Traumatic rib fractures are common, resulting from significant forces impacting on the chest, and are associated with significant morbidity and mortality.• Respiratory complications, including pneumonia, are common occurring in up to 31% of patients.

BackgroundThere is a paucity of data comparing effectiveness of various techniques for pain management of traumatic rib fractures. This study compared the quality of analgesia provided by serratus anterior plane (SAP) catheters against thoracic epidural (TEA) or paravertebral catheters (PA) in patients with multiple traumatic rib fractures (MRFs).Methods354 patients who received either SAP, TEA or PA at two tertiary referral major trauma centers in the UK were included (2016–2018). Primary outcome were change in inspiratory volumes and pain scores. Secondary outcomes included in-hospital mortality, along with the length of stay in hospital and critical care. Data were analyzed using linear, log-binomial and negative binomial regression models.Main resultsAcross all blocks, there was a mean (SD) increase in inspiratory volume postblock of 789.4 mL (479.7). Ninety-eight per cent of all participants reported moderate/severe pain prior to regional analgesia, which was reduced to 34% postblock. There was no significant difference in the change in inspiratory volume or pain scores between the TEA, PA or SAP groups. Overall crude mortality was 13.2% (95% CI 7.8% to 18.7%). In an adjusted analysis and compared with TEA, in-hospital mortality was similar between groups (relative risk (RR) 0.4, 95% CI 0.1 to 1.0) and (RR 0.5, 95% CI 0.2 to 1.6) for SAP and PA, respectively.ConclusionSAP, TEA and PA all appear to offer the ability to reduce pain scores and improve respiratory function.

SummaryWe compared the time taken to perform cricothyroidotomy on a manikin to that on a medium fidelity simulator, to assess the effect of psychological stress and time pressure on performance. Seventy anaesthetists participated in this randomised cross-over study. Fifty-four (77%) anaesthetists took longer on the simulator, with the mean (SD) time taken to perform the procedure on the manikin and simulator 34 (18) and 48 (11) s, respectively (p < 0.001). Anaesthetists with more experience performed the procedure more quickly on both manikin and simulator. We conclude that psychological stress and time pressure in real-life scenarios can affect the performance of cricothyroidotomy. Cricothyroidotomy is a life-saving emergency airway procedure in a 'can't intubate can't ventilate' situation. It is the final step in the difficult airway algorithm of the American Society of Anesthesiologists [1] and the Difficult Airway Society [2]. However, most anaesthetists have only limited experience in the technique as it is infrequently required, nearly always in a crisis (stressful) situation. In such situations, theoretical knowledge and regular training of the skill on a manikin or simulator is the key to success [3,4].The majority of studies related to emergency cricothyroidotomy are performed on manikins, animals or human cadavers [5]. In an emergency 'can't intubate can't ventilate' situation, when the patient is hypoxic, cricothyroidotomy should be performed rapidly and safely to achieve rapid re-oxygenation. However, the performance of a clinical skill can be affected by stressful conditions [6] and, in a real life emergency, psychological stress and time pressure could affect the performance of this life-saving skill. It would be unethical and impractical to provide training in real life-and-death situations. Therefore, we assessed the effect of psychological stress and time pressure by comparing the time taken to perform cricothyroidotomy on a manikin to that of an emergency 'can't intubate can't ventilate' scenario on a medium fidelity simulator. MethodsThe subcommittee of our local Research Ethics Committee decided that full committee approval was unnecessary because the study was not performed on human subjects and participation by anaesthetists was voluntary. Nevertheless, all prospective participants were fully informed about the study and data collection and a detailed information sheet was given to all participants, all of whom gave written consent before participation. Each participant was given the opportunity to withdraw from the study at any stage, and informed that if they did not consent or chose to withdraw, they could still practise the cricothyroidotomy but their data would not be recorded.A series of cricothyroidotomy training sessions was organised for anaesthetists in our department and all anaesthetists were encouraged to attend. Each session was restricted to a group of six anaesthetists, lasted for an hour and included: a lecture and discussion on the relevant anatomy; techniques of cricothyr...

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P Pu ur rp po os se e: : Recurrent laryngeal nerve damage remains one of the most devastating complications of thyroid surgery. However, nerve identification is not always easy, and a reliable method to locate nerves intraoperatively is needed.M Me et th ho od ds s: : Thirty consecutive patients were anesthetized for elective thyroid surgery using a standard technique. Indications for surgery covered a broad spectrum of conditions. In the technique described, the airway is secured with a micro laryngeal tube, and a laryngeal mask airway is inserted through which a fibreoptic scope is inserted to view the larynx. Movement of the arytenoids in response to nerve stimulation can be viewed at any time on a television monitor. The airway is secure throughout the procedure and nerve identification is continuously available.R Re es su ul lt ts s: : In our study 30 patients were anesthetized and nerve stimulation used in all of them to identify both superior and recurrent laryngeal nerve. None of them developed intraoperative complications. One patient had temporary postoperative recurrent laryngeal nerve damage, which was not attributable to use of this method.C Co on nc cl lu us si io on n: : On the basis of our results so far, the method described is feasible and provides a safe method of nerve location during surgery. Laryngeal nerve stimulation is likely to become an integral part of thyroid surgery. Objectif : Les dommages du nerf laryngé récurrent demeurent la Conclusion : D'après les résultats obtenus jusqu'à maintenant, la méthode décrite est faisable et permet une identification peropéra-toire du nerf sans danger. La stimulation du nerf laryngé pourrait donc être intégrée à l'opération de la thyroïde.HYROIDECTOMIES continue to produce complications with the most devastating being damage to the recurrent laryngeal nerve. 1 The rate of recurrent laryngeal nerve palsy varies from 2% to 17% and for superior laryngeal nerve from 9% to 14%. 2 Trauma to one of the laryngeal nerves is more likely if there are variations or distortions of anatomy, malignancy, previous radiation or revision surgery.It is standard practice to identify the recurrent laryngeal nerve but this is not always possible. A recent study identifies failure to find the nerve in as many as 18% of cases. 3 Mountain et al. showed that the incidence of nerve paralysis was three to four times greater in cases where the nerve was not exposed than in cases where it was routinely exposed.