Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review

Aziz, Shadman; Foster, Elizabeth A.; Lockey, David; Christian, Michael D.

doi:10.1136/emermed-2020-210305

Cited by 29 publications

(18 citation statements)

References 22 publications

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“…All three of these patients sustained severe panfacial fractures with imminent airway obstruction. Similar findings were reported by Aziz et al over a twenty-year period [ 18 ].…”

Section: Discussionsupporting

confidence: 92%

“A” stands for airway – Which factors guide the need for on-scene airway management in facial fracture patients?

et al. 2022

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Background Numerous guidelines highlight the need for early airway management in facial trauma patients since specific fracture patterns may induce airway obstruction. However, the incidence of these hallmark injuries, including flail mandibles and posterior displacement of the maxilla, is contentious. We aim to evaluate specific trauma-related variables in facial fracture patients, which affect the need for on-scene versus in-hospital airway management. Methods This retrospective cohort study included all patients with any type of facial fracture, who required early airway management on-scene or in-hospital. The primary outcome variable was the site of airway management (on-scene versus hospital) and the main predictor variable was the presence of a traumatic brain injury (TBI). The association of fracture type, mechanism, and method for early airway management are also reported. Altogether 171 patients fulfilled the inclusion criteria. Results Of the 171 patients included in the analysis, 100 (58.5) had combined midfacial fractures or combination fractures of facial thirds. Altogether 118 patients (69.0%) required airway management on-scene and for the remaining 53 patients (31.0%) airway was secured in-hospital. A total of 168 (98.2%) underwent endotracheal intubation, whereas three patients (1.8%) received surgical airway management. TBIs occurred in 138 patients (80.7%), but presence of TBI did not affect the site of airway management. Younger age, Glasgow Coma Scale-score of eight or less, and oro-naso-pharyngeal haemorrhage predicted airway management on-scene, whereas patients who had fallen at ground level and in patients with facial fractures but no associated injuries, the airway was significantly more often managed in-hospital. Conclusions Proper preparedness for airway management in facial fracture patients is crucial both on-scene and in-hospital. Facial fracture patients need proper evaluation of airway management even when TBI is not present.

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“…All three of these patients sustained severe panfacial fractures with imminent airway obstruction. Similar findings were reported by Aziz et al over a twenty-year period [ 18 ].…”

Section: Discussionsupporting

confidence: 92%

“A” stands for airway – Which factors guide the need for on-scene airway management in facial fracture patients?

et al. 2022

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“…This 82% success rate is slightly lower than the 90.5% reported in a previous meta-analysis [ 23 ], likely due to the more serious injury profile, and by extension anatomical disruption, in the military patient cohort. In comparison, a review of the last 20 years of experience of London HEMS demonstrated a much lower incidence of only 0.19% (72 of 37,725 patients) with a 97% success rate [ 24 ]. Of interest, penetrating trauma (stabbing of gunshot wound) at any anatomical location, accounted for only 8 (10.3%) cases of scalpel cricothyroidotomy over this 20-year case review.…”

Section: Resultsmentioning

confidence: 99%

Pre-hospital management of penetrating neck injuries: a scoping review of current evidence and guidance

Simpson

Tucker

Hudson

2021

Scand J Trauma Resusc Emerg Med

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Penetrating injuries to the neck pose a unique challenge to clinicians due to the proximity of multiple significant anatomical structures with little protective soft tissue coverage. Injuries to this area, whilst low in incidence, are potentially devastating. Respiratory, vascular, gastro-oesophageal and neurological structures may all be involved, either in isolation or combination. These injuries are particularly difficult to manage in the resource poor, often austere and/or remote, pre-hospital environment. A systematic scoping review of the literature was conducted to evaluate the current available research pertaining to managing this injury profile, prior to the patient arriving in the emergency department. The available research is discussed in sections based on the commonly used trauma management acronym ‘cABCD’ (catastrophic haemorrhage, Airway, Breathing, Circulation, Disability) to facilitate a systematic approach and clinical evaluation familiar to clinicians. Based on the available reviewed evidence, we have proposed a management algorithm for this cohort of patients. From this we plan to instigate a Delphi process to develop a consensus statement on the pre-hospital management of this challenging presentation.

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“…While surgeons familiar with the technique may prefer to perform rapid tracheotomy in the CVCO situation, 204 in the hands of non-surgeon clinicians, and because of anatomic advantages in adult patients, eFONA should generally proceed via the cricothyroid space. For its simplicity, ease of equipment stocking, generalizability to different airway manager types, and emerging evidence of first-pass success in various settings, 205 , 206 the CAFG recommends a scalpel-bougie-tube approach for cricothyrotomy. If feasible, the neck should be fully extended.…”

Section: Response To An Unsuccessful First (Or Subsequent) Attempt At the Intended Airway Techniquementioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

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Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. Findings and key recommendations Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider “exit strategy” options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a “cannot ventilate, cannot oxygenate” emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as “airway lead” to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

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Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review

Cited by 29 publications

References 22 publications

“A” stands for airway – Which factors guide the need for on-scene airway management in facial fracture patients?

“A” stands for airway – Which factors guide the need for on-scene airway management in facial fracture patients?

Pre-hospital management of penetrating neck injuries: a scoping review of current evidence and guidance

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

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