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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...

Objectives: The objective was to determine if there is a difference in pain relief or frequency and severity of side effects in emergency department (ED) patients with primary headache treated with either intramuscular (IM) olanzapine or IM droperidol.Methods: This was a prospective, randomized nonblinded clinical trial of adult ED patients undergoing treatment for suspected primary headache. Consenting patients were randomized to receive either droperidol 5 mg IM or olanzapine 10 mg IM. Prior to receiving treatment, patients were asked to complete a 100-mm visual analog scale (VAS) describing their pain and a 4-point verbal rating scale (VRS) describing their pain as none, mild, moderate, or severe. Patients also completed a 100-mm VAS describing their level of nausea. Pain and nausea measurements were repeated 30 and 60 minutes after medication administration. Patients also completed the Barnes Akathisia Scale (BAS) 30 and 60 minutes after medication administration. Descriptive statistics were used as appropriate. Pain relief was compared both in terms of the decrease in VAS scores and in the proportion of patients who reported moderate or severe pain whose report later changed to mild or no pain.Results: One-hundred patients were enrolled; 13 were withdrawn before administration of the study medication, 8 in the droperidol group and 5 in the olanzapine group, leaving 87 patients for analysis. Forty-two patients received droperidol and 45 received olanzapine. In the droperidol group, 35 ⁄ 40 (87.5%) patients who had reported moderate or severe pain at baseline reported mild or no pain at 60 minutes. In the olanzapine group, 38 ⁄ 44 (86.4%) reported this change (p = 0.89). The mean percent change from baseline VAS pain score at 60 minutes was )37% (95% CI = )84% to 11%) for droperidol and )37% (95% CI = )64% to 10%) for olanzapine (p = 0.30). The mean percent change from baseline for the VAS nausea score was )59% (95% CI = )70% to )47%) for droperidol and )64% (95% CI = )77% to )51%) for olanzapine (p = 0.83). There was no difference in any report of akathisia by the BAS between the groups (p = 0.63).Conclusions: Both olanzapine and droperidol are effective treatments for primary headaches in the ED. No significant differences were found between the medications in terms of pain relief, antiemetic effect, or akathisia. Olanzapine may be used to treat primary headache and it is an effective alternative to droperidol. ACADEMIC EMERGENCY MEDICINE 2008; 15:806-811 ª 2008 by the Society for Academic Emergency MedicineKeywords: emergency department, headache, migraine, treatment, droperidol, olanzapine H eadaches present a frequent diagnostic and therapeutic challenge in the emergency department (ED), accounting for more than 3 million ED visits a year. This makes headaches, representing 2.7% of all ED visits, a more common complaint than back pain.1 While a headache can be a sign of serious and potentially life-threatening pathology, 90% of headaches encountered in the ED are benign and are not secondary to o...

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