Airway Injury During Emergency Transcutaneous Airway Access: A Comparison at Cricothyroid and Tracheal Sites

Salah, Nazar; Saigh, Ismat El; Hayes, Niamh; McCaul, Conán

doi:10.1213/ane.0b013e3181bdd1ba

Cited by 18 publications

(13 citation statements)

References 17 publications

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“…Transverse incision in the lower half of the cricothyroid membrane is recommended to avoid the cricothyroid arteries and the vocal cords. The circumferential cricoid cartilage is partially resistant to compression [34] and its posterior lamina lies behind the cricothyroid membrane, providing some protection against posterior wall and oesophageal injury during cricothyroidotomy. Failure to identify the cricothyroid membrane occurs frequently [35] and is the principal cause of failed cricothyroidotomy.…”

Section: Anaesthetic Management Of Cicomentioning

confidence: 99%

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Equipment and strategies for emergency tracheal access in the adult patient

Hamaekers

Henderson

2011

Anaesthesia

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SummaryThe inability to maintain oxygenation by non‐invasive means is one of the most pressing emergencies in anaesthesia and emergency care. To prevent hypoxic brain damage and death in a ‘cannot intubate, cannot oxygenate’ situation, emergency percutaneous airway access must be performed immediately. Even though this emergency is rare, every anaesthetist should be capable of performing an emergency percutaneous airway as the situation may arise unexpectedly. Clear knowledge of the anatomy and the insertion technique, and repeated skill training are essential to ensure completion of this procedure rapidly and successfully. Various techniques have been described for emergency oxygenation and several commercial emergency cricothyroidotomy sets are available. There is, however, no consensus on the best technique or device. As each has its limitations, it is recommended that all anaesthetists are skilled in more than one technique of emergency percutaneous airway. Avoiding delay in initiating rescue techniques is at least as important as choice of device in determining outcome.

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Section: Anaesthetic Management Of Cicomentioning

confidence: 99%

“…This underlines the importance of taking care to identify the cricothyroid membrane. Inferior placement through the cricotracheal space increases the risk of airway injury [34] and bleeding, but can still result in effective reoxygenation.…”

Section: ó 2011 the Authorsmentioning

confidence: 99%

Equipment and strategies for emergency tracheal access in the adult patient

Hamaekers

Henderson

2011

Anaesthesia

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“…2 A misplaced incision puts surrounding vascular structures at risk, 6,7 can prolong time to completion, and can lead to hypoxia or death.…”

Section: Introductionmentioning

confidence: 99%

“…1,2 This is particularly relevant to techniques like the rapid four-step technique, where the skin and CTM can be incised simultaneously, thus saving critical time. [3][4][5] However, a misplaced incision, particularly if too high in the neck, can lead to serious complications.2 A misplaced incision puts surrounding vascular structures at risk, 6,7 can prolong time to completion, and can lead to hypoxia or death.In contrast to the rapid four-step technique, one approach to cricothyrotomy relies on making a midline vertical incision to more directly identify the CTM. Such identification is still often based on palpation of the membrane through the incision, as the inevitable bleeding frequently obscures direct visualization of the membrane.…”

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confidence: 99%

The Inaccuracy of Using Landmark Techniques for Cricothyroid Membrane Identification: A Comparison of Three Techniques

Bair

Chima

2015

Acad Emerg Med

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Objectives: Successful cricothyrotomy is predicated on accurate identification of the cricothyroid membrane (CTM) by palpation of superficial anatomy. However, recent research has indicated that accuracy of the identification of the CTM can be as low as 30%, even in the hands of skilled providers. To date, there are very little data to suggest how to best identify this critical landmark. The objective was to compare three different methods of identifying the CTM.Methods: A convenience sample of patients and physician volunteers who met inclusion criteria was consented. The patients were assessed by physician volunteers who were randomized to one of three methods for identifying the CTM (general palpation of landmarks vs. an approximation based on four finger widths vs. an estimation based on overlying skin creases of the neck). Volunteers would then mark the skin with an invisible but florescent pen. A single expert evaluator used ultrasound to identify the superior and inferior borders of the CTM. The variably colored florescent marks were then visualized with ultraviolet light and the accuracy of the various methods was recorded as the primary outcome. Additionally, the time it took to perform each technique was measured. Descriptive statistics and report 95% confidence intervals (CIs) are reported.Results: Fifty adult patients were enrolled, 52% were female, and mean body mass index was 28 kg/m 2 (95% CI = 26 to 29 kg/m 2 ). The general palpation method was successful 62% of the time (95% CI = 48% to 76%) and took an average of 14 seconds to perform (range = 5 to 45 seconds). In contrast, the fourfinger technique was successful 46% of the time (95% CI = 32% to 60%) and took an average of 12 seconds to perform (range = 6 to 40 seconds). Finally, the neck crease method was successful 50% of the time (95% CI = 36% to 64%) and took an average of 11 seconds to perform (range = 5 to 15 seconds).Conclusions: All three methods performed poorly overall. All three techniques might potentially be even less accurate in instances where the superficial anatomy is not palpable due to body habitus. These findings should alert clinicians to the significant risk of a misplaced cricothyrotomy and highlight the critical need for future research.ACADEMIC EMERGENCY MEDICINE 2015;22:908-914 © 2015 by the Society for Academic Emergency Medicine S uccessful cricothyrotomy is predicated on accurate identification of the cricothyroid membrane (CTM) by palpation of superficial anatomy. 1,2 This is particularly relevant to techniques like the rapid four-step technique, where the skin and CTM can be incised simultaneously, thus saving critical time. [3][4][5] However, a misplaced incision, particularly if too high in the neck, can lead to serious complications.2 A misplaced incision puts surrounding vascular structures at risk, 6,7 can prolong time to completion, and can lead to hypoxia or death.In contrast to the rapid four-step technique, one approach to cricothyrotomy relies on making a midline vertical incision to more direct...

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“…For instance, the cuffed 4-mm ID Quicktrach Ò II (VBM Medizintechnik) is 7.3-mm in maximum outer diameter (OD), whereas the MT has an OD of 5.4 mm. 19 The recently introduced cuffed Melker Ò is 5 mm in ID and has a 7.2-mm maximum OD. Although the differences in OD between these devices and the MT may be small, the smaller OD would be beneficial for the patients' quality of recovery.…”

Section: Discussionmentioning

confidence: 99%

Elective use of an uncuffed small-bore cricothyrotomy tube with balloon occlusion of the subglottic airway

Suzuki

Ikeda

Iwamoto

et al. 2013

Can J Anesth/J Can Anesth

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Airway Injury During Emergency Transcutaneous Airway Access: A Comparison at Cricothyroid and Tracheal Sites

Abstract: Airway injury and luminal compression were more common at the tracheal site than at the CTM. The ST and TT were associated with the highest incidence of injury. This has implications for emergency airway access in cases in which it may be difficult to accurately identify the CTM.

Cited by 18 publications

References 17 publications

Equipment and strategies for emergency tracheal access in the adult patient

Equipment and strategies for emergency tracheal access in the adult patient

The Inaccuracy of Using Landmark Techniques for Cricothyroid Membrane Identification: A Comparison of Three Techniques

Elective use of an uncuffed small-bore cricothyrotomy tube with balloon occlusion of the subglottic airway

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