SummaryWe compared the time taken to perform cricothyroidotomy on a manikin to that on a medium fidelity simulator, to assess the effect of psychological stress and time pressure on performance. Seventy anaesthetists participated in this randomised cross-over study. Fifty-four (77%) anaesthetists took longer on the simulator, with the mean (SD) time taken to perform the procedure on the manikin and simulator 34 (18) and 48 (11) s, respectively (p < 0.001). Anaesthetists with more experience performed the procedure more quickly on both manikin and simulator. We conclude that psychological stress and time pressure in real-life scenarios can affect the performance of cricothyroidotomy. Cricothyroidotomy is a life-saving emergency airway procedure in a 'can't intubate can't ventilate' situation. It is the final step in the difficult airway algorithm of the American Society of Anesthesiologists [1] and the Difficult Airway Society [2]. However, most anaesthetists have only limited experience in the technique as it is infrequently required, nearly always in a crisis (stressful) situation. In such situations, theoretical knowledge and regular training of the skill on a manikin or simulator is the key to success [3,4].The majority of studies related to emergency cricothyroidotomy are performed on manikins, animals or human cadavers [5]. In an emergency 'can't intubate can't ventilate' situation, when the patient is hypoxic, cricothyroidotomy should be performed rapidly and safely to achieve rapid re-oxygenation. However, the performance of a clinical skill can be affected by stressful conditions [6] and, in a real life emergency, psychological stress and time pressure could affect the performance of this life-saving skill. It would be unethical and impractical to provide training in real life-and-death situations. Therefore, we assessed the effect of psychological stress and time pressure by comparing the time taken to perform cricothyroidotomy on a manikin to that of an emergency 'can't intubate can't ventilate' scenario on a medium fidelity simulator. MethodsThe subcommittee of our local Research Ethics Committee decided that full committee approval was unnecessary because the study was not performed on human subjects and participation by anaesthetists was voluntary. Nevertheless, all prospective participants were fully informed about the study and data collection and a detailed information sheet was given to all participants, all of whom gave written consent before participation. Each participant was given the opportunity to withdraw from the study at any stage, and informed that if they did not consent or chose to withdraw, they could still practise the cricothyroidotomy but their data would not be recorded.A series of cricothyroidotomy training sessions was organised for anaesthetists in our department and all anaesthetists were encouraged to attend. Each session was restricted to a group of six anaesthetists, lasted for an hour and included: a lecture and discussion on the relevant anatomy; techniques of cricothyr...

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