Emergency Cricothyroidotomy: A Randomized Crossover Trial Comparing Percutaneous Techniques: Classic Needle First Versus “Incision First”

Abstract

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.

A porcine model for teaching surgical cricothyridootomy

“…Trainees also graded the model similarity with human anatomy to be medium to high. Other studies have shown similar results 20 . Each porcine airway model allowed 10 trainees in average to practice per specimen, due to the practice of sliding the model under the skin and glove.…”

“…In consequence, only three tested the model. Nevertheless, other studies used similar animal models for training 10,18,19,20 . The trainees opinion about anatomical correlation may not be as accurate, since they have relatively low knowledge of the anatomy and low experience in airway management.…”

Comparing success rates of anesthesia providers versus trauma surgeons in their use of palpation to identify the cricothyroid membrane in female subjects: a prospective observational study

“…Performing a surgical airway with an open vs a percutaneous technique not only achieves higher success rates but also accomplishes the procedure in nearly half the time. 21 Based on this study and findings in recent literature, [22][23][24][25] we propose that clinicians should always pause before proceeding with an open cricothyrotomy to enable better identification of the anatomy within the initial wound. Although ultrasonography may be ideal for identifying the CTM, 26 we cannot assume its availability and universal clinical applicability, and therefore, it is not included in this discussion.…”

Emergency Cricothyroidotomy for Difficult Airway Management After Asynchronous Bilateral Neck Dissections: A Case Report and Literature Review

“…Cricothyroidotomy can be performed considerably faster than conventional tracheostomy, 21 and the technique involves a prepackaged kit consisting of a dilator that is passed percutaneously through a breakaway needle. [22][23][24] Cricothyroidotomy also was judged to be considerably easier to perform than obtaining an airway using a percutaneous needle device. 23 In 1921, Jackson 25 criticized cricothyroidotomy because of the potential complication of laryngeal stenosis.…”