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27/02/2021

Coniotomie: Apprendre ET s'entretenir

Emergency Cricothyrotomy: A 10-Year Single Institution Experience
Moroco AE et Al. Am Surg. 2021 Feb 10;3134821995075. doi: 10.1177/0003134821995075.

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Même entre des mains chirurgicales ce geste n'est pas si simple que certains le disent. Pourtant il faut le connaître et surtout maintenir la pratique enseignée.

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Background:

With recent technological advances reducing the demand for emergent surgical airway placement, surgeons are less often performing this life-saving procedure. We sought to assess the characteristics and outcomes surrounding patients undergoing modern emergent cricothyrotomy.

Methods:

A retrospective case series was performed between January 2010 and January 2020 at a single tertiary academic level 1 trauma center. Patients who underwent tracheostomy (CPT 31600, 31601) within 48 hours of admission or listed in the trauma registry were queried. Charts were individually reviewed to identify patients with cricothyrotomy. Demographic, operative and relevant hospital course data were collected.

Results:

A total of 1642 patients were identified with 12 of those found to have met inclusion criteria. The population was mostly male (91.7%) with an average age of 43 years and average body mass index of 30. Survival rate of patients was 75%. A total of 7 patients (58%) had appropriate anatomical placement of cricothyrotomy. Of those patients, 75% were performed by Trauma Surgery. Of the 5 patients with misplaced cricothyrotomy, all were male, with an average age and body mass index of 36 years and 25, respectively. Procedures were performed by prehospital personnel (20%), referring hospital (20%), and Trauma Surgery (60%).

Discussion:

Cricothyrotomy remains a vital tool in the successful management of emergent airway access. The most common complication observed was improper anatomical placement, which occurred in nearly half of patients. Trauma surgeons perform 75% of cricothyrotomies, with an anatomical accuracy rate of 66.7%.

 

27/11/2020

Trauma du larynx: Faites une échographie !

Novel role of focused airway ultrasound in early airway assessment of suspected laryngeal trauma

Background

Upper airway injury secondary to blunt neck trauma can lead to upper airway obstruction and potentially cause a life-threatening condition. The most important aspect in the care of laryngeal trauma is to establish a secure airway. Focused airway ultrasound enables recognition of important upper airway structures, offers early opportunity to identify life-threatening upper airway injury, and allows assessment of the extent of injury. This information that can be obtained rapidly at the bedside has the potential to facilitate rapid intervention.

Case presentation

We report a case series that illustrate the diagnostic value of focused airway ultrasound in the diagnosis of laryngeal trauma in patients presenting with blunt neck injury.

Conclusion

Early recognition, appropriate triaging, accurate airway evaluation, and prompt management of such injuries are essential. In this case series, we introduce the potential role of focused airway ultrasound in suspected laryngeal trauma, and the correlation of these exam findings with that of computed tomography (CT) scanning, based on the Schaefer classification of laryngeal injury.

26/09/2020

Le doigt plutôt qu'un guide

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Une situation au final rare mais  c'est pour ce genre d'évènements  qu'un médecin ENTRAÎNE est sur place. C'est clair.

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Background: Front-of-neck airway rescue in a cannot intubate, cannot oxygenate (CICO) scenario with impalpable anatomy is particularly challenging. Several techniques have been described based on a midline vertical neck incision with subsequent finger dissection, followed by either a cannula or scalpel puncture of the now palpated airway. We explored whether the speed of rescue oxygenation differs between these techniques.

Methods: In a high-fidelity simulation of a CICO scenario in anaesthetised Merino sheep with impalpable front-of-neck anatomy, 35 consecutive eligible participants undergoing airway training performed scalpel-finger-cannula and scalpel-finger-bougie in a random order. The primary outcome was time from airway palpation to first oxygen delivery. Data, were analysed with Cox proportional hazards.

Results: Scalpel-finger-cannula was associated with shorter time to first oxygen delivery on univariate (hazard ratio [HR]=11.37; 95% confidence interval [CI], 5.14-25.13; P<0.001) and multivariate (HR=8.87; 95% CI, 4.31-18.18; P<0.001) analyses. In the multivariable model, consultant grade was also associated with quicker first oxygen delivery compared with registrar grade (HR=3.28; 95% CI, 1.36-7.95; P=0.008).

HPN592.png

With scalpel-finger-cannula, successful oxygen delivery within 3 min of CICO declaration and ≤2 attempts was more frequent; 97% vs 63%, P<0.001. In analyses of successful cases only, scalpel-finger-cannula resulted in earlier improvement in arterial oxygen saturations (-25 s; 95% CI, -35 to -15; P<0.001), but a longer time to first capnography reading (+89 s; 95% CI, 69 to 110; P<0.001). No major complications occurred in either arm.

Conclusions: The scalpel-finger-cannula technique was associated with superior oxygen delivery performance during a simulated CICO scenario in sheep with impalpable front-of-neck anatomy.

| Tags : airway

20/01/2020

Vidéos de cricothyroïdotomie de l'Université de Sherbrooke

banner_crico.jpg

Clic sur l'image pour accéder au document

21/12/2019

Crico Chir:Plutôt avec 1 bougie ?

Randomized Comparative Assessment of Three Surgical Cricothyrotomy Devices on Airway Mannequins.

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Un travail qui met en avant l'intérêt de l'emploi d'une bougie, l'importance de l'entraînement pour cette procédure peu fréquemmment réaloisée et le recul nécessaire à avoir envers les nouveaux équipements , en l'occurence le control-cric, fussent ils promus par le TCCC.

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Background:

Airway obstruction is the second leading cause of preventable battlefield death, at least in part because surgical cricothyrotomy (SC) failure rates remain unacceptably high. Ideally, SC should be a rapid, simple, easily-learned, and reliably-performed procedure. Currently, 3 SC devices meet Tactical Combat Casualty Care (TCCC) standards: The Tactical CricKit® (TCK), Control-CricTM(CC), and Bougie-assisted Technique (BAT). However, no previous studies have compared these devices in application time, application success, user ratings, and user preference.

Methods:

United States Navy Corpsmen (N = 25) were provided 15 minutes of standardized instruction, followed by hands-on practice with each device on airway mannequins. Participants then performed SC with each of the 3 devices in a randomly assigned sequence. In this within-subjects design, application time, application success, participant ratings, and participant preference data were analyzed using repeated-measures ANOVA, regression, and non-parametric statistics at p < 0.05.

Results:

Application time for CC (M = 184 sec, 95% CI 144-225 sec) was significantly slower than for BAT (M = 135 sec, 95% CI 113-158 sec, p < 0.03) and TCK (M = 117 sec, 95% CI 93-142 sec, p < 0.005). Success was significantly greater for BAT (76%) than for TCK (40%, p < 0.02) and trended greater than CC (48%, p = 0.07). CC was rated significantly lower than TCK and BAT in ease of application, effectiveness, and reliability (each p < 0.01). User preference was significantly (p < 0.01) higher for TCK (58%) and BAT (42%) than for CC (0%). Improved CC blade design was the most common user suggestion.

Conclusion:

While this study was limited by the use of mannequins in a laboratory environment, present results indicate that none of these devices was ideal for performing SC. Based on slow application times, low success rates, and user feedback, the Control-CricTM cannot be recommended until improvements are made to the blade design

| Tags : coniotomie

07/10/2019

Membrane cricoïdienne à (0.13xP kg) + 0.86 mm

Depth to the airway lumen at the level of the cricothyroid membrane measured by ultrasound.

Athanassoglou V et Al. Acta Anaesthesiol Scand. 2019 Aug 22. doi: 10.1111/aas.13464

BACKGROUND:

Knowing the likely depth to the airway before emergency cricothyroidotomy may improve success in cases where it cannot be measured. Our aim was to measure the depth to the airway at the cricothyroid membrane by ultrasound in a large group of adult patients.

METHOD:

Prospective, observational study in two centres, Oxford and Gloucester. Patients presenting for a large variety of surgical operations were studied. Patients under 18 years old; pregnant; critically ill; had a history of neck surgery not included. Ultrasound examination was performed pre-operatively while participants lay supine with their head and neck extended, with light transducer pressure. We measured depth to the airway lumen in mm; age; weight; height and sex.

RESULTS:

In total 352 patients were studied. We found that depth to the airway lumen strongly correlated with weight (r=0.855, p<0.001) and to a lesser extent body mass index (r=0.781, p<0.001) but did not correlate to sex. Statistical analysis produced an equation to predict upper 95% CI of depth to the airway from the patient's weight: Depth to the airway lumen in mm = (0.13 x weight in kg) + 0.86.

CONCLUSIONS:

If ultrasound measurement is not possible before emergency cricothyroidotomy, the clinician could use our results to predict the depth to the airway by using the patient's weight. If the upper 95% CI were used as the depth of incision, it would enter the airway in 39 out of 40 patients of that weight, without damage to posterior structures in those with a shallower airway.

26/07/2019

Maîtriser l'intubation: Un vrai challenge

Procedural Experience With Intubation: Results From a National Emergency Medicine Group.

 

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Un geste à laquelle les médecins urgentistes US sont peu exposés dans leur pratique quotidienne. Un vrai challenge personnel et pour les formateurs notamment des centres de simulations.

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STUDY OBJECTIVE:

Although intubation is a commonly discussed procedure in emergency medicine, the number of opportunities for emergency physicians to perform it is unknown. We determine the frequency of intubation performed by emergency physicians in a national emergency medicine group.

METHODS:

Using data from a national emergency medicine group (135 emergency departments [EDs] in 19 states, 2010 to 2016), we determined intubation incidence per physician, including intubations per year, intubations per 100 clinical hours, and intubations per 1,000 ED patient visits. We report medians and interquartile ranges (IQRs) for estimated intubation rates among emergency physicians working in general EDs (those treating mixed adult and pediatric populations).

RESULTS:

We analyzed 53,904 intubations performed by 2,108 emergency physicians in general EDs (53,265 intubations) and pediatric EDs (639 intubations). Intubation incidence varied among general ED emergency physicians (median 10 intubations per year; IQR 5 to 17; minimum 0, maximum 109). Approximately 5% of emergency physicians did not perform any intubations in a given year. During the study, 24.1% of general ED emergency physicians performed fewer than 5 intubations per year (range 21.2% in 2010 to 25.7% in 2016).

Urge Intub.jpg

Emergency physicians working in general EDs performed a median of 0.7 intubations per 100 clinical hours (IQR 0.3 to 1.1) and 2.7 intubations per 1,000 ED patient visits (IQR 1.2 to 4.6).

CONCLUSION:

These findings provide insights into the frequency with which emergency physicians perform intubations.

25/07/2019

Crico: Plutôt une lame de 20 ?

Scalpel bougie tube versus hook-assisted emergency front of neck airway—a prospective randomised bench top study in porcine larynges

Caulfield K. et Al.  https://doi.org/10.1016/j.bja.2019.05.017 

 

Cette lettre a pour objet de comparer l'insertion d'une canule au travers de la membrane crico-thyroidienne d'un larynx de cochon (membrane que l'on sait relativement profonde) soit en utilisant un crochet de Hook soit une bougie. Les deux techniques se valent. Chose intéressante ils observent près de 17% de difficultés d'insertion avec une lame de 10 versus 7% avec une lame de 20. Cette dernière, qui est une version XL de la lame 10, semble donc préférable ?

 

swann_lamesfic.jpg

 

"...In the Phase 1 study, the maximum sized ET tube to be placed into the CTM was a size 8. Time to insertion of ET tube averaged 30 s using a Size 20 blade and 31 s using a size 10 blade for all ETT sizes. There was a 16% recorded difficulty by candidates with the size 10 blade and only 7.5% recorded difficulty with the size 20 blade. In the Phase 2 study (blinded RCT), all attempted eFONA attempts were ultimately successful. There were no differences in time required, proportion successful in less than 40 s, or perceived difficulty between groups. Neither CTM incision width nor the proportion of attempts requiring re-incision was different between groups. Reassuringly, all eFONA attempts with both techniques were successful. Neither technique outperformed the other in any aspect of performance."

 

 

 

 

05/05/2019

Pour savoir, se ets'in/former

The effectiveness of educational methods for cricothyroid membrane identification by dental students: A prospective study using neck photographs and tracheotomy trainers.

Goto T et Al. Clin Exp Dent Res. 2019 Mar 4;5(2):170-177.

 

The purpose of this study was to evaluate the accurate identification of the cricothyroid membrane (CTM) by fifth grade dental students, before undergoing the relevant anesthesiology practicum. Moreover, we aimed to determine the educational effectiveness of the cricothyrotomy practicum in anesthesiology.

Before the lecture and without prior notification, 119 students were provided with a photograph of a man's neck and instructed to attach a blue sticker to the cricothyrotomy puncture site and to a palpable tracheotomy trainer, after applying sufficient palpation. After this, students attended a 60-min lecture on the emergency airway management method. Two and 16 days after the lecture and practicum, students were presented with a new neck photograph and the tracheotomy trainer and asked again to place stickers (red stickers: at 2 days; green stickers: at 16 days) on the cricothyrotomy penetration site. The data were analyzed with an image processing software, by superimposing the 119 stickers on the neck photographs and tracheotomy trainers, to visually examine the accuracy of CTM identification.

The rate of correct sticker placement in the neck photographs was 41.2% before the lecture, 80.7% 2 days after the lecture, and 77.3% 16 days after the lecture (before vs. 2 and 16 days after, p value < 0.01). For the tracheotomy trainer, the rate was 36.1% before the lecture, 97.5% 2 days after the lecture, and 94.1% 16 days after the lecture (before vs. 2 and 16 days after, p value < 0.01).

CricoTraining.jpeg

Furthermore, the proportion of students with mistakes above and below the CTM was higher than that of students with mistakes to the right or left. In conclusion, the rate of accurate CTM identification among dental students was low before they underwent the relevant practicum, but most students were able to identify the CTM accurately after the lecture and practicum in a small class.

16/04/2019

Coniotomie: Plutôt une lame de 22

Front-of-neck access technique and scalpels

 
Le choix de la lame de bistouri n'est pas anodin. Ce travail le confirme et met en avant l'intérêt d'utiliser une lame de 22.

Conio Scalpel 22.jpg

Clic sur l'image pour accéder au document

| Tags : airway

07/04/2019

ControlCric: Plutôt à éviter

Necessity to depict difficult neck anatomy for training of cricothyroidotomy: A pilot study evaluating two surgical devices on a new hybrid training model.

BACKGROUND:

Everyone dealing with airway emergencies must be able to accomplish cricothyroidotomy, which cannot be trained in real patients. Training models are necessary.

OBJECTIVE:

To evaluate the suitability of a hybrid training model combining synthetic and porcine parts to depict variable neck anatomy.

DESIGN:

Model-based comparative trial.

SETTING:

Armed Forces Hospital Ulm, Germany, August 2018.

INTERVENTION:

On four anatomical neck variations (long slim/long obese/short slim/short obese) we performed two surgicalrapproaches to cricothyroidotomy (SurgiCric II vs. ControlCric).

PARTICIPANTS:

Forty-eight volunteers divided into two groups based on their personal skill level: beginners group and proficient performers group.

MAIN OUTCOME MEASURES:

Time to completion was recorded for each procedure. Once the operator had indicated completion, the correct anatomical tube placement was confirmed by dissection and structures were inspected for complications. Primary outcomes were successful tracheal placement of an airway tube and time needed to achieve a patent airway. Secondary outcome was assessment of complications.

RESULTS:

Overall, 384 procedures were performed. Median time to completion was 74 s. In total, 284 procedures (74%) resulted in successful ventilation. Time to completion was longer in short obese than in long slim and the risk of unsuccessful procedures was increased in short obese compared with long slim. Even if ControlCric resulted in faster completion of the procedure, its use was less successful and had an increased risk of complications compared with SurgiCric II. Proficient performers group performed faster but had an increased risk of injuring the tracheal wall compared with beginners group.

CONCLUSION:

Participants had difficulties in performing cricothyroidotomy in obese models, but various and difficult anatomical situations must be expected in airway management and therefore must be taught. A new hybrid model combining porcine and synthetic materials offers the necessary conditions for the next step in training of surgical airway procedures.

 

ControlCric: Plutôt à éviter

Necessity to depict difficult neck anatomy for training of cricothyroidotomy: A pilot study evaluating two surgical devices on a new hybrid training model.

BACKGROUND:

Everyone dealing with airway emergencies must be able to accomplish cricothyroidotomy, which cannot be trained in real patients. Training models are necessary.

OBJECTIVE:

To evaluate the suitability of a hybrid training model combining synthetic and porcine parts to depict variable neck anatomy.

DESIGN:

Model-based comparative trial.

SETTING:

Armed Forces Hospital Ulm, Germany, August 2018.

INTERVENTION:

On four anatomical neck variations (long slim/long obese/short slim/short obese) we performed two surgicalrapproaches to cricothyroidotomy (SurgiCric II vs. ControlCric).

PARTICIPANTS:

Forty-eight volunteers divided into two groups based on their personal skill level: beginners group and proficient performers group.

MAIN OUTCOME MEASURES:

Time to completion was recorded for each procedure. Once the operator had indicated completion, the correct anatomical tube placement was confirmed by dissection and structures were inspected for complications. Primary outcomes were successful tracheal placement of an airway tube and time needed to achieve a patent airway. Secondary outcome was assessment of complications.

RESULTS:

Overall, 384 procedures were performed. Median time to completion was 74 s. In total, 284 procedures (74%) resulted in successful ventilation. Time to completion was longer in short obese than in long slim and the risk of unsuccessful procedures was increased in short obese compared with long slim. Even if ControlCric resulted in faster completion of the procedure, its use was less successful and had an increased risk of complications compared with SurgiCric II. Proficient performers group performed faster but had an increased risk of injuring the tracheal wall compared with beginners group.

CONCLUSION:

Participants had difficulties in performing cricothyroidotomy in obese models, but various and difficult anatomical situations must be expected in airway management and therefore must be taught. A new hybrid model combining porcine and synthetic materials offers the necessary conditions for the next step in training of surgical airway procedures.

 

| Tags : airway

27/03/2019

Management of tracheal intubation in critically ill adults

 

BJA Guidelines intubation critically ill.jpg

Clic sur l'image pour accéder au document

| Tags : airway

19/03/2019

Trauma et formation: Progrès encore à faire

Surgical interns in 2018: Objective assessment suggests they are better but still lack critical knowledge and skill.

BACKGROUND:

The transition from fourth-year medical student to surgical intern is difficult. A lack of repetitions, experience, and knowledge is problematic. We report our experience using simulation-based technical and nontechnical skills to assess the competency of surgical interns in July and January of their intern year.

DESIGN:

As part of a larger assessment effort, our general surgery interns (2010-2016) have been tested on performing an emergent cricothyrotomy, interpreting 2 arterial blood gases, and reading 3 chest x-rays in fewer than 7 minutes. We retrospectively analyzed general surgery interns' performance on these 3 tests (total score = 20).

RESULTS:

A total of 210 interns completed both July and January (identical) assessments. Overall mean scores improved from July (12.62 ± 3.44) to January (16.5 ± 2.46; P < .05). During the study period general surgery interns' mean baseline scores improved in both July (P < .05) and in January (P < .05). Although most individual general surgery interns did improve their total scores (92% improved, 3% same, 5% worse) between July and January (P < .05), in January 40% could not perform an emergent cricothyrotomy swiftly, and 6% missed a tension pneumothorax on chest x-ray.

 

Crico olympiades.jpg

CONCLUSION:

Our data suggest that surgical interns start residency training with low levels of skill and comprehension with emergent cricothyrotomy, arterial blood gas, and chest x-ray. They improve with 6 months of clinical and simulation training. Encouragingly, overall scores for both July and January assessments have improved during the study period. Given that some interns still struggle in January to perform these three tasks, we believe that 2018 interns are better, but still potentially lack critical knowledge and skill.

15/03/2019

Encore à la recherche d'un simulateur de crico

A trial comparing emergency front of neck airway performance in a novel obese-synthetic neck, meat-modified obese neck and conventional slim manikin.

 

Conventional emergency front of neck airway training manikins mimic slim patients and are associated with unrealistic procedural ease. We have described previously a pork belly-modified manikin that more realistically simulated an obese patient's neck. In this study, we compared a novel obese-synthetic manikin (obese-synthetic manikin) with a pork belly-modified manikin (obese-meat manikin) and a conventional slim manikin (slim manikin). Thirty-three experienced anaesthetists undertook simulated emergency front of neck airway procedures on each manikin (total 99 procedures). Time to ventilation was longer on both obese manikins compared with the slim manikin (median (IQR [range]) time to intubation 159 (126-243 [73-647]) s in the obese-synthetic, 105 (72-138 [43-279]) s in the obese-meat and 58 (47-74 [30-370]) s in the slim manikin; p < 0.001 between each manikin). Cricothyroidotomy success rate was similar in the both obese manikins but lower when compared with the slim manikin (15/33 obese-synthetic vs. 14/33 obese-meat vs. 27/33 slim manikin).
 

Crico new.jpg

 
Participant feedback indicated performance difficulty was similar between both obese manikins, which were both more difficult than the slim manikin. The tissues of the obese-meat manikin were judged more realistic than those of either other manikin. Overall, the obese-synthetic manikin performed broadly similarly to the obese-meat manikin and was technically more difficult than the conventional slim manikin. The novel obese-synthetic manikin maybe useful for training and research in front of neck airway procedures.

03/03/2019

Crico: Simulation classique = Haute fidélité

 

A high-fidelity simulator for needle cricothyroidotomy training is not associated with increased proficiency compared with conventional simulators: A randomized controlled study.

 
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L'apprentissage de la coniotomie connait un regain important depuis la publication de l'étude NAP4. Un temps oubliée, ce geste de médecine d'urgence rarement mis en oeuvre est pourtant essentiel à maîtriser non seulement dans un bloc opératoire mais aussi en préhospitalier et tout particulièrement en médecine de guerre où la fréquence des traumatismes ballistiques de la face va croissant. La simulation de ce geste est largement utilisée et des modèles sophistiqués sont proposéss. Il n'est pas certain que ces modèles relativement coûteux aient un intérêt. Un bémol doit cependant être mis. Le modèle "larynx de porc", quoique largement utilisé, ne correspond pas tout à fait à un larynx humain.
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BACKGROUND:

A high-fidelity task simulator for cricothyroidotomy was created using data from a 3-dimensional (3D) computed tomography scan using a 3D printer. We hypothesized that this high-fidelity cricothyroidotomy simulator results in increased proficiency for needle cricothyroidotomy compared with conventional simulators.

METHODS:

Cricothyroidotomy-naive residents were recruited and randomly assigned to 2 groups, including simulation training with a conventional simulator (Group C) and with a high-fidelity simulator (Group 3D). After simulation training, participants performed cricothyroidotomy using an ex vivo porcine larynx fitted with an endoscope to record the procedure. The primary outcomes were success rate and procedure time. The secondary outcome was a subjective measure of the similarity of the simulator to the porcine larynx.

RESULTS:

Fifty-two residents participated in the study (Group C: n = 27, Group 3D: n = 25). There was no significant difference in the success rate or procedure time between the 2 groups (success rate: P = .24, procedure time: P = .34). There was no significant difference in the similarity of the simulators to the porcine larynx (P = .81).

CONCLUSION:

We developed a high-fidelity simulator for cricothyroidotomy from 3D computed tomography data using a 3D printer. This anatomically high-fidelity simulator did not have any advantages compared with conventional dry simulators.

| Tags : airway, coniotomie

28/01/2019

Crico: Entraînez vous car cela rapporte de la survie

Prehospital cricothyrotomies in a helicopter emergency medical service: analysis of 19,382 dispatches

Patrick Schober et Al. BMC Emerg Med. 2019; 19: 12. Published online 2019 Jan 23. doi: 10.1186/s12873-019-0230-9

 

BACKGROUND:

Creating a patent airway by cricothyrotomy is the ultimate maneuver to allow oxygenation (and ventilation) of the patient. Given the rarity of airway management catastrophes necessitating cricothyrotomy, sufficiently sized prospective randomized trials are difficult to perform. Our Helicopter Emergency Medical Service (HEMS) documents all cases electronically, allowing a retrospective analysis of a larger database for all cases of prehospital cricothyrotomy.

METHODS:

We analyzed all 19,382 dispatches of our HEMS 'Lifeliner 1', since set-up of a searchable digital database. This HEMS operates 24/7, covering ~ 4.5 million inhabitants of The Netherlands. The potential cases were searched and cross-checked in two independent databases.

RESULTS:

We recorded n = 18 cases of prehospital cricothyrotomy. In all 18 cases, less invasive airway techniques, e.g., supraglottic devices, were attempted before cricothyrotomy. With exception of 2 cases, at least one attempt of orotracheal intubation had been performed before cricothyrotomy. Out of the 18 cases, 4 were performed by puncture-based technique (Melker), the remaining 14 cases by surgical technique. Indications for cricothyrotomy were diverse, dividable into 9 trauma cases and 9 medical cases. The procedure was successful in all but one case (17/18, i.e., 94%; with a 95% confidence interval of 72.7-99.9%). Outcome was such that 6/18 patients arrived at the hospital alive. Long term outcome was poor, with only 2/18 patients discharged from hospital alive.

CONCLUSIONS:

Cricothyrotomy remains, although rare, a regularly occurring requirement in (H)EMS. Our finding of a convincingly high success rate of 94% in trained hands encourages training and a timely performance of cricothyrotomy.

05/12/2018

Crico: Manque d'expérience/Entraînement

Emergency front-of-neck airway by ENT surgeons and residents: A dutch national survey

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Ce travail hollandais met en avant le caractère non anecdotique des accès chirurgicaux aux voies aériennes. Pour les chirurgiens ORL hollandais, il s'agit essentiellement de trachéotomies. Le faible recours à la coniotomie s'explique surtout par le manque d'entraînement et d'équipements spécifiques. L'article souligne l'importance des démarches d'acquisition et de maintien des compétences, ce qui ne doit pas nous étonner. Comme pour les chirurgiens ORL le besoin d'un programme structuré de formations à l'accès aux voies aériennes en condition de combat est un impératif.

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Objectives:

ENT surgeons and anesthesiologists work closely together in managing challenging airway cases. Sharing knowledge, experiences, and expectations interdisciplinary is essential in order to facilitate decision-making and adequate management in emergency front-of-neck airway cases.

Methods:

A survey was performed, to analyze level of experience, technique of preference, training, knowledge of material and protocols, and self-efficacy scores of Dutch ENT surgeons and residents in performing an urgent or emergency front-of-neck airway.

Results:

Within one year (January 2014-2015), 25.7% of the 257 respondents had performed an urgent or emergency front-of-neck airway. Of all reported emergency front-of-neck airways (N = 30), 80% were managed by tracheotomy. In future emergency front-of-neck airway cases, 74% stated cricothyrotomy would be their technique of preference. The majority would choose an uncuffed large-bore cannula technique. Post-academic hands-on training was attended by 42% of respondents. Self-efficacy scores were highest for surgical tracheotomy, and higher when trained or experienced. In case of an emergency scenario, 8.6% would not perform a front-of-neck airway themselves.

LIO2-3-356-g002.jpg

LIO2-3-356-g003.jpg

The main reasons for reluctance to start in general were lack of experience and lack of training. Reported items for improvement were mainly the development of a protocol and training.

Conclusion:

The chance of encountering an airway emergency scenario requiring front-of-neck airway is realistic. There is inconsistency between advised technique, technique of preference and technique actually performed by ENT surgeons. This study shows that there is both a need and desire for improvement in training and organization of care. Interdisciplinary guidelines and education is needed and could eventually safe lives.

| Tags : airway

02/12/2018

Crico: Incisez VERTICAL et LARGE

Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length

 

Background

A vertical incision is recommended for cricothyroidotomy when the anatomy is impalpable, but no evidence-based guideline exists regarding optimum site or length. The Difficult Airway Society guidelines, which are based on expert opinion, recommend an 80–100 mm vertical caudad to cephalad incision in the extended neck position. However, the guidelines do not advise the incision commencement point. We sought to determine the minimum incision length and commencement point above the suprasternal notch required to ensure that the cricothyroid membrane would be accessible within its margins.

 Methods

We measured using ultrasound, in 80 subjects (40 males and 40 females) without airway pathology, the distance between the suprasternal notch and the cricothyroid membrane, in the neutral and extended neck positions. We assessed the inclusion of the cricothyroid membrane within theoretical incisions of 0–100 mm in length made at 10 mm intervals above the suprasternal notch.

Results

In 80 subjects (40 males and 40 females), the distance ranged from 27 to 105 mm. Movement of the cricothyroid membrane on transition from the neutral to extended neck position varied from 15 mm caudad to 27 mm cephalad.

Crico incision.jpeg

The minimum incision required in the extended position was 70 mm in males and 80 mm in females, commencing 30 mm above the suprasternal notch.

 

Conclusions

An 80 mm incision commencing 30 mm above the suprasternal notch would include all cricothyroid membrane locations in the extended position in patients without airway pathology, which is in keeping with the Difficult Airway Society guidelines recommended incision length.

| Tags : airway

19/10/2018

Intubation dans le noir: Plutôt Poncho que JVN

A Study on the Tactical Safety of Endotracheal Intubation Under Darkness.
 
 

OBJECTIVE:

Strict blackout discipline is extremely important for all military units. To be able to effectively determine wound characteristics and perform the necessary interventions at nighttime, vision and light restrictions can be mitigated through the use of tactical night vision goggles (NVGs). The lamp of the classical laryngoscope (CL) can be seen with the naked eye; infrared light, on the other hand, cannot be perceived without the use of NVGs. The aim of the study is to evaluate the safety of endotracheal intubation (ETI) procedures in the darkunder tactically safe conditions with modified laryngoscope (ML) model.

METHODS:

We developed an ML model by changing the standard lamp on a CL with an infrared light-emitting diode lamp to obtain a tool which can be used to perform ETI under night conditions in combination with NVGs. We first evaluated the safety of ETI procedures in prehospital conditions under darkness by using both the CL and the ML for the study, and then researched the procedures and methods by which ETI procedure could be performed in the dark under tactically safe conditions. In addition, to better ensure light discipline in the field of combat, we also researched the benefits, from a light discipline standpoint, of using the poncho liner (PL) and of taking advantage of the oropharyngeal region during ETIs performed by opening the laryngoscope blades directly in the mouth and using a cover. During the ETI procedures performed on the field, two experienced combatant staff simulated the enemy by determining whether the light from the two different types of laryngoscope could be seen at 100-m intervals up to 1,500 m.

RESULTS:

In all scenarios, performing observations with an NVG was more advantageous for the enemy than with the naked eye. The best measure that can be taken against this threat by the paramedic is to ensure tactical safety by having an ML and by opening the ML inside the mouth with the aid of a PL. The findings of the study are likely to shed light on the tactical safety of ETI performed with NVGs under darkness.

CONCLUSION:

Considering this finding, we still strongly recommend that it would be relatively safer to open the ML blade inside the mouth and to perform the procedures under a PL. In chaotic environments where it might become necessary to provide civilian health services for humanitarian aid purposes (Red Crescent, Red Cross, etc.) without NVGs, we believe that it would be relatively safer to open the CL blade inside the mouth and to perform the procedures under a PL.