Prehospital cricothyrotomies in a helicopter emergency medical service: analysis of 19,382 dispatches

Abstract

BackgroundCreating a patent airway by cricothyrotomy is the ultimate maneuver to allow oxygenation (and ventilation) of the patient. Given the rarity of airway management catastrophes necessitating cricothyrotomy, sufficiently sized prospective randomized trials are difficult to perform. Our Helicopter Emergency Medical Service (HEMS) documents all cases electronically, allowing a retrospective analysis of a larger database for all cases of prehospital cricothyrotomy.MethodsWe analyzed all 19,382 dispatches of our HEMS ‘Lifeliner 1’, since set-up of a searchable digital database. This HEMS operates 24/7, covering ~ 4.5 million inhabitants of The Netherlands. The potential cases were searched and cross-checked in two independent databases.ResultsWe recorded n = 18 cases of prehospital cricothyrotomy. In all 18 cases, less invasive airway techniques, e.g., supraglottic devices, were attempted before cricothyrotomy. With exception of 2 cases, at least one attempt of orotracheal intubation had been performed before cricothyrotomy. Out of the 18 cases, 4 were performed by puncture-based technique (Melker), the remaining 14 cases by surgical technique. Indications for cricothyrotomy were diverse, dividable into 9 trauma cases and 9 medical cases.The procedure was successful in all but one case (17/18, i.e., 94%; with a 95% confidence interval of 72.7–99.9%). Outcome was such that 6/18 patients arrived at the hospital alive. Long term outcome was poor, with only 2/18 patients discharged from hospital alive.ConclusionsCricothyrotomy remains, although rare, a regularly occurring requirement in (H)EMS. Our finding of a convincingly high success rate of 94% in trained hands encourages training and a timely performance of cricothyrotomy.

Needle Cricothyroidotomy by Intensive Care Paramedics

“…Overall, the majority of cricothyroidotomies were performed by road-based ICPs (66.7%) with the remaining performed by the aeromedical ICPs (Table 2). All cricothyroidotomy indications were categorized as either being a part of the failed intubation algorithm or performed as the primary airway management intervention (Table 3 4 , [10][11][12][13] ).…”

“…1 However, numerous studies have since been published which may provide another opportunity for a follow-up assessment of the most effective technique. [2][3][4] Although a superior technique is yet to be statistically determined, surgical cricothyroidotomy techniques appear to be a more commonly adopted technique for FONA. 5 There is a paucity of literature that examines the success of needle cricothyroidotomy devices within the prehospital environment.…”

“…Establishing a definitive airway is a priority when managing critically ill or injured patients in the prehospital environment, enabling targeted ventilation and oxygenation, as well as protection against aspiration. 1,2 There are a broad range of maneuvers, adjuncts, and interventions that can assist with maintaining airway patency, including continuous bag-valve-mask ventilation, supraglottic airway devices, and endotracheal tube placement. In circumstances where these measures fail leading to a "cannot ventilate, cannot oxygen" situation, a rescue cricothyroidotomy may be required.…”

Western Trauma Association critical decisions in trauma: airway management in adult trauma patients

“…Instead, in situations where there is failure of orotracheal intubation, the prehospital provider should fall back to basic airway management techniques including jaw thrust, NPA, OPA, BVM, or rescue airway. If all methods fail (cannot intubate, cannot ventilate), which should be a rare occurrence, 18 the prehospital provider may be tasked with performing a surgical airway in a trauma patient. Surgical airway options include needle cricothyroidotomy, needle directed percutaneous cricothyroidotomy, or open cricothyroidotomy, with open cricothyroidotomy having higher success rates in the prehospital setting.…”

Data_Sheet_1.PDF

“…Students achieved a 100% success rate for both techniques following a brief training session. Interestingly, the rapidity of the CTT did not diminish its success and suggests the CTT technique used in this study is easy to learn and is on par or better than techniques used in experimental and clinical studies in humans (18,(23)(24)(25)(26). We hypothesised that the success rate for CTT would be lower as the anatomy would not be directly visualised as opposed to the more extensive dissection and subsequent visualisation associated with TT.…”