Cricothyrotomy in the emergency department revisited

Erlandson, Mark J.; Clinton, Joseph E.; Ruiz, Ernest; Cohen, James

doi:10.1016/0736-4679(89)90254-0

Cited by 107 publications

(56 citation statements)

References 10 publications

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“…The significant risk of a misplaced cricothyrotomy was reported more than 30 years ago, but a solution to this problem has not been established. 19,21,22 The authors of several previous reports believe that the best way to identify the CTM is to palpate the sternal notch, the hyoid bone, the thyroid cartilage, as well as the cricoid cartilage (personal communication with Drs. Clinton and McGill, e-mail, April 2015).…”

Section: Discussionmentioning

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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Section: Discussionmentioning

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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“…I prefer to do it fibreoptically, but I can do it surgically if necessary with a cricothyrotomy. Before I attempt a fibreoptic intubation such as this one, I prepare the drugs and equipment for a crash RSI and setup for an emergency cricothyrotomy [3]. If the patient deteriorates during the fibreoptic attempt I can go on rigid laryngoscopy using a conventional laryngoscope or a video laryngoscope.…”

Section: Dr Davismentioning

confidence: 99%

A 36-year-old man with odynophagia

et al. 2007

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E M ination were as follows: the patient was in no acute distress and appeared healthy. He was sitting upright and breathing normally. He was mildly hoarse without audible stridor. He was able to manage his secretions. There was minimal pharyngeal erythema. There were no exudates. There were no palpable lymph nodes, and the trachea was midline. The remainder of the physical examination was normal.Dr. Davis: This patient was well oxygenated with only positional dyspnoea and no turbulent air sounds. The concern was for epiglottitis or retropharyngeal abscess rather than for simple pharyngitis or tonsilitis, given the unremarkable throat examination and peri-glottic symptoms (position dyspnoea and hoarse voice).The most important tenet of airway management in this type of patient is anticipation. The initial presentation does not suggest impending airway compromise, and a diagnostic workup including radiographs (plain films or CT scan) is reasonable. It would be important to determine the degree of respiratory distress when supine before sending this patient for CT scan unaccompanied.The ideal approach for definitive airway management in a patient with periglottic infection would be a fibreoptic intubation. Intubation equipment should be prepared if any concern for airway compromise exists, including an intubating bougie and cricothyrotomy equipment. Adequate preoxygenation should be initiated with a nonrebreather mask throughout his ED stay to "buy more time" if the airway rapidly deteriorates. The patient should be allowed to assume a position of comfort at all times (i.e., "sniffing dog"). If a "crash" intubation is required, one individual should perform laryngoscopy while another prepares for cricothyrotomy. A shorter time period should be allowed before laryngoscopy is abandoned and a surgical approach initiated.Dr. Sakles: Dr. Ban, how would you approach this clinical scenario?John Sakles: Today's patient was a 36-year-old man who came to the emergency department (ED) complaining of a severe sore throat for 2 days. It had become progressively worse over the previous 24 h prior to his arrival in the ED prompting his visit. He was able to swallow, but said the pain worsened when eating or drinking. The patient reported subjective fevers at home. When lying flat, he found it difficult to breathe.The patient did not have medical problems, did not take any medications and had no drug allergies.The patient's blood pressure was 162/82 torr, the pulse was 108 beats/min, the respirations were 24 breaths/min, the temperature was 37.9°C and the oxygen saturation was 98% on room air. The pertinent findings on physical examIntern Emerg Med (

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“…through the thyrohyoid membrane above the larynx); long execution time; failed tube placement; and significant hemorrhage. 34,35 Long-term complications include: subglottic stenosis; dysphonia; injury to the recurrent laryngeal nerve; pulmonary aspiration; fracture of tracheal cartilage and esophageal perforation. 36 However, failure to perform a surgical airway as a last resort results in failure to oxygenate the patient and ultimately death.…”

Section: Surgical Airwaysmentioning

confidence: 99%

Airway Management: Methods of Oxygenation

DeCoste

Ismaiel

Burnett

et al. 2014

DMJ

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A 41-year old male with a large body habitus (BMI 35 kg/m2) is scheduled for cystoscopy and insertion of a ureteric stent for renal stones at a local tertiary care center. He has no known allergies and general anesthesia was previously well-tolerated. His past medical history is significant only for an uncomplicated laparoscopic cholecystectomy two years ago. He is otherwise well and does not take any medications. He has been NPO for 12 hours prior to his procedure and his history does not suggest significant anesthetic risk.Upon arrival in the Operating Room (OR), all routine monitors (ECG monitor, pulse oximeter, and noninvasive blood pressure) were placed on the patient. Intravenous access was secured in the left antecubital fossa. Following denitrogenation, general anesthesia was induced with a combination of midazolam (Versed), fentanyl (Sublimaze), and propofol (Diprivan). Immediately following induction, the patient vomited into the mask, aspirated, and his oxygenation quickly desaturated to 40%. How should this patient's airway be managed and what interventions are necessary? Introduction A patient's inability to ventilate and oxygenate is always a medical emergency. Urgent measures must be taken to restore tissue oxygenation to prevent serious damage to major organs (e.g. brain) or death. The primary goal of emergency airway management is to restore oxygenation, with a secondary goal of protecting the airway from aspiration of foreign substances. To accomplish these goals, the practitioner must have a series of back-up plans available in case of a failed airway, defined as three unsuccessful attempts at direct laryngoscopy or the inability to maintain acceptable tissue oxygenation.1 In recent years several airway management algorithms, including the American Society of Anesthesiologists (ASA) Difficult Airway Management Algorithm, have been developed to guide practitioners towards effective evidence-based methods to restore oxygenation.2 Unfortunately, algorithms have limitations and must be used as informative guides depending on the clinical context, rather than as rigid instructions. While restoring and maintaining oxygenation in the event of an emergency is crucial, practitioners should note that in the event of a cardiac arrest, Cardiopulmonary Resuscitation (CPR) by chest compressions should take priority over definitive airway management by intubation. Given that bag-mask ventilation (BMV) is a key aspect of CPR, a strong BMV technique is important when CPR takes priority over tracheal intubation.Significant innovation has led to the development of new techniques that aid practitioners in managing AbstractAirway management in the emergency or elective setting encompasses a collection of important skills and training necessary for all health care providers. The purpose of this review is to provide trainees with a general overview of the important techniques and strategies used in airway management. We present a case scenario of a failed airway to illustrate the clinical application of these techn...

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Cricothyrotomy in the emergency department revisited

Cited by 107 publications

References 10 publications

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

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

A 36-year-old man with odynophagia

Airway Management: Methods of Oxygenation

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