Clinical paperEmergency cricothyrotomy—A comparative study of different techniques in human cadavers☆
Introduction
Management of the difficult airway is one of the most challenging situations in emergency medicine. Cricothyrotomy is the final lifesaving option for establishing an airway when tracheal intubation or ventilation is impossible,1, 2 and the quickest, most reliable and safest technique should be used to reestablish oxygenation. Several techniques have been studied, which can basically be grouped into two categories: anatomical-surgical and puncture.3 The efficiency of each technique varies with the degree of experience and training of the user. Whenever possible, cricothyrotomy should be performed by experienced personnel. However, if expert help is not readily available, inexperienced health care personnel may be forced to attempt this maneuver as a last resort to save the patients life. To date no consensus exists on which technique might be most appropriate for inexperienced health care personnel in emergency situations. Therefore, we prospectively compared tracheal tube insertion time, success rate and complication rate of standard techniques performed by inexperienced personnel in human cadavers. In addition, we evaluated a novel technique using special cricothyrotomy scissors. Although this technique is basically an anatomical-surgical (“cutting”) technique, it also involves puncture of the skin and underlying tissue and might be an alternative, especially for surgically untrained personnel.
Section snippets
Cadavers
In accordance to German law and ethical requirements, all body donors had consented to the use of their cadaver for educational and scientific purposes during their lifetime in written form. Unembalmed cadavers (38 female, 25 male, Table 1) were made available by the Department of Anatomy, Heinrich-Heine-University Düsseldorf, Germany. Cadavers with pre-existing invasive airway access were excluded.
Participants and study groups
The 63 volunteer participants who were asked to perform a cricothyrotomy were 5th year medical
Success rate
Airway access was almost always successful with the anatomical-surgical techniques (success rate 94% in the standard surgical group and 100% in the scissors group, Table 2, Figure 3). In contrast, with the puncture techniques the success rate was smaller (82% in the catheter-over-needle group and 71% with the wire-guided technique, p < 0.05 vs. anatomical-surgical). For puncture techniques, the overall relative risk (RR) for misplacement of the tube was 1.25 [95% CI: 1.02–1.53] as compared to
Discussion
Anatomical-surgical techniques showed an overall higher success rate, a faster tracheal tube insertion time and a lower complication rate compared with puncture techniques, suggesting that they may be the techniques of choice for inexperienced health care providers in emergency situations.
Conclusions
Anatomical-surgical techniques were in general faster, safer and had a higher success rate than the puncture techniques. Specifically, surgical cricothyrotomy has shown to be a quick, successful and safe technique and may therefore be the favored technique for first time performers. The novel scissors technique, although burdened with a higher complication rate than the surgical technique, has shown an excellent success rate and was the fastest technique, making it a promising alternative.
Conflict of interest statement
All authors of the enclosed manuscript “Emergency cricothyrotomy—a comparative study of different techniques in human cadavers” declare that they have no conflicts of interest.
The Cricothyrotomy Scissors as well as the bronchoscope were a loan from the manufacturer Karl Storz, Tuttlingen, Germany, without restriction. All other support was provided by the Department of Anesthesiology and the Department of Anatomy of the Heinrich-Heine-University Düsseldorf. No grant was provided by any of the
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A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.10.023.