Randomized controlled trial comparing an open surgical technique and a Seldinger technique for cricothyrotomy performed on a simulated airway

Prehospital Surgical Airway Management Skills in a Rural Emergency Medical Service System

BACKGROUND

The objective of this study is to describe the education, training, and use of prehospital surgical airways in a rural Emergency Medical Service (EMS) system.

MATERIALS AND METHODS

We conducted an internet-based survey instrument of all advanced life support (ALS) EMS agencies in a seven-county rural EMS system in Pennsylvania. ALS agencies were queried regarding basic demographic information as well as the number of surgical airways performed in the previous 10 years as well as the education and training of EMS providers in surgical airways.

RESULTS

The survey was completed by 11 of 20 ALS EMS agencies in our region (55% rate of return). The content and frequency of training varied considerably among EMS agencies. Only four prehospital surgical airways were performed during the study period. One patient survived to hospital discharge to home.

CONCLUSION

Surgical airways are an infrequently performed procedure in the rural prehospital setting. There is no universally accepted standard for teaching or evaluating the competency of this potentially life-saving procedure. Further efforts to establish a core educational curriculum appear warranted.

[Cricothyrotomy : Data situation, guidelines and techniques for the definitive surgical airway]

Cricothyrotomy represents the final approach to secure the airway, in the course of which less invasive measures have failed. It can also primarily be carried out to establish a secure airway. This is essential to protect the patient from a significant hypoxia. This is a cannot ventilate-cannot oxygenate (CVCO) situation, which presumably all colleagues in emergency intensive care medicine and anesthesia have already been confronted with. Evidence-based algorithms for the management of a difficult airway and CVCO have been established. If oxygenation using an endotracheal tube, an extraglottic airway device or bag-valve mask ventilation all fail, the airway must be surgically secured, i.e. using cricothyrotomy. The prevalence of the CVCO situation in a prehospital setting is ca. 1%. No valid prospective randomized in vivo studies have been carried with respect to the question of the best method.

Scalpel cricothyrotomy versus punctured cricothyrotomy in the context of the CICO crisis. A systematic review and Meta-analysis

IMPORTANCE

The preferential use of a scalpel (SCT) or puncture techniques (PCT) for cricothyrotomy remains a controversial topic.

OBJECTIVE

We performed a systematic review and meta-analysis comparing puncture cricothyrotomy with scalpel cricothyrotomy using overall success rate, first-time success rate, and time taken to perform the procedure as the primary outcome together with complications as a secondary outcome.

EVIDENCE REVIEW

Pubmed databases, EMBASE databases, MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials, from 1980 to October 2022.

FINDINGS

A total of 32 studies were included in the systematic review and meta-analysis. It also showed that PCT was close to SCT in terms of overall success rate (82.2% vs. 82.6%, Odd Ratios OR = 0.91, [95%CI: 0.52-1.58], p = 0.74) as well as first-performance success rate (62.9% vs. 65.3%, OR = 0.52, [0.22-1.25], p = 0.15). PCT does not compare favorably with SCT in terms of required time for the procedure (the mean time required for PCT versus SCT incision in the intervention groups was 0.34 standard deviations higher (Mean Difference MD = 17.12, [3.37-30.87], p = 0.01) as well as complications (21.4% vs. 15.1%, Relative Risk RR = 1.49, [0.80-2.77], p = 0.21).

CONCLUSIONS AND RELEVANCE

The results show that SCT has an advantage over PCT in terms of time required for the procedure, while there is no difference in overall success rate, first-time success rate after training, and complications. The superiority of SCT may be the result of fewer and more reliable procedural steps. However, the level of evidence is low (GRADE).