Earlier this week I posted about the integration of a cric task-trainer at ARHT. I’ve decided to follow this up with some general evidence about cricothyroidotomy training.
The data regarding technique selection for cricothyroidotomy exists primarily in the context of simulation. It would be impossible to run a trial to compare techniques in real patients given the rarity of the scenario. In general, there are two types of techniques: 1) open or surgical cricothyroidotomy 2) percutaneous or needle cricothyroidotomy. I tend to favor an open technique (and maybe with a bougie) given the simplicity but there is some evidence to support the needle method. There is a nice Below is a brief outline of some evidence-based considerations for anyone involved in training clinicians for cric performance.
Needle vs. Open
- Randomized trial of emergency physicians performing surgical and percutaneous cricothyroidotomy on cadavers. Time to first ventilation was significantly longer using the surgical technique (108 seconds vs. 136 seconds) while there were significantly more injuries to surrounding structures using the open technique (6 thyroid vessel injuries vs. none)
- Authors concluded results tend to favor percutaneous technique
- I’m quite surprised that time was shorter with the percutaneous technique – interesting result!
- Randomized trial comparing standard surgical technique with a modified technique for percutaneous insertion using “incision-first” technique – described as 2cm vertical incision then palpate cricoid membrane through incision, once identified continue with needle technique
- Scalpel-finger-tube technique
- Ultrasound guided, bougie assisted cricothyroidotomy with a median time to completion of 26 seconds
- We should probably NOT be teaching a percutaneous indicator guided approach
Time to Completion
- Highly dependent on when the timer starts but regardless everyone agrees time is important! And less is more!
- 40 seconds was achievable in one study – time to skin palpation to first ventilation when all equipment was laid out
- 95 seconds (mean) was recorded in another study as time from first grasping cric equipment to first ventilation
Number of times to achieve competence
- Debatable whether experience = competence
- Performance times plateau after 4 attempts (using a manikin)
- Very little evidence to support number of times needed especially since all evidence is manikins or cadavers
Room for improvement as an inter-disciplinary approach
- Several studies show that often it’s the surgeon performing cricothyroidotomies in emergent settings (article 1, article 2)
- This has important training implications – we should be training as a trauma team and incorporating the trauma team during in-situ simulation
- EM teachers & educators must also be aware of this issue and work with surgeons so that they understand cricothyroidotomy is completely within the scope of practice for EM physicians (or anyone who performs RSI)
Some High Quality Learning (FOAMed)
- Needle vs. Knife for cricothyroidotomy from EMCrit
- Great compiled list of cric resources and literature from Andy Neill at emergencymedicineireland.com
- Amazing description of 24 surgical cricothryoidotomies!