Objectives: Emergency cricothyroidotomy is potentially lifesaving in patients with airway compromise who cannot be intubated or ventilated by conventional means. The literature remains divided on the best insertion technique, namely, the open ⁄ surgical and percutaneous methods. The two are not mutually exclusive, and the study hypothesis was that an ''incision-first'' modification (IF) may improve the traditional needle-first (NF) percutaneous approach. This study assessed the IF technique compared to the NF method.Methods: A randomized controlled crossover design with concealed allocation was completed for 180 simulated tracheal models. Attending and resident emergency physicians were enrolled. The primary outcome was time to successful cannulation; secondary outcomes included needle insertion(s), incision, and dilatation attempts. Finally, proportions of intratracheal insertion on the first attempt and subjective ease of insertion were compared. Results:The IF technique was significantly faster than the standard NF technique (median = 53 seconds, interquartile range [IQR] = 45.0 to 86.4 seconds vs. median = 90 seconds, IQR = 55.2 to 108.6 seconds; p < 0.001). The median number of needle insertions was significantly higher for the NF technique (p = 0.018); there was no significant difference in dilation or incision attempts. Intratracheal insertion on the first attempt was documented in 90 and 93% of the NF and IF techniques, respectively (p = 0.317). All the study participants found the IF hybrid approach easier. Conclusions:The IF modification allows faster access, fewer complications, and more favorable clinician endorsement than the classic NF percutaneous technique in a validated model of cricothyroidotomy. We suggest therefore that the IF technique be considered as an improved method for insertion of an emergency cricothyroidotomy.
Penetrating craniofacial trauma, although uncommon, has a high potential for death or serious morbidity from injury to vital neurovascular structures. An in situ facial foreign body, particularly if large, presents significant challenges beyond safe and timely removal. Airway management, stabilization of the object, management of increased intracranial pressure, and identification of injuries to local structures are all issues that may require addressing. We present a case of penetrating facial trauma from a vice clamp, with an in situ foreign body, that illustrates several of these challenges and provides a forum for their discussion. RÉ SUMÉLe traumatisme craniofacial pé né trant, bien qu'il soit rare, pré sente un potentiel é levé de dé cè s ou de morbidité grave en raison de l'atteinte aux structures neurovasculaires vitales. Un corps é tranger in situ au niveau du visage, en particulier s'il est gros, pré sente des dé fis importants hormis son retrait sû r et en temps opportun. La prise en charge des voies respiratoires, la stabilisation de l'objet, la gestion de la pression intracrâ nienne accrue et la dé termination de la pré sence de lé sions aux structures locales sont autant de questions qui devront ê tre ré solues. Nous pré sentons un cas de traumatisme pé né trant au visage causé par un serre-joint, avec un corps é tranger in situ, qui illustre plusieurs de ces dé fis et fournit un forum pour la discussion.
Is endotracheal intubation (ETI) superior to bag valve mask (BVM) alone for prehospital pediatric airway management? Article chosenGausche M, Lewis RJ, Stratton SJ, Haynes BF, Gunter CS, Goodrich, SM, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;283:783-90. ResultsA total of 830 patients were enrolled, with 410 assigned to BVM and 420 to ETI. Baseline characteristics were similar SELECTED ARTICLES
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