The emergency surgical airway

Randomized crossover trial comparing two open surgical cricothyrotomy techniques

Objective

Emergency cricothyrotomy is a life-saving procedure that is performed in "can't intubate can't oxygenate" scenario. A recent study comparing an open surgical technique using a bougie and endotracheal tube (ETT) with a Seldinger technique using the Cook Melker catheter showed that the open technique was quicker but suggested that the open technique could be quicker if using the Melker catheter instead of a bougie and ETT. The objective of this study was to compare the surgical technique using bougie and ETT with an open technique using the Melker catheter.

Methods

A randomized crossover trial was conducted involving emergency physicians (EPs) and trainees. Participants performed both techniques in succession on an airway model, with the technique performed first being randomized for each participant. The primary outcome was time to first insufflation of the artificial lung. Participants also indicated their comfort with each technique on a 5-point Likert scale and which technique they preferred.

Results

Seventeen EPs and 19 trainees participated. The Melker catheter technique was performed quicker with a mean time of 29.2 s versus 44.3 s for the bougie/ETT technique (difference 15.1 s, 95% confidence interval 10.8-19.4 s). The Melker catheter was most preferred by participants (61% vs. 39%). There was no significant difference in the comfort ratings between each technique. Time to model lung insufflation was not affected by training level or time since last performed a cricothyrotomy, either real or simulated.

Conclusions

The Melker catheter was quicker to perform and the most preferred by participants.

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

OBJECTIVES

Emergency cricothyrotomy is a lifesaving procedure performed when intubation fails and oxygenation cannot occur. There are multiple techniques and kits to perform this procedure. However, current evidence does not provide a definitive answer as to which method is superior. Two techniques in common use are a surgical technique and a percutaneous Seldinger-based cricothyrotomy kit. The objective was to determine which of these two methods was quickest to perform and to determine which was most preferred by participants.

METHODS

A prospective randomized controlled crossover trial was conducted involving emergency physicians and trainees. Each participant performed both cricothyrotomy techniques in succession on an airway model, with the technique performed first being randomized for each participant. The primary outcome was time to first insufflation of the artificial lung. A survey was completed by participants asking their comfort with each technique on a 5-point scale from 1 (not at all comfortable) to 5 (very comfortable) and which technique they preferred.

RESULTS

Twenty-one emergency physicians and nine emergency medicine trainees were recruited. The surgical technique was performed the fastest, with a mean (±SD) time of 51.6 (±16.3) s versus 66.6 (±14.9) s for the Seldinger technique, with a statistically significant difference of 15.0 s (95% confidence interval = 8.5 to 21.5, p < 0.001). The surgical technique was rated the most comfortable to perform, with a median rating of 5 (interquartile range [IQR] = 4-5) versus 4 (IQR = 3-5) for the Seldinger technique. The surgical technique was most preferred by participants (80% vs 20%).

CONCLUSION

The surgical technique was the fastest to perform and was rated the most comfortable to perform and the most preferred technique.