Best practices for emergency surgical airway: A systematic review

Abstract

ObjectiveIn the case of an emergency surgical airway, current guidelines state that surgical cricothyrotomy is preferable to tracheotomy. However, complications associated with emergency cricothyrotomy may be more frequent and severe. We systematically reviewed the English literature on emergency surgical airway to elicit best practices.MethodsPubMed, Embase, MEDLINE, and the Cochrane Library were searched from inception to January 2019 for studies reporting emergency cricothyrotomy and tracheotomy outcomes. All English‐language retrospective analyses, systematic reviews, and meta‐analyses were included. Case reports were excluded, as well as studies with pediatric, nonhuman, or nonliving subjects.ResultsWe identified 783 articles, and 20 met inclusion criteria. Thirteen evaluated emergency cricothyrotomy and included 1,219 patients (mean age = 39.8 years); 4 evaluated emergency tracheotomy and included 342 patients (mean age = 46.0 years); 2 evaluated both procedures. The rate of complications with both cricothyrotomy and tracheotomy was comparable. The most frequent early complications were failure to obtain an airway (1.6%) and hemorrhage (5.6%) for cricothyrotomy and tracheotomy, respectively. Airway stenosis was the most common long‐term complication, occurring at low rates in both procedures (0.22–7.0%).ConclusionsComplications associated with emergency cricothyrotomy may not occur as frequently as presumed. Tracheotomy is an effective means of securing the airway in an emergent setting, with similar risk for intraoperative and postoperative complications compared to cricothyrotomy. Ultimately, management should depend on clinician experience and patient characteristics.Level of EvidenceIV

Broken Scalpel Blade During Emergent Cricothyroidotomy: An Unexpected Complication in a Critical Situation

“…Like any other procedure, surgical cricothyroidotomy can be complicated by unexpected events. Known early complications include injury to cartilaginous structures, failure to obtain airway, hemorrhage, prolonged execution time, pneumothorax and subcutaneous emphysema [ 10 ]. To our knowledge, this is the first reported case of a surgical blade breaking and getting lodged in the neck during surgical cricothyroidotomy.…”

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

“…Open TS under local anaesthesia in a CICV scenario for patients with an unknown or positive COVID-19 status is too hazardous for the health care workers involved in the procedure. Instead, CTT is easier, safer, faster, and is associated with less bleeding [32,33]. Therefore, we decided to promote such an alternative emergent procedure following the latest Advanced Trauma Life Support manual that recommends surgical CTT over TS for patients in need of the emergent establishment of a surgical airway [32,33].…”

“…Traditionally, CTT was converted to formal TS within 72 h [33,38]. This statement was based upon the historical assumption that CTT is associated with an extremely high risk of subglottic stenosis [39].…”

“…It was later argued that this is not necessarily the case [ 40 ]. Moreover, there seems to be no significant difference in the complication rates of CTT and TS [ 41 ], while the incidence of late complications might be even higher with TS compared to CTT (25.1% vs. 13.6%) [ 33 ]. Various studies report the rate of conversion for CTT as ranging from 0–100% [ 38 ], without differences in terms of long-term benefits between the conversion and permanence of CTT [ 42 , 43 ].…”

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

“…Furthermore, the cricoid cartilage injury may result in a long-term complication such as stenosis. Note that all the other tissue trauma occurred in this study (S1, S2 and S4 Tables) would most likely not have long-term clinical consequences [31,32].…”