the cricothyroid membrane were not significantly different between the groups. However, time to tracheal puncture (P < 0.01) and time to first ventilation (P < 0.001) were significantly longer in group 2. No time effect could be observed in both groups. The airway was accurately placed into the trachea through the cricothyroid membrane in 88.2% (82 of 93) of the cadavers in group 1 and in 84.0% (79 of 94) in group 2 (not significant). No injuries were observed in group 1, whereas there were six punctures of the thyroid vessels in group 2 (P < 0.05).     

Chirurgische Atemwegssicherung in der pr?klinischen Notfallmedizin

In all of the numerous recommendations of various national as well as international medical societies on the management of a difficult airway, cricothyroidotomy is the life-saving procedure and the final ??cannot intubate?Ccannot ventilate?? option, whether in the prehospital, emergency department, intensive care unit or the operating room patient. The surgical approach to the airway in the prehospital setting is synonymous with emergency cricothyroidotomy. In the literature emergency cricothyroidotomy is described as an ??infrequent?? or ??uncommon?? procedure. In paramedic-based emergency medical services (EMS) systems, the incidence is significantly higher than in physician-based EMS systems (10.9?C14% vs. 0.1?C3.3%). A number of different techniques for performing cricothyroidotomy have been described in the literature. All these techniques can in principle be assigned to two groups: anatomical surgical techniques and puncture techniques. There is no technique which equally fulfills all requirements for emergency cricothyroidotomy in the prehospital setting (i.e. fast airway access + easy to use + low complication rate). Studies indicate complication rates for cricothyroidotomy up to approximately 40% when performed under emergency conditions. The surgical airway (cricothyroidotomy) must be part of a defined and clearly structured difficult airway algorithm. Providers have to be trained in this algorithm and especially in the technique of cricothyroidotomy. Within this context it is recommended to ??do what you can do best?? (e.g. surgeons should use the surgical technique and anesthesiologists should use the puncture technique).     

The Airway App: exploring the role of smartphone technology to capture emergency front‐of‐neck airway experiences internationally

In this exploratory study we describe the utility of smartphone technology for anonymous retrospective observational data collection of emergency front‐of‐neck airway management. The medical community continues to debate the optimal technique for emergency front‐of‐neck airway management. Although individual clinicians infrequently perform this procedure, hundreds are performed annually worldwide. Ubiquitous smartphone technology and internet connectivity have created the opportunity to collect these data. We created the ‘Airway App’, a smartphone application to capture the experiences of healthcare providers involved in emergency front‐of‐neck airway procedures. In the first 18‐month period, 104 emergency front‐of‐neck airway management reports were received; 99 (95%) were internally valid and unique from 21 countries. Eighty‐one (82%) were performed by non‐surgeons and 63 (64%) were ‘cannot intubate, cannot oxygenate’ emergencies. Overall first‐attempt success varied by technique; 45 scalpel–bougie cricothyroidotomy (37 first‐attempt success), 25 surgical cricothyroidotomy (15 first‐attempt success), eight cannula cricothyroidotomy (five first‐attempt success), six wire‐guided cricothyroidotomy (three first‐attempt success) and 15 tracheostomy reports (11 first‐attempt success). The most commonly reported positive human factors were good communication, good teamwork and/or skilled personnel. The most commonly reported negative human factors were fixation on multiple tracheal intubation attempts, delay in initiating emergency front‐of‐neck airway and/or the failure to plan for failure. Due to the anonymous nature of reporting, reports are open to recollection bias and spurious reporting. We conclude collection of data using a smartphone application is feasible and has the potential to expand our knowledge of emergency front‐of‐neck airway management.     

Cricothyroidotomy: elective use in respiratory problems requiring tracheotomy.

Surgical teachings insist that cricothyroidotomy should be performed only under emergency conditions as a temporary means of securing an airway. Subsequent subglottic stenosis is thought to occur in alarming numbers of patients intubated for any length of time. The incidence of complications associated with cricothyroidotomy has not been critically examined since Jackson's classic paper in 1921, condemning the operation. A total of 655 patients with cricothyroidotomy tubes in place from hours to months were studied to determine the incidence of problems associated with this procedure. The over-all complication rate was 6.1 per cent. There was one cricothyroidotomy-associated death. Chronic subglottic stenosis did not occur, although 5 patients required resection of tracheal strictures. No additional complications occurred if the procedure was carried out at the bedside instead of in the operating room. The simplicity, absence of cross-contamination of median sternotomy incisions, and safety documented by this study recommend routine use of cricothyroidotomy in patients whose management requires tracheotomy.     

What is the minimum training required for successful cricothyroidotomy?: a study in mannequins

BACKGROUND: A correctly performed cricothyroidotomy may be lifesaving in a cannot-ventilate, cannot-intubate situation. However, many practicing anesthesiologists do not have experience with cricothyroidotomy. The purpose of this study was to determine the minimum training required to perform cricothyroidotomy in 40 s or less in mannequins. METHODS: After informed consent, participants were shown a demonstration video and asked to perform 10 consecutive cricothyroidotomy procedures on a mannequin using a preassembled percutaneous dilational cricothyroidotomy set. Each attempt was timed from skin palpation to lung insufflation. Cricothyroidotomy was considered successful if it was performed in 40 s or less, and the cricothyroidotomy time was considered to have plateaued when there were no significant reductions in cricothyroidotomy times in three consecutive attempts. RESULTS: One hundred two anesthesiologists participated in the study. There was a significant reduction of cricothyroidotomy times over the 10 attempts (P < 0.0001) and between three consecutive attempts until the fourth attempt (P < 0.03). The cricothyroidotomy times plateaued by the fourth attempt, while the success rate plateaued at the fifth attempt (94, 96, 96, and 96% at the fourth, fifth, sixth, and seventh attempts, respectively). CONCLUSION: Practice on mannequins leads to reductions in cricothyroidotomy times and improvement in success rates. By the fifth attempt, 96% of participants were able to successfully perform the cricothyroidotomy in 40 s or less. While clinical correlates are not known, the authors recommend that providers of emergency airway management be trained on mannequins for at least five attempts or until their cricothyroidotomy time is 40 s or less. The most appropriate retraining intervals have yet to be determined for optimal cricothyroidotomy skill retention.     

Emergency cricothyroidotomy: a randomised crossover study of four methods

Emergency physicians and registrars performed emergency cricothyroidotomy on an artificial airway model using a standard surgical approach and three common commercial products, participants had received no refresher training. The order in which the methods were used was randomised to minimise any learning effect. Three methods (standard surgical, Minitrach II, and Quicktrach) were universally successful in obtaining ventilation within 150 s, whilst the Melker kit had a 26% failure rate and significantly longer median time to ventilation (126 s vs≤48 s for other methods, p < 0.001). Despite success in using the surgical method, the Quicktrach and Minitrach II were rated as first or second preference by the majority of operators (78% and 70% respectively). Without refresher training emergency physicians and registrars successfully performed emergency cricothyroidotomy using the standard surgical method, Quicktrach and Minitrach II kits however the use of the Melker kit under these conditions resulted in significant delays or failure to establish an airway.     

Surgical approach in difficult airway management

In all difficult airway algorithms, cricothyroidotomy is the life-saving procedure and is the final 'cannot ventilate, cannot intubate' option, whether in pre-hospital, emergency department, intensive care unit, or operating room patients. Cricothyroidotomy is a relatively safe and rapid means of securing an emergency airway. As with all other critical procedures in emergency medicine, a thorough knowledge of the technique and adequate practice prior to attempting to perform an emergency cricothyroidotomy are essential.     

Acute airway management. Role of cricothyroidotomy

Thirty-four cases of emergency cricothyroidotomy performed formed from September 1984 through January 1988 are reviewed. Thirty-one of the cases were required out of 2,200 acute-trauma patients. The indication for cricothyroidotomy was inability to establish an airway by intubation usually in a situation of possible neck injury or severe facial trauma. Fourteen of the patients died as a result of their injuries, 13 of these in the first several hours after injury. The 20 surviving patients are studied in two groups: eleven patients whose cricothyroidotomy remained in place until decannulation (group I) and nine patients who underwent tracheostomy subsequent to cricothyroidotomy (group II). Clinical follow-up included physical examination in all survivors and endoscopic evaluation in twelve patients. Three minor complications were discovered in each of the two groups and two major complications were noted in group II. The major complications included a case of tracheal stomal stenosis requiring tracheal resection and a case of partially obstructing tracheal granulation tissue requiring endoscopic resection. This study supports the use of emergency cricothyroidotomy in situations in which intubation is not successful or thought to be safe. Data is also presented that suggests that tracheostomy subsequent to emergency cricothyroidotomy does not necessarily reduce airway-related morbidity in these patients.     

Comparison of four different emergency airway access equipment sets on a human patient simulator

This study used a patient simulator to study the ease of use and efficacy of four currently available cricothyroidotomy sets. We assessed the success of insertion of each piece of equipment and measured the subsequent adequacy of oxygenation and ventilation. We also examined the complications encountered using each set. We found that there was a 100% success rate of achieving an adequate airway within acceptable time limits using the 'Quiktrach' and 'Melker' sets, with good airway patency and ease of ventilation. There was an unacceptably high failure rate in achieving a patent airway when using the 'Transtracheal airway catheter with ENK-flow modulator' and 'Patil's airway'. The pre-assembled and user-friendly 'Quiktrach' set provided the fastest and most effective means of oxygenation in the simulated patient requiring an emergency surgical airway.     

A stab in the dark! Are you ready to perform needle cricothyroidotomy?

The objective of this study was to assess the availability of pre-prepared equipment for needle cricothyroidotomy, and the knowledge of staff in its use in Accident and Emergency (A&E) departments in Great Britain. A telephone survey was undertaken of all A&E departments seeing more than 30 000 new patients per year. 184 hospitals were contacted. 98% of the doctors agreed to be interviewed. 47% of the departments had made provision for immediate use of needle cricothyroidotomy. 45% of the doctors interviewed were fully conversant in the use of needle cricothyroidotomy. Provision of equipment for immediate use of needle cricothyroidotomy in A&E departments is generally inadequate. All departments should ensure that such equipment is immediately accessible, and that the staff is regularly trained in its use.     

What Is the Minimum Training Required for Successful Cricothyroidotomy?: A Study in Mannequins

Background: A correctly performed cricothyroidotomy may be lifesaving in a cannot-ventilate, cannot-intubate situation. However, many practicing anesthesiologists do not have experience with cricothyroidotomy. The purpose of this study was to determine the minimum training required to perform cricothyroidotomy in 40 s or less in mannequins.

Methods: After informed consent, participants were shown a demonstration video and asked to perform 10 consecutive cricothyroidotomy procedures on a mannequin using a preassembled percutaneous dilational cricothyroidotomy set. Each attempt was timed from skin palpation to lung insufflation. Cricothyroidotomy was considered successful if it was performed in 40 s or less, and the cricothyroidotomy time was considered to have plateaued when there were no significant reductions in cricothyroidotomy times in three consecutive attempts.

Results: One hundred two anesthesiologists participated in the study. There was a significant reduction of cricothyroidotomy times over the 10 attempts (P < 0.0001) and between three consecutive attempts until the fourth attempt (P < 0.03). The cricothyroidotomy times plateaued by the fourth attempt, while the success rate plateaued at the fifth attempt (94, 96, 96, and 96% at the fourth, fifth, sixth, and seventh attempts, respectively).     

Evaluation of a novel Surgicric® cricothyroidotomy device for emergency tracheal access in a porcine model

A can't intubate, can't ventilate scenario can result in morbidity and death. Although a rare occurrence (1:50 000 general anaesthetics), it is crucial that anaesthetists maintain the skills necessary to perform cricothyroidotomy, and are well‐equipped with appropriate tools. We undertook a bench study comparing a new device, Surgicric^®, with two established techniques; the Melker Emergency Cricothyroidotomy, and a surgical technique. Twenty‐five anaesthetists performed simulated emergency cricothyroidotomy on a porcine model, with the primary outcome measure being insertion time. Secondary outcomes included success rate, tracheal trauma and ease of use. The surgical technique was fastest. The median (IQR [range]) was 81 (62–126 [37–300]) s, followed by the Melker 124 (100–217 [71–300]) s, and the Surgicric 127 (68–171 [43–300]), p = 0.003. The Surgicric device was the most traumatic, as evaluated by a blinded Ear, Nose and Throat surgeon. Subsequently, the authors contacted the device manufacturer, who has now modified the kit in the hope that its clinical application might be improved. Further studies are required to evaluate the revised model.     

Equipment and strategies for emergency tracheal access in the adult patient

The inability to maintain oxygenation by non-invasive means is one of the most pressing emergencies in anaesthesia and emergency care. To prevent hypoxic brain damage and death in a 'cannot intubate, cannot oxygenate' situation, emergency percutaneous airway access must be performed immediately. Even though this emergency is rare, every anaesthetist should be capable of performing an emergency percutaneous airway as the situation may arise unexpectedly. Clear knowledge of the anatomy and the insertion technique, and repeated skill training are essential to ensure completion of this procedure rapidly and successfully. Various techniques have been described for emergency oxygenation and several commercial emergency cricothyroidotomy sets are available. There is, however, no consensus on the best technique or device. As each has its limitations, it is recommended that all anaesthetists are skilled in more than one technique of emergency percutaneous airway. Avoiding delay in initiating rescue techniques is at least as important as choice of device in determining outcome.     

不同引流术急诊处理输尿管结石梗阻合并尿脓毒血症的比较

目的比较2种不同引流术急诊处理输尿管结石梗阻合并脓毒血症的有效性及安全性。方法 2003年3月～2011年3月52例输尿管结石梗阻合并尿脓毒血症,27例采用输尿管镜直视下逆行置入双J管引流术(输尿管镜组),25例采用B超引导下经皮肾穿刺造瘘术治疗(经皮肾组)。结果输尿管镜组由6名不同级别术者完成,经皮肾组由2名高级别术者完成。输尿管镜组置管引流成功率(100%)明显高于经皮肾组(21/25,84.0%)(Fisher’s检验,P=0.047);2组术后尿脓毒血症控制时间无统计学差异[(6.5±1.2)d vs.(6.4±1.2)d,t=0.300,P=0.765];2组无输尿管穿孔、大出血及死亡等严重并发症。结论输尿管镜直视下逆行置入双J管引流术和经皮肾穿刺造瘘术均为急诊处理输尿管结石梗阻合并尿脓毒血症安全有效的方法;输尿管镜直视下逆行置入双J管引流术置管成功率更高;对于超声技术不熟练的术者和患肾轻度积水的患者,推荐首选输尿管镜手术。     

Clinical experience with percutaneous tracheostomy and cricothyroidotomy in 100 patients

Ninety-four cases of percutaneous tracheostomy and six cases of percutaneous cricothyroidotomy are reported in this study. There was one death attributable to the use of the device. A complication rate of 14% is reported. Clinical use for the adult and pediatric patient is reported. The procedure is compared to the standard dissection tracheostomy method of Chevalier Jackson. This procedure has several advantages over the standard dissection method, the most significant of which appears to be the speed with which it can be performed. It can be done in 30 seconds, as opposed to the dissection procedure which requires 3 minutes or more for a surgeon to complete it. Autopsies on 14 of these patients are discussed. Long-term followup, that is for 1 year and more, is reported in 19 cases. Advantages of the percutaneous technique over the standard dissection technique are detailed.     

Comparison of bupivacaine and prilocaine used in Bier block—a double blind trial

The value of Bier blocks for the manipulation of fractures and for operations on the upper limb is well recognized. Two anaesthetic agents, bupivacaine and prilocaine, are widely used for this purpose. A prospective double blind trial of 200 patients has been carried out to compare the efficacy of each drug and the incidence of side effects.The study shows that bupivacaine was associated with a greater number of successful fracture reductions than prilocaine with little difference in their analgesic effects, but this was balanced by more minor side effects with bupivacaine. There was little difference in the time from injection to analgesia in the two groups.All intravenous regional analgesia procedures were carried out by junior orthopaedic or accident and emergency doctors. The overall success rate for analgesia was 91 per cent but marked cuff discomfort occurred in 9 per cent of patients. There was a clear association between failure of analgesia and two of the doctors carrying out the procedure.     

Cricothyrotomy in emergency context: assessment of a cannot intubate cannot ventilate scenario

Objective

The aim of this study was to assess airway management by emergency physicians in case of a simulated situation where intubation and ventilation were both impossible.

Study design

Observational manikin study.

Methods

A manikin (Airman^®; Laerdal) allowing simulating difficult airway situations was used. The scenario assessed concerned a patient needing tracheal intubation for severe traumatic brain injury. The manikin was settled to make tracheal intubation under direct laryngoscopy impossible at the first attempt and to make facemask ventilation impossible after the second attempt. Manikin could initially be ventilated through the intubating laryngeal mask Airway (ILMA) but became impossible few seconds after its insertion. With impossible ventilation through the ILMA, arterial oxygen saturation decreased during 2 minutes before an hypoxic cardiac arrest occurred. Physicians could use classic laryngoscope with Macinthosh blade, a Gum Elastic Bougie, an ILMA and a cricothyrotomy set. Adhesion to the national airway management algorithm was assessed. Time to cricothyroidotomy decision after ventilation through ILMA became impossible was measured.

Results

Twenty-five emergency physicians were assessed. For 14 of them, national expert conference algorithm was perfectly followed. For ten physicians, cricothyroidotomy decision was taken after hypoxic cardiac arrest occurred.

Conclusion

Simulation with a manikin is useful to assess the adhesion rate to difficult intubation algorithms. Our study shows that the decision making process for cricothyrotomy is too often delayed as soon as ventilation became impossible and oxygenation compromized.     

Evaluation of a novel cricothyroidotomy introducer in a simulated obese porcine model: a randomised crossover comparison with scalpel cricothyroidotomy

The Difficult Airway Society 2015 guidelines for management of unanticipated difficulties in tracheal intubation in adults have generated much discussion regarding Plan D: emergency front‐of‐neck access with a scalpel‐bougie cricothyroidotomy technique. There is concern that this technique may not provide an adequate pathway for the bougie and subsequently the tracheal tube, especially in obese patients with deeper airway structures. This could lead to the formation of a false passage, trauma and failure. A novel cricothyroidotomy introducer, 8 mm wide and 170 mm long, with a sharp leading edge and guiding channel to pass a bougie into the trachea, has been designed to complement the scalpel cricothyroidotomy technique. A comparison study of the use of this novel introducer with the scalpel technique in a simulated obese porcine laryngeal model demonstrated shorter insertion times (median (IQR [range]) 85 (65–123 [48–224]) s vs. 84 (72–184 [46–377]) s, p = 0.030). All 26 (100%) participants successfully performed cricothyroidotomy in the introducer group, whereas only 24 (92%) participants were successful in the scalpel group. The introducer group required fewer attempts to access the trachea compared with the scalpel group (p = 0.046). False passages occurred eight (31%) times in the introducer group compared with 17 (65%) times in the scalpel group (p = 0.022). There were no statistical differences in tracheal trauma (p = 0.490), ease of use (p = 0.220) and device preference (p = 0.240). This novel cricothyroidotomy introducer has shown promising results in securing the airway in an emergency front‐of‐neck access situation. With robust training, this introducer could potentially be complementary to the scalpel‐bougie cricothyroidotomy technique.     

Neuer Facharzt für das Durchgangsarzt- und Verletzungsartenverfahren

The requirements that currently have to be met to allow involvement in emergency and injury typing procedures are introduced, and the reasons that have led to them are explained. As always, a special qualification is still needed before a doctor can take part in emergency procedures, as the emergency call-out doctors bear a decisive share of the responsibility for implementation of the statutory tasks of prompt and appropriate specific traumatological rehabilitation that devolve on the statutory accident insurance scheme. In contrast to the doctors accepted as qualified to apply treatments approved by the employers’ liability insurance associations, the emergency doctors decide on the kind of treatment to be initiated. The hospitals in which the injury typing procedure is applied are also required to fulfil specific requirements concerning patient accommodation and staff. The insurance associations pay particular attention to the currently variable management of how the medical councils of the länder redefine the emphasis of trauma surgery used hitherto fit the supplementary designation of special trauma surgery, so as to be able to step in promptly in the event of any problems.