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...

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Objectives: Because of the prevalence of methamphetamine abuse worldwide, it is not uncommon for subjects in law enforcement encounters to be methamphetamine-intoxicated. Methamphetamine has been present in arrest-related death cases in which an electronic control device (ECD) was used. The primary purpose of this study was to determine the cardiac effects of an ECD in a methamphetamine intoxication model. Methods:Sixteen anesthetized Dorset sheep (26-78 kg) received 0.0 mg ⁄ kg (control animals, n = 4), 0.5 mg ⁄ kg (n = 4), 1.0 mg ⁄ kg (n = 4), or 1.5 mg ⁄ kg (n = 4) of methamphetamine hydrochloride as a slow intravenous (IV) bolus during continuous cardiac monitoring. The animals received the following exposures in sequence from a TASER X26 ECD beginning at 30 minutes after the administration of the drug: 1) 5-second continuous exposure, 2) 15-second intermittent exposure, 3) 30-second intermittent exposure, and 4) 40-second intermittent exposure. Darts were inserted at the sternal notch and the cardiac apex, to a depth of 9 mm. Cardiac motion was determined by thoracotomy (smaller animals, £ 32 kg) or echocardiography (larger animals, > 68 kg). Data were analyzed using descriptive statistics and chi-square tests.Results: Animals given methamphetamine demonstrated signs of methamphetamine toxicity with tachycardia, hypertension, and atrial and ventricular ectopy in the 30-minute period immediately after administration of the drug. Smaller animals (n = 8, £ 32 kg, mean = 29.4 kg) had supraventricular dysrhythmias immediately after the ECD exposures. Larger animals (n = 8, > 68 kg, mean = 72.4) had only sinus tachycardia after the exposures. One of the smaller animals had frequent episodes of ventricular ectopy after two exposures, including runs of delayed onset, nonsustained six-to eight-beat unifocal and multifocal ventricular tachycardia that spontaneously resolved. This animal had significant ectopy prior to the exposures as well. Thoracotomy performed on three smaller animals demonstrated cardiac capture during ECD exposure consistent with previous animal studies. In the larger animals, none of the methamphetamine-intoxicated animals demonstrated cardiac capture. Two control sheep showed evidence of capture similar to the smaller animals. No ventricular fibrillation occurred after the exposure in any animal. Conclusions:In smaller animals (32 kg or less), ECD exposure exacerbated atrial and ventricular irritability induced by methamphetamine intoxication, but this effect was not seen in larger, adult-sized animals. There were no episodes of ventricular fibrillation after exposure associated with ECD exposure in methamphetamine-intoxicated sheep.ACADEMIC EMERGENCY MEDICINE 2010; 17:436-443 ª

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