Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab

Abstract

Objectives: The objective was to compare time to completion, failure rate, and subjective difficulty of a new cricothyrotomy technique to the standard technique. The new bougie-assisted cricothyrotomy technique (BACT) is similar to the rapid four-step technique (RFST), but a bougie and endotracheal tube are inserted rather than a Shiley tracheostomy tube.Methods: This was a randomized controlled trail conducted on domestic sheep. During a 3-month period inexperienced residents or students were randomized to perform cricothyrotomy on anesthetized sheep using either the standard technique or the BACT. Operators were trained with an educational video before the procedure. Time to successful cricothyrotomy was recorded. The resident or student was then asked to rate the difficulty of the procedure on a five-point scale from 1 (very easy) to 5 (very difficult).Results: Twenty-one residents and students were included in the study: 11 in the standard group and 10 in the BACT group. Compared to the standard technique, the BACT was significantly faster with a median time of 67 seconds (interquartile range [IQR] = 55-82) versus 149 seconds (IQR = 111-201) for the standard technique (p = 0.002). The BACT was also rated easier to perform (median = 2, IQR = 1-3) than the standard technique (median = 3, IQR = 2-4; p = 0.04). The failure rate was 1 ⁄ 10 for the BACT compared to 3 ⁄ 11 for the standard method (p = NS).Conclusions: This study demonstrates that the BACT is faster than the standard technique and has a similar failure rate when performed by inexperienced providers on anesthetized sheep. ACADEMIC EMERGENCY MEDICINE 2010; 17:666-669 ª 2010 by the Society for Academic Emergency MedicineKeywords: cricothyrotomy, gum elastic bougie, difficult airway C ricothyrotomy is a critical procedure in emergency airway management. While the incidence of emergency department cricothyrotomy is decreasing, it remains one of the most important skills of the emergency physician (EP).1,2 Many techniques of cricothyrotomy have been described in the literature. 3-9The accepted standard is an open technique that involves the use of a midline vertical incision, a dilator to open this incision, and the insertion of a tracheostomy tube. 6,7 A simplified technique known as the rapid four-step technique (RFST) has been described and found to be faster with a higher success rate than the standard technique. 8The RFST offers the advantages of eliminating both the vertical midline incision and the use of a tracheal dilator that are recommended in the standard open surgical method. This makes the procedure faster to perform while continuing to be highly successful in cadaver models. 8 In our clinical and laboratory experience with both the standard technique and the RFST, we have noted that the limiting step in this procedure is the insertion of a tracheostomy tube through the tracheal incision. This step can require significant force, and inexperienced providers often are unable to pass the tube into the trachea or create a false tract int...

Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists

“…The success rates with BACT in this study are comparable to the study by Hill and co-workers, but the time to successful insertion (median 44 seconds in baseline and 37 seconds in post-training tests) were less than those reported by Hill (median 67 seconds) [14]. One explanation for this may be that different models were used.…”

“…The “bougie-assisted emergency cricothyrotomy” (BACT) described by Hill and co-workers is the most recent refinement [14]. This technique makes use of simple equipment including the bougie that may be used in earlier phases of the difficult airway algorithm.…”

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

“…It has been shown in a previous study that insertion force, device diameter and curvature are important determinants in trauma [19], possibly explaining some of the complications observed with the Surgicric device. Several techniques have been described for emergency open surgical cricothyroidotomy: as per Advanced Trauma and Life Support (ATLS); Bair Claw device [20]; rapid four-step technique [21]; bougie-assisted emergency cricothyroidotomy [7] and cricothyroidotomy scissor [22]. No significant difference in success rates was found in a recent systematic review [12].…”

“…We wished to test the efficacy and safety of three cricothyroidotomy techniques in achieving successful emergency tracheal access and subsequent oxygenation. We chose to compare the new Surgicric â device with two well-established techniques, namely a surgical method (comprising scalpel, tracheal hook, tracheal dilator, bougie and cuffed tracheal tube) [6,7] and the Melker emergency cricothyroidotomy kit [8].…”

“Cannot ventilate, cannot intubate” situation after penetration of the tongue root through to the epipharynx by a surfboard: a case report

“…The bougie-assisted cricothyrotomy technique described by Hill et al . may be faster and easier than the rapid four-step technique, especially in inexperienced hands [15]. Percutaneous cricothyrotomy is a reported alternative to open cricothyrotomy [16]; however, the percutaneous technique has severe potential complications, such as pretracheal false passage, and hypopharyngeal and esophageal intubation [17].…”