Characterizing emergency department surgical airway placement in the setting of trauma.

INTRODUCTION: Airway management is a key intervention during the resuscitation of critically ill trauma patients. Emergency surgical airway (ESA) placement is taught as a backup option when endotracheal intubation (ETI) fails. We sought to (1) describe the incidence of the emergency department (ED) ESA, (2) compare ESA versus ETI-only recipients, and (3) determine which factors were associated with receipt of an ESA. METHODS: We searched within the Trauma Quality Improvement Program datasets from 2017 to 2022 for all emergency department surgical airway placement and/or endotracheal intubations recipients. We compared ESA versus ETI-only recipients. RESULTS: From 2017 to 2022, there were 6,477,759 within the datasets, of which 238,128 met inclusion for this analysis. Within that, there were 236,292 ETIs, 2264 ESAs, with 428 (<1 %) having documentation of both. Of the ESAs performed, there were 82 documented in children <15 years of age with the youngest being 1 year of age. The ETI-only group had a lower proportion serious injuries to the head/neck (52 % versus 59 %), face (2 % versus 8 %), and skin (3 % versus 6 %). However, the ETI-only group had a higher proportion of serious injuries to the abdomen (15 % versus 9 %) and the extremities (19 % versus 12 %). Survival at 24-h was higher in the ETI-only group (83 % versus 76 %) as well as survival to discharge (70 % versus 67 %). In the subanaysis of children <15 years (n = 82), 34 % occurred in the 1-4 years age group, 35 % in the 5-9 years age group, and 30 % in the 10-14 years age group. In our multivariable logistic regression analysis, serious injuries to the head/neck (odds ratio [OR] 1.37, 95 % CI 1.23-1.54), face (OR 3.41, 2.83-4.11), thorax (OR 1.19, 1.06-1.33), and skin (OR 1.53, 1.15-2.05) were all associated with receipt of cricothyrotomy. Firearm (OR 3.62, 3.18-4.12), stabbing (2.85, 2.09-3.89), and other (OR 2.85, 2.09-3.89) were associated with receipt of ESA when using collision as the reference variable. CONCLUSIONS: ESA placement is a rarely performed procedure but frequently used as a primary airway intervention in this dataset. Penetrating mechanisms, and injuries to face were most associated with ESA placement. Our findings reinforce the need to maintain this critical airway skill for trauma management.

Virtual reality cricothyrotomy - a case-control study on gamification in emergency education.

BACKGROUND: Cricothyrotomy is an invasive and rare emergency intervention to secure the airway in a "cannot intubate, cannot ventilate" situation. This leads to lack of routine. Cricothyrotomy is performed only hesitantly. Therefore, we aim to improve teaching by including a virtual reality (VR) cricothyrotomy as a learning tool. METHODS: We programmed the VR cricothyrotomy in the C# programming language on the open-source Unity platform. We could include 149 students that we randomly assigned to either a study group (VR cricothyrotomy) or control group (educational video). We asked the study group to subjectively rate the VR cricothyrotomy. To evaluate our intervention (VR cricothyrotomy) we took the time participants needed to perform a cricothyrotomy on a plastic model of a trachea and evaluated the correct procedural steps. RESULTS: The majority of students that performed the VR simulation agreed that they improved in speed (81%) and procedural steps (92%). All participants completed the cricothyrotomy in 47s ± 16s and reached a total score of 8.7 ± 0.7 of 9 possible points. We saw no significant difference in time needed to perform a cricothyrotomy between study and control group (p > 0.05). However, the total score of correct procedural steps was significantly higher in the study group than in the control group (p < 0.05). CONCLUSIONS: Virtual reality is an innovative learning tool to improve teaching of emergency procedures. The VR cricothyrotomy subjectively and objectively improved correct procedural steps. Digitized education fills an educational gap between pure haptic experience and theoretical knowledge. This is of great value when focusing on extension of factual knowledge. TRIAL REGISTRATION: DRKS00031736, registered on the 20th April 2023.

Incidence of rescue surgical airways after attempted orotracheal intubation in the emergency department: A National Emergency Airway Registry (NEAR) Study.

BACKGROUND: Cricothyrotomy is a critical technique for rescue of the failed airway in the emergency department (ED). Since the adoption of video laryngoscopy, the incidence of rescue surgical airways (those performed after at least one unsuccessful orotracheal or nasotracheal intubation attempt), and the circumstances where they are attempted, has not been characterized. OBJECTIVE: We report the incidence and indications for rescue surgical airways using a multicenter observational registry. METHODS: We performed a retrospective analysis of rescue surgical airways in subjects ≥14 years of age. We describe patient, clinician, airway management, and outcome variables. RESULTS: Of 19,071 subjects in NEAR, 17,720 (92.9%) were ≥14 years old with at least one initial orotracheal or nasotracheal intubation attempt, 49 received a rescue surgical airway attempt, an incidence of 2.8 cases per 1000 (0.28% [95% confidence interval 0.21 to 0.37]). The median number of airway attempts prior to rescue surgical airways was 2 (interquartile range 1, 2). Twenty-five were in trauma victims (51.0% [36.5 to 65.4]), with neck trauma being the most common traumatic indication (n = 7, 14.3% [6.4 to 27.9]). CONCLUSION: Rescue surgical airways occurred infrequently in the ED (0.28% [0.21 to 0.37]), with approximately half performed due to a trauma indication. These results may have implications for surgical airway skill acquisition, maintenance, and experience.

Anatomical morphometry for Cricothyrotomy puncture and incision.

PURPOSE: Emergency surgical airway securing techniques include cricothyrotomy, puncture, and incision. While the instruments used for these methods vary in size, no index of laryngeal morphology exists to guide instrument selection. Therefore, we measured the morphology of the cricothyroid ligament in Japanese individuals and assessed its correlations with height. METHODS: This retrospective study used 61 anatomical practice specimens. The cricothyroid ligament of the laryngeal area was dissected, and a frontal image was recorded. Next, images of the midsagittal sections of the larynx and trachea were recorded. The width and height of the cricothyroid ligament were measured from the frontal images, and the depth of the larynx and the angle to the lower edge of the cricothyroid plate were measured from the mid-sagittal cross-sectional images. The height was estimated from the tibial lengths of the specimens and statistically analyzed for correlations. 　 RESULTS: The width and depth were significantly greater in males. Overall, there was a slight correlation between the results of each laryngeal measurement and estimated height for all items. CONCLUSION: The morphology of cricothyrotomy revealed that the width and depth of the laryngeal area varied according to sex. Moreover, the results also showed a correlation with the estimated height. Thus, it is important to predict the morphology of the laryngeal area and cricothyroid ligament by considering factors such as patient sex, weight, and height.

Establishment and application of cricothyrotomy in vivo.

BACKGROUND: Cricothyrotomy is a procedure performed to establish an airway in critical airway events. It is performed only rarely and anesthesiologists are often unprepared when called upon to perform it. This study aimed to simulate cricothyrotomy using pig larynx and trachea models to help anesthesiologists master cricothyrotomy and improve the ability to establish cricothyrotomy quickly. METHODS: The porcine larynx and trachea were dissected and covered with pigskin to simulate the structure of the anterior neck of a human patient. An animal model of cricothyrotomy was established. Forty anesthesiologists were randomly divided into four groups. Each physician performed three rounds of cricothyrotomy, and recorded the time to accomplish each successful operation. After training the cricothyrotomy procedure, a questionnaire survey was conducted for the participating residents using a Likert scale. The participants were asked to score the utility of the training course on a scale of 1 ((minimum) to 5 ((maximum). RESULTS: Through repeated practice, compared with the time spent in the first round of the operation (67 ± 29 s), the time spent in the second round of the operation (47 ± 21 s) and the time spent in the third round of the operation (36 ± 11 s) were significantly shortened (P < 0.05). Results of the survey after training were quite satisfied, reflecting increased the ability of proficiency in locating the cricothyroid membrane and performing a surgical cricothyrotomy. CONCLUSION: The porcine larynx and trachea model is an excellent animal model for simulating and practicing cricothyrotomy, helping anesthesiologists to master cricothyrotomy and to perform it proficiently when required.

Equivalence of the top-down manoeuvre and bottom-up manoeuvre in speed and accuracy of identifying the cricothyroid membrane: a prospective randomised cross-over study.

BACKGROUND: Accurate identification of the cricothyroid membrane is crucial for successful cricothyrotomy; however, a manoeuvre that helps identify it both accurately and quickly remains unclear. The effectiveness of the so-called 'bottom-up manoeuvre' has never been investigated. This study aimed to examine whether the bottom-up manoeuvre is as rapid and accurate as the conventional 'top-down manoeuvre' at identifying the cricothyroid membrane. METHODS: This study was a prospective randomised cross-over trial conducted at an academic medical centre between 2018 and 2019. Fifth-year medical students participated. The students were trained in the use of either the top-down manoeuvre or the bottom-up manoeuvre first. Each student subsequently performed the technique once on a volunteer. The students were then taught and practiced the other manoeuvre as well. The accuracy of cricothyroid membrane identification and the time taken by successful participants only were measured and compared between the manoeuvres using equivalence tests with two one-sided tests. RESULTS: A total of 102 medical students participated in this study and there was no missing data. The accuracy of identification and time required for success were similar between the top-down manoeuvre and the bottom-up manoeuvre (65.7% vs. 70.6%, taking 13.8 s [interquartile range (IQR): 9.4-17.5] vs. 15.5 s [IQR: 11.5-19.9], respectively). The success rate was statistically equivalent (rate difference, 4.9%; 90% confidence interval [CI], -5.8 to 15.6; equivalence margin, -20.0 to 20.0). The time required for success was also statistically equivalent (median difference, 1.7 s; 90% CI, -0.2 to 3.3; equivalence margin, -4.0 to 4.0). CONCLUSION: Among students first trained in both manoeuvres for identifying the cricothyroid membrane, the speed and accuracy of identification were similar between those using the bottom-up manoeuvre and those using the top-down manoeuvre.

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

BACKGROUND: In this study, we aimed to evaluate the educational value and students' satisfaction with the hand-made low-cost cricothyrotomy simulation model. MATERIALS AND METHODS: A low-cost and hand-made model and a high-fidelity model were used to assess the students. The students' knowledge and satisfaction were evaluated using a 10-item checklist and a satisfaction questionnaire, respectively. Medical interns in the present study participated in a two-hour briefing and debriefing session held in the Clinical Skills Training Center by an emergency attending doctor. RESULTS: Based on the results of data analysis, no significant differences were found between the two groups in terms of gender, age, the month of internship, and last semester's grade (P = .628, .356, .847, and .421, respectively). We also found no significant differences between our groups in terms of the median score of each item in the assessment checklist (P = .838, .736, .805, .172, .439, .823, .243, .950, .812, and .756, respectively). The study groups had no significant difference in the median total scores of the checklist as well (P = .504). Regarding the students' satisfaction, our results showed that interns evaluated their experience of the model as positive (median scores of 4 and 5 out of 5). They also gave the hand-made model a median score of 7 in comparison with the high-fidelity model and 8 out of 10 for its usability. CONCLUSION: The study results showed that a low-cost model could be as effective as an expensive high-fidelity model for teaching the necessary knowledge of cricothyrotomy techniques to medical trainees.

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.

The effect of patient positioning on ultrasound landmarking for cricothyrotomy.

PURPOSE: Our primary objective was to assess the difference in position of the ultrasound-guided landmark of the cricothyroid membrane (CTM) when performed with the supine patient positioned at different head of bed (HOB) elevations. METHODS: In this prospective observational study of patients presenting to the emergency department with non-life-threatening complaints, subjects underwent ultrasound-guided landmarking of the CTM with HOB elevation at 0°, 30°, and 90°. A linear mixed effects regression model was used to assess the change in the CTM landmark associated with head position. We used a second adjusted linear mixed effects model to assess possible confounding patient factors associated with these changes. RESULTS: One-hundred and ten patients were enrolled, with a median [interquartile range] age of 39 [29-59] yr and 51:49 female:male ratio. Head of bed elevation at 30° and 90° resulted in a cephalad change in the CTM landmark of 2.7 mm (99% confidence interval [CI], 1.7 to 3.8; P < 0.001) and 4.2 mm (99% CI, 3.2 to 5.3; P < 0.001) respectively compared with the landmark at 0°. Body mass index (BMI) was associated with a change of 4.6 mm (99% CI, 0.5 to 8.7; P = 0.004) for BMI ≥ 30 compared with < 18.5 kg·m-2 The impact of patient age on distance depended on HOB elevation, where patients > 70 yr had a change of 2.6 mm (99% CI, 0.01 to 5.1; P = 0.009) at 90° HOB elevation compared with 30°. CONCLUSION: The location of the ultrasound-identified surface landmark of the CTM moves in a cephalad direction by changing the position of the HOB from supine 0° to elevation at 30° and 90°. This may be clinically important when attempting cricothyrotomy using a percutaneous (blind) technique, particularly when CTM identification and cricothyrotomy are performed at different head elevations.

RéSUMé: OBJECTIF: Notre objectif principal était d'évaluer la différence de position de la membrane cricothyroïdienne en tant que repère échoguidé selon qu'elle est identifiée à différentes élévations de la tête du lit avec le patient en décubitus dorsal. MéTHODE: Cette étude observationnelle prospective a inclus des patients se présentant à l'urgence pour des problèmes de santé ne mettant pas leur vie en danger. Les repères échoguidés de la membrane cricothyroïdienne ont été identifiés chez ces patients en positionnant la tête de lit à 0°, 30° et 90°. Un modèle de régression linéaire à effets mixtes a été utilisé pour évaluer les modifications du repère de la membrane cricothyroïdienne associés à la position de la tête. Nous avons utilisé un deuxième modèle linéaire à effets mixtes ajustés pour évaluer les facteurs confondants potentiels liés au patient et associés à ces changements. RéSULTATS: Cent dix patients ont été recrutés, d'un âge médian [écart interquartile] de 39 [29-59] ans et avec un ratio femmes : hommes de 51 : 49. L'élévation de la tête de lit à 30° et 90° a entraîné un glissement céphalade de 2,7 mm (intervalle de confiance [IC] 99 %, 1,7 à 3,8; P < 0,001) et de 4,2 mm (IC 99 %, 3,2 à 5,3; P < 0,001) du marquage de la membrane cricothyroïdienne, respectivement, comparativement au repère identifié à un angle de 0°. L'indice de masse corporelle (IMC) était associé à un changement de 4,6 mm (IC 99 %, 0,5 à 8,7; P = 0,004) pour un IMC ≥ 30, comparativement à < 18,5 kg·m−2. L'impact de l'âge du patient sur la distance dépendait de l'élévation de la tête de lit : chez les patients > 70 ans, le changement était de 2,6 mm (IC 99 %, 0,01 à 5,1; P = 0,009) à une élévation de la tête de lit de 90° comparativement à un angle de 30°. CONCLUSION: L'emplacement du repère de surface identifié par échoguidage de la membrane cricothyroïdienne se déplace en direction céphalade lorsqu'on change la position de la tête de lit d'un décubitus dorsal à 0° à une élévation de 30° et 90°. Cela pourrait avoir une importance clinique lors d'une tentative de cricothyrotomie à l'aide d'une technique percutanée (en aveugle), particulièrement si l'identification de la membrane cricothyroïdienne et la cricothyrotomie sont réalisées à différentes élévations de la tête.

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.

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.

Randomized Comparative Assessment of Three Surgical Cricothyrotomy Devices on Airway Mannequins.

BACKGROUND: Airway obstruction is the second leading cause of preventable battlefield death, at least in part because surgical cricothyrotomy (SC) failure rates remain unacceptably high. Ideally, SC should be a rapid, simple, easily-learned, and reliably-performed procedure. Currently, 3 SC devices meet Tactical Combat Casualty Care (TCCC) standards: The Tactical CricKit® (TCK), Control-CricTM(CC), and Bougie-assisted Technique (BAT). However, no previous studies have compared these devices in application time, application success, user ratings, and user preference. METHODS: United States Navy Corpsmen (N = 25) were provided 15 minutes of standardized instruction, followed by hands-on practice with each device on airway mannequins. Participants then performed SC with each of the 3 devices in a randomly assigned sequence. In this within-subjects design, application time, application success, participant ratings, and participant preference data were analyzed using repeated-measures ANOVA, regression, and non-parametric statistics at p < 0.05. RESULTS: Application time for CC (M = 184 sec, 95% CI 144-225 sec) was significantly slower than for BAT (M = 135 sec, 95% CI 113-158 sec, p < 0.03) and TCK (M = 117 sec, 95% CI 93-142 sec, p < 0.005). Success was significantly greater for BAT (76%) than for TCK (40%, p < 0.02) and trended greater than CC (48%, p = 0.07). CC was rated significantly lower than TCK and BAT in ease of application, effectiveness, and reliability (each p < 0.01). User preference was significantly (p < 0.01) higher for TCK (58%) and BAT (42%) than for CC (0%). Improved CC blade design was the most common user suggestion. CONCLUSION: While this study was limited by the use of mannequins in a laboratory environment, present results indicate that none of these devices was ideal for performing SC. Based on slow application times, low success rates, and user feedback, the Control-CricTM cannot be recommended until improvements are made to the blade design.

The REAL CRIC Trainer: Instructions for Building an Inexpensive, Realistic Cricothyrotomy Simulator With Skin and Tissue, Bleeding, and Flash of Air.

BACKGROUND: Surgical cricothyrotomy is a rare procedure but it must be mastered by any physician who is involved in advanced airway management. Lack of experience and practice, the high-stress nature of a "can't intubate, can't oxygenate" emergency, and the unavailability of realistic simulators all contribute to physician hesitance and inaptitude while employing cricothyrotomy during difficult and failed airways. The REAL CRIC Trainer was created to alleviate some of the barriers surrounding a surgical airway. It is designed to provide the user an affordable, easy to replicate, reusable, and extremely realistic experience in cricothyrotomy to prepare for this rare event. DISCUSSION: The REAL CRIC Trainer uses a 3-dimensional printed tracheal model that is covered with pork belly skin, replicating human neck tissue. Red dyed normal saline is connected to the pork belly using intravenous tubing to simulate bleeding as an incision is made into the porcine skin. A bag-valve-mask connected to an endotracheal tube and to the trachea model will simulate breathing and replicate the puff of air experienced as the cricothyroid membrane is pierced with a scalpel. This simulator is cost effective and easy to replicate. Detailed step-by-step instructions are provided so that physicians working in any specialty involved in advanced airway management can easily recreate this trainer. CONCLUSIONS: This simulator makes it practical for physicians in a variety of clinical settings to incorporate its use into regular practice sessions, thereby assuring that physicians are ready to perform an emergent cricothyrotomy if necessary.

Prehospital cricothyrotomies in a helicopter emergency medical service: analysis of 19,382 dispatches.

BACKGROUND: Creating a patent airway by cricothyrotomy is the ultimate maneuver to allow oxygenation (and ventilation) of the patient. Given the rarity of airway management catastrophes necessitating cricothyrotomy, sufficiently sized prospective randomized trials are difficult to perform. Our Helicopter Emergency Medical Service (HEMS) documents all cases electronically, allowing a retrospective analysis of a larger database for all cases of prehospital cricothyrotomy. METHODS: We analyzed all 19,382 dispatches of our HEMS 'Lifeliner 1', since set-up of a searchable digital database. This HEMS operates 24/7, covering ~ 4.5 million inhabitants of The Netherlands. The potential cases were searched and cross-checked in two independent databases. RESULTS: We recorded n = 18 cases of prehospital cricothyrotomy. In all 18 cases, less invasive airway techniques, e.g., supraglottic devices, were attempted before cricothyrotomy. With exception of 2 cases, at least one attempt of orotracheal intubation had been performed before cricothyrotomy. Out of the 18 cases, 4 were performed by puncture-based technique (Melker), the remaining 14 cases by surgical technique. Indications for cricothyrotomy were diverse, dividable into 9 trauma cases and 9 medical cases. The procedure was successful in all but one case (17/18, i.e., 94%; with a 95% confidence interval of 72.7-99.9%). Outcome was such that 6/18 patients arrived at the hospital alive. Long term outcome was poor, with only 2/18 patients discharged from hospital alive. CONCLUSIONS: Cricothyrotomy remains, although rare, a regularly occurring requirement in (H)EMS. Our finding of a convincingly high success rate of 94% in trained hands encourages training and a timely performance of cricothyrotomy.

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

INTRODUCTION: An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments. METHODS: We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT). RESULTS: Of 207 DAMT activations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event. CONCLUSION: An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.

A randomized cross-over study comparing surgical cricothyrotomy techniques by combat medics using a synthetic cadaver model.

OBJECTIVE: Cricothyrotomy is a complex procedure with a high rate of complications including failure to cannulate and injury to adjacent anatomy. The Control-Cric™ System and QuickTrach II™ represent two novel devices designed to optimize success and minimize complications with this procedure. This study compares these two devices against a standard open surgical technique. METHODS: We conducted a randomized crossover study of United States Army combat medics using a synthetic cadaver model. Participants performed a surgical cricothyrotomy using the standard open surgical technique, Control-Cric™ System, and QuickTrach II™ device in a random order. The primary outcome was time to successful cannulation. The secondary outcome was first-attempt success. We also surveyed participants after performing the procedures as to their preferences. RESULTS: Of 70 enrolled subjects, 65 completed all study procedures. Of those that successfully cannulated, the mean times to cannulation were comparable for all three methods: standard 51.0s (95% CI 45.2-56.8), QuickTrach II™ 39.8s (95% CI 31.4-48.2) and the Cric-Control™ 53.6 (95% CI 45.7-61.4). Cannulation failure rates were not significantly different: standard 6.2%, QuickTrach II™ 13.9%, Cric-Control™ 18.5% (p=0.106). First pass success rates were also similar (93.4%, 91.1%, 88.7%, respectively, p=0.670). Of respondents completing the post-study survey, a majority (52.3%) preferred the QuickTrach II™ device. CONCLUSIONS: We identified no significant differences between the three cricothyrotomy techniques with regards to time to successful cannulation or first-pass success.

Impact of prehospital airway management on combat mortality.

INTRODUCTION: Analysis of modern military conflicts suggests that airway compromise remains the second leading cause of preventable death of combat fatalities. This study compares outcomes of combat casualties that received prehospital airway interventions, specifically bag valve mask (BVM) ventilation, cricothyrotomy, and supraglottic airway (SGA) placement. The goal is to compare the effectiveness of airway management strategies used in the military pre-hospital setting. METHODS: This retrospective chart review of 1267 US Army medical evacuation patient care records, compared outcomes of casualties that received prehospital advanced airway interventions. The patients consisted of US military injured in Operation Enduring Freedom January 2011-March 2014. Compared outcomes consisted of vent-, ICU-, and hospital-free days. RESULTS: Those with SGA placement experienced fewer vent-free days, ICU-free days, and hospital-free days compared to BVM and cricothyrotomy patients. The groups did not significantly differ in rates of 30-day survival. The odds for survival were not significantly higher for BVM versus SGA patients (OR 1.5, 95% CI 0.2-9.8), cricothyrotomy versus SGA patients (OR 3.9, 95% CI 0.6-24.9), or cricothyrotomy versus BVM patients (OR 2.7, 95% CI 0.5-13.8) in a logistic regression model adjusting for GCS. CONCLUSION: This study supports prehospital BVM ventilation as a possible alternative to cricothyrotomy as there was no difference in measured outcomes between the groups. It further cautions against SGA use in the prehospital combat setting due to higher morbidity demonstrated by fewer ventilator, hospital, and ICU free days than those receiving cricothyrotomy or BVM ventilation. There was no difference in 30-day survival between the groups.

Ultrasound for identifying the cricothyroid membrane prior to the anticipated difficult airway.

BACKGROUND: Prior to the anticipated difficult airway, the emergency physician commonly palpates the neck to identify the presumed location of the cricothyroid membrane (CTM). In the event of a "cannot-intubate, cannot­oxygenate" airway, precise CTM localization is vital to the success of a cricothyrotomy and hence, the patient's survival. OBJECTIVE: This narrative review will summarize the prospective studies evaluating CTM identification. It will demonstrate the inaccuracy of the classically used landmark palpation technique. It will then describe the use of ultrasound (US) as a superior tool for CTM identification, illustrate the technique itself, and propose its implementation in the pre-intubation checklist for the anticipated difficult airway. DISCUSSION: Evidence demonstrates that physicians are not sufficiently accurate in palpating the CTM in both cadavers and volunteers in a stable non-emergent setting. In preparing for a real-time intubation, this fine motor task would be more difficult to achieve. Moreover, this particular patient group may often exhibit difficult airway features. US has been demonstrated to be superior for locating the CTM than landmark palpation across body habitus, gender, and failed airway simulations. This technique carries a short learning curve even without prior airway US experience, along with a high retention rate. An illustrative tutorial is provided. CONCLUSION: Emergency physicians may apply this US technique for CTM localization in preparation for an anticipated difficult airway. However, since this technique takes longer than landmark palpation, using US is not recommended once already in the midst of a failed airway situation.

[Algorithm for securing an unexpected difficult airway : User analysis on a simulator]. / Algorithmus zur Sicherung des unerwartet schwierigen Atemwegs : Eine Anwenderanalyse am Simulator.

BACKGROUND: Critical incidents in difficult airway management are still a main contributory factor for perioperative morbidity and mortality. Many national associations have developed algorithms for management of these time critical events. For implementation of these algorithms the provision of technical requirements and procedure-related training are essential. Severe airway incidents are rare events and clinical experience of the individual operators is limited; therefore, simulation is an adequate instrument for training and evaluating difficult airway algorithms. OBJECTIVE: The aim of this observational study was to evaluate the application of the institutional difficult airway algorithm among anesthetists. MATERIAL AND METHODS: After ethics committee approval, anesthetists were observed while treating a "cannot intubate" (CI) and a "cannot intubate, cannot ventilate" (CICV) situation in the institutional simulation center. As leader of a supportive team the participants had to deal with an unexpected difficult airway after induction of anesthesia in a patient simulator. The following data were recorded: sequence of the applied airway instruments, time to ventilation after establishing a secured airway using any instrument in the CI situation and time to ventilation via cricothyrotomy in the CICV situation. Conformity to the algorithm was defined by the sequence of the applied instruments. Analysis comprised conformity to the algorithm, non-parametric tests for time to ventilation and differences between junior and senior anesthetists. RESULTS: Out of 50 participants 45 were analyzed in the CI situation. In this situation 93% of the participants acted in conformity with the algorithm. In 62% the airway was secured by flexible intubation endoscopy, in 38% with another device. Data from 46 participants were analyzed in the CICV situation. In this situation 91% acted in conformity with the algorithm. The last device used prior to the decision for cricothyrotomy was flexible intubation endoscopy in 39%, a laryngeal mask in 22% and other instruments in 39%. Of the 50 participants 38 had already been institutionally trained in difficult airway management during the previous 2 years. For cricothyrotomy the participants needed a median time of 63 s and there was no difference between junior and senior anesthetists (p = 0.46). The cricothyrotomy was performed faster using a surgical approach than a transtracheal puncture approach using a Melker emergency cricothyrotomy set (52 s vs. 73 s, p = 0.014). CONCLUSION: The conformity to the algorithm of over 90% indicates a good training level of the participants concerning the difficult airway algorithm. In the observed sample flexible intubation endoscopy tended to be of high significance even in the unanticipated difficult airway. Cricothyrotomy was performed faster surgically than by the use of the transtracheal puncture approach, while no differences between junior and senior anesthetists were observed. For the successful management of an unexpected difficult airway, specific training of these special and rare events is crucial. A standardized provision of special airway instruments stored in a special trolley and frequent application of this trolley in the clinical routine is recommended.

Awake Cricothyrotomy: A Novel Approach to the Surgical Airway in the Tactical Setting.

Airway obstruction on the battlefield is most often due to maxillofacial trauma, which may include bleeding and disrupted airway anatomy. In many of these cases, surgical cricothyrotomy (SC) is the preferred airway management procedure. SC is an emergency airway procedure performed when attempts to open an airway using nasal devices, oral devices, or tracheal intubation have failed, or when the risks from intubation are unacceptably high. The aim of this overview is to describe a novel approach to the inevitably surgical airway in which SC is the first and best procedure to manage the difficult or failed airway. The awake SC technique and supporting algorithm are presented along with the limitations and future directions. Awake SC, using local anesthetic with or without ketamine, will allow the knowledgeable provider to manage patients with a compromised airway across the continuum of emergency care ranging from remote/en route care, austere settings, and prehospital to the emergency department.