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08/07/2016

Coniotomie: Plaidoyer UK pour la chirurgie

The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective

Tyle T et Al. J R Army Med Corps. 2016 Jun 6. pii: jramc-2016-000637. doi: 10.1136/jramc-2016-000637

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Un geste peu fréquent: 86 blessés sur une période de 8 ans et pourtant un geste essentiel à maîtriser. Faire simple est mieux. Pour cela pas besoin d'être chirurgien, urgentiste ou anesthésiste-réanimateur.

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BACKGROUND:

The insertion of a surgical airway in the presence of severe airway compromise is an uncommon occurrence in everyday civilian practice. In conflict, the requirement for insertion of a surgical airway is more common. Recent military operations in Afghanistan resulted in large numbers of severely injured patients, and a significant proportion required definitive airway management through the insertion of a surgical airway.

OBJECTIVE:

To examine the procedural success and survival rate to discharge from a military hospital over an 8-year period.

METHODS:

A retrospective database and chart review was conducted, using the UK Joint Theatre Trauma Registry and the Central Health Records Library. Patients who underwent surgical airway insertion by UK medical personnel from 2006 to 2014 were included. Procedural success, demographics, Injury Severity Score, practitioner experience and patient survival data were collected. Descriptive statistics were used for data comparison, and statistical significance was defined as p<0.05.

RESULTS:

86 patients met the inclusion criterion and were included in the final analysis. The mean patient age was 25 years, (SD 5), with a median ISS of 62.5 (IQR 42). 79 (92%) of all surgical airways were successfully inserted. 7 (8%) were either inserted incorrectly or failed to perform adequately. 80 (93%) of these procedures were performed either by combat medical technicians or General Duties Medical Officers (GDMOs) at the point of wounding or Role 1. 6 (7%) were performed by the Medical Emergency Response Team. 21 (24%) patients survived to hospital discharge.

DISCUSSION:

Surgical airways can be successfully performed in the most hostile of environments with high success rates by combat medical technicians and GDMOs. These results compare favourably with US military data published from the same conflict.

 

| Tags : airway, coniotomie

28/06/2016

Crico: Incisez et palpez sous la peau !

Deficiencies in locating the cricothyroid membrane by palpation: We can’t and the surgeons can’t, so what now for the emergency surgical airway ?

Law JA et Al. Can J Anesth (2016) 63:791–796

"......Certaines questions concernant la localisation de la membrane cricothyroïdienne demeurent sans réponse. Nous savons désormais que la palpation externe manque de précision, indépendamment de la spécialité du médecin évaluateur. En d’autres termes, les techniques qui s’appuient sur un accès direct à la trachée via la membrane cricothyroïdienne palpée depuis l’extérieur (par ex., les techniques percutanées de Seldinger ou réalisées à l’aide d’un trocart, un accès basé sur un scalpel à l’aide d’une coupure horizontale unique) courent toutes le risque d’un mauvais positionnement. L’alternative, lorsqu’on a recours à ces techniques de cricothyrotomie (en fait, à toutes ces techniques), est de commencer par une incision verticale médiane de 3-4 cm à travers la peau et les tissus sous-cutanés situés sur l’emplacement estimé de la membrane cricothyroïdienne.5,6 La membrane cricothyroïdienne est ensuite palpée à nouveau dans la lésion, et son emplacement devrait être bien plus facile à déterminer lorsqu’il y a considérablement moins de tissu mou entre le doigt qui palpe et la membrane cricothyroïdienne. La cricothyrotomie peut ensuite se faire à l’aide de la technique choisie et en étant absolument certain de son bon positionnement......"

| Tags : airway, coniotomie

27/06/2016

Crico: Utilisez le manche du bistouri !

Crico.jpg

Surgical Procedures in Trauma Management. New York, NY: Thieme Inc; 1986:303

| Tags : airway, coniotomie

15/06/2016

Coniotomie: Chirurgicale SVP !

Emergency Cricothyrotomy Performed by Surgical Airway–naive Medical Personnel

Heymans F. et Al. Anesthesiology 2016; 125:00-00

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L'obstruction des voies aériennes est une cause rare mais évitable de décès au combat. savoir ouvrir un cou est donc un geste qui doit être maîtrisé par le médecin ou l'infirmier présent. Se pose cependant la question de la méthode: chirurgicale ou dispositif spécifique ? Ce travail apporte clairement une réponse. Des personnels de santé novice obtiennent de meilleurs résultats avec la technique chirurgicale. Même si la technique utilisée n'est pas celle promue par la procédure du sauvetage au combat (emploi d'un crochet de hook au lieu d'une pince de Monro-Kelly), ce travail conforte le choix qui est fait d'avoir recours à la technique chirurgicale. 

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Background: When conventional approaches to obtain effective ventilation and return of effective spontaneous breathing fail, surgical airway is the last rescue option. Most physicians have a limited lifetime experience with cricothyrotomy, and it is unclear what method should be taught for this lifesaving procedure. The aim of this study is to compare the performance of medical personnel, naive to surgical airway techniques, in establishing an emergency surgical airway in cadavers using three commonly used cricothyrotomy techniques.

Methods: Twenty medical students, without previous knowledge of surgical airway techniques, were randomly selected from their class. After training, they performed cricothyrotomy by three techniques (surgical, Merkel, and QuickTrach II) in a random order on 60 cadavers with comparable biometrics. The time to complete the procedure, rate of success, and number of complications were recorded. A success was defined as the correct placement of the cannula within the trachea in 3min.

 

"After intact skin palpation of relevant structures (step 1), a vertical midline skin incision (step 2) is emphasized because it can be extended up or down if not correctly placed and because fewer vessels are located at the midline. Although
rarely emphasized, we recommend finger palpation through the subcutaneous tissue (step 3) and even in the trachea as a guide, as a dissector, and as a dilator; finger palpation is oblivious to bleeding and a better guide to the ligament, being the “surgeon’s eye” during cricothyrotomy. A horizontal incision of the lower aspect of the cricotracheal ligament (step 4) allows for tension release and better opening. A hook permits to maintain the skin and the tracheal opening. Caudal traction (step 5) is recommended because the cricoid cartilage is more resistant and in order to prevent laryngeal injuries. We did not use a dilator, forceps, or a retractor during this experiment. Finally, a cuffed cannula is inserted (step 6)"

 

Results: The success rates were 95, 55, and 50% for surgical cricothyrotomy, QuickTrach, and Merkel, respectively (P = 0.025).

 

airway

The majority of failures were due to cannula misplacement (15 of 20). In successful procedures, the mean procedure time was 94± 35 s in the surgical group, 77 ± 34 in the QuickTrach II group, and 149 ±24 in the Melker group (P < 0.001). Few significant complications were found in successful procedures. No cadaver biometric parameters were correlated with success of the procedure.

Conclusion: Surgical airway–naive medical personnel establish emergency cricothyrotomy more efficiently and safely with the surgical procedure than with the other two commonly used techniques

 

 

| Tags : airway

12/05/2016

Crico: Incisez large

The inaccuracy of using landmark techniques for cricothyroid membrane identification: a comparison of three techniques

Bair AE et Al. Acad Emerg Med 2015 Aug; 22:908

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Le recours à la coniotomie est rare mais il s'agit d'un geste technique à connaître pour la prise en charge des obstructions des voies aériennes. Le repérage de la membrane crio-thyroïdienne peut être difficile. Ce travail  rappelle que l'identification manuelle de cette dernière est fiable dans moins de 60 % des cas. L'échographie améliorerait la fiabilité de cette localisation (Campbell M et Al. 1) mais ceci n'est pas, et c'est surprenant, retrouvé par tous (Yldiz G et Al. 2). En ce qui nous concerne, la disponibilité d'un appareil d'échographie sur le terrain est peu probable . En cas de difficulté de repérage pensez à réaliser une incision large pour repérer au doigt directement cette membrane (regardez cette vidéo)

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OBJECTIVES:

Successful cricothyrotomy is predicated on accurate identification of the cricothyroid membrane (CTM) by palpation of superficial anatomy. However, recent research has indicated that accuracy of the identification of the CTM can be as low as 30%, even in the hands of skilled providers. To date, there are very little data to suggest how to best identify this critical landmark. The objective was to compare three different methods of identifying the CTM.

METHODS:

A convenience sample of patients and physician volunteers who met inclusion criteria was consented. The patients were assessed by physician volunteers who were randomized to one of three methods for identifying the CTM (general palpation of landmarks vs. an approximation based on four finger widths vs. an estimation based on overlying skin creases of the neck). Volunteers would then mark the skin with an invisible but florescent pen. A single expert evaluator used ultrasound to identify the superior and inferior borders of the CTM. The variably colored florescent marks were then visualized with ultraviolet light and the accuracy of the various methods was recorded as the primary outcome. Additionally, the time it took to perform each technique was measured. Descriptive statistics and report 95% confidence intervals (CIs) are reported.

RESULTS:

Fifty adult patients were enrolled, 52% were female, and mean body mass index was 28 kg/m(2) (95% CI = 26 to 29 kg/m(2) ). The general palpation method was successful 62% of the time (95% CI = 48% to 76%) and took an average of 14 seconds to perform (range = 5 to 45 seconds). In contrast, the four-finger technique was successful 46% of the time (95% CI = 32% to 60%) and took an average of 12 seconds to perform (range = 6 to 40 seconds). Finally, the neck crease method was successful 50% of the time (95% CI = 36% to 64%) and took an average of 11 seconds to perform (range = 5 to 15 seconds).

CONCLUSIONS:

All three methods performed poorly overall. All three techniques might potentially be even less accurate in instances where the superficial anatomy is not palpable due to body habitus. These findings should alert clinicians to the significant risk of a misplaced cricothyrotomy and highlight the critical need for future research.

23/01/2016

Maîtriser l'airway +++, entre autres

Augmentation of point of injury care: Reducing battlefield
mortality—The IDF experience

Benov A. et Al. Injury. 2015 Nov 18. pii: S0020-1383(15)00697-X. doi: 10.1016/j.injury.2015.10.078.

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Une publication particulièrement intéressante car elle émane de collègues militaires qui interviennent dans un contexte très particulier de prise en charge de blessés tels qu'on peut les rencontrer en opérations extérieures mai dans un contexte de réseau de traumatologie civile puisque que les hôpitaux de recueil de ces blessés sont les hôpitaux civils. Les données présentées ne portent que sur la prise en charge de combattants.

Un des points analysé est la performance des équipes dans certains gestes considérés comme essentiel, notamment la gestion des voies aériennes. Comme dans l'armée française l'intubation orotrachéale et la criciothyrotomie représentent les deux procédures mises en oeuvre par des médecins. Manifestement, il existe une grande maîtrise de la coniotomie alors que celle de l'Intubation est moins évidente: 41% de succès et une moyenne de 2 tentatives. Ceci reste problématique lorsque la prise en charge des blessés se fait loin d'un trauma center et qu'il faut envisager la gestion de ces voies aériennes et l'initiation d'une ventilation pendant plusieurs heures (jours ?). Pour ces raisons et même si la probabilité d'être confronté à une telle situation est faible, ce travail rapporte les 2/3 des blessés ne sont pas urgent et que 5% seulement des nécessitent un geste sur les voies aériennes, il s'agit d'un point fondamental en matière de réduction de morts indues.

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STUDY OBJECTIVE:

In 2012, the Israel Defense Forces Medical Corps (IDF-MC) set a goal of reducing mortality and eliminating preventable death on the battlefield. A force buildup plan entitled "My Brother's Keeper" was launched addressing: trauma medicine, training, change of Clinical Practice Guidelines (CPGs), injury prevention, data collection, global collaboration and more. The aim of this article is to examine how military medical carehas evolved due "My Brother's Keeper" between Second Lebanon War (SLW, 2006) to Operation Protective Edge (OPE, 2014).

METHODS:

Records of all casualties during OPE and SLW were extracted and analyzed from the I.D.F Trauma Registry. Noncombat injuries and civilian injuries from missile attacks were excluded from this analysis.

RESULTS:

The plans main impacts were; incorporation of a physician or paramedic as an integral part of each fighting company, implementation of new CPGs, introduction of new approaches for extremity haemorrhage control and Remote Damage Control Resuscitation at point of injury (POI) using single donor reconstituted freeze dried plasma (25 casualties) and transexamic acid (98 casualties). During OPE, 704 soldiers sustained injuries compared with 833 casualties during SLW. Fatalities were 65 and 119, respectively, cumulating to Case Fatality Rate of 9.2% and 14.3%, respectively.

CONCLUSIONS:

Significant changes in the way the IDF-MC provides combat casualty care have been made in recent years. It is the transformation from concept to doctrine and integration into a structured and Goal-Oriented Casualty Care System, especially POI care that led to the unprecedented survival rates in IDF as shown in this conflict.

| Tags : airway

18/12/2015

Ejector ventilator: Quésaco ?

Ventrain: an ejector ventilator for emergency use

Hamaekers AE et Al. Br J Anaesth. 2012 Jun;108(6):1017-21

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La ventilation sur cathéter de coniotomie n'est pas chose aisée du fait de l'importance des résistances à l'écoulement des gaz dans un cathéter de petit diamètre. On considère que sans dispositif d'injection de type manujet, il faut un cathéter d'au moins 4 mm pour assurer un minimum acceptable. Certains ont proposé d'avoir recours à une expiration active. Il s'agissait de dispositifs expérimentaux. Ce n'est pas le cas du Ventrain qui apparaît être un produit abouti. A suivre

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The Use of Ventrain from Ventinova Medical BV on Vimeo.

| Tags : coniotomie

12/11/2015

IOT: Affaire de tous et pas de spécialiste

A review of pre-admission advanced airway management in combat casualties, Helmand Province 2013

Pugh HEJ, et al. J R Army Med Corps 2014;0:1–6. doi:10.1136/jramc-2014-000271

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Parmi les enjeux de la médicalisation de l'avant, ou en d'autres termes du prolonged field care, il y a la maîtrise de la gestion des voies aériennes, notamment l'intubation et la coniotome. Ce document qui analyse tous les blessés ayant bénéficié d'une manoeuvre avancée avant leur prise en charge au role 3 de Camp Bastion.Très clairement la prise en charge des blessés par des personnels expert de part leur emploi en UK permet l'obtention de 100 % de réussite alors que ce geste conduit par les équipes US n'atteint un taux de succès que de 64%. Les équipes UK n'ont pas eu besoin d'avoir recours à la coniotomie. Cette dernière est réalisée à 14 reprises par les équipes US avec 1 seul échec vrai. Les vraies complications étaient une intubation sélective à 3 reprises et un placement oesophagien. Notons la place relativement restreinte du tube laryngé de King. Une fois de plus il faut insister sur la nécessité de maîtrise de l'abord trachéal par tout personnel médical. Alors si cette éventualité n'est pas fréquente, les conditions actuelles avec les éloignements et la durée des MEDEVAC font qu'acquérir et entretenir cette maîtrise  est fondamental et que chacun soit conscient de cette nécessité. 

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Objectives

Airway compromise is the third leading cause of potentially preventable combat death. Pre-hospital airway management has lower success rates than in hospital. This study reviewed advanced airway management focusing on cricothyroidotomies and supraglottic airway devices in combat casualties prior to admission to a Role 3 Hospital in Afghanistan.


Methods

This was a retrospective review of all casualties who required advanced airway management prior to arrival at the Role 3 Hospital, Bastion, Helmand Province over a 30-week period identified by the US Joint Theatre Trauma Registry. The notes and relevant X-rays were analysed. The opinions of US and UK clinical Subject Matter Experts (SME) were then sought.

Results

Fifty-seven advanced airway interventions were identified. 45 casualties had attempted intubations, 37 (82%) were successful and of those who had failed intubations, one had a King LT Airway (supraglottic device) and seven had a rescue cricothyroidotomy. The other initial advanced airway interventions were five attempted King LT airways and seven attempted cricothyroidotomies. In total, 14 cricothyroidotomies were performed; in this group, there were nine complications/significant events.

Intubation.jpg


Conclusions

The SMEs suggested that dedicated surgical airway kits should be used and students in training should be taught to secure the cricothyroidotomy tube as well as how to insert it. This review re-emphasises the need to "ensure the right person, with the right equipment and the right training, is present at the right time if we are to improve the survival of patients with airway compromise on the battlefield".

| Tags : airway

30/10/2015

Coniotomie: l'insertion de la canule !

 

Crico Rotation Canule.png

L'insertion de la canule lors d'une coniotomie chirurgical est simple si l'orifice créé est suffisamment large ET si les élements suivants sont respectés:

1.           Présenter la canule à 90°

2.           Enfoncer la canule de telle sorte que le ballonet ne soit presque plus visible.

3 et 4. .  Réaliser une rotation de la canule tout en l'enfonçant dans la trachée

5.           Enfoncer la sonde jusqu'à la garde

Cliquer sur l'image pour voir le geste 

(Attention la technique utiliser pour créer l'orifice est celle de la Four Step Cricothyrotomy)

 

 

| Tags : coniotomie

12/09/2015

Abord trachéal: Point sur l'équipement

Equipment and strategies for emergency tracheal access in the adult patient

Hamaekers AE et Al; Anaesthesia, 2011, 66 (Suppl. 2), pages 65–80

 

The inability to maintain oxygenation by non-invasive means is one of the most pressing emergencies in anaesthesia and emergency care. To prevent hypoxic brain damage and death in a ‘cannot intubate, cannot oxygenate’ situation, emergency percutaneous airway access must be performed immediately. Even though this emergency is rare, every anaesthetist should be capable of performing an emergency percutaneous airway as the situation may arise unexpectedly. Clear knowledge of the anatomy and the insertion technique, and repeated skill training are essential to ensure completion of this procedure rapidly and successfully. Various techniques have been described for emergency oxygenation and several commercial emergency cricothyroidotomy sets are available. There is, however, no consensus on the best technique or device. As each has its limitations, it is recommended that all anaesthetists are skilled in more than one technique of emergency percutaneous airway. Avoiding delay in initiating rescue techniques is at least as important as choice of device in determining outcome.

| Tags : airway

Ouvrir un cou: Le doigt est important +++



| Tags : coniotomie

12/08/2015

Airway: Pratiques UK en Helmand

A review of pre-admission advanced airway management in combat casualties, Helmand Province 2013

Pugh HE et Al. J R Army Med Corps. 2015 Jun;161(2):121-6.

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Il faut savoir intuber et ouvrir un cou. Ce qui fait la médicalisation de l'avant n'est pas la présence d'un docteur  en médecine mais d'un professionnel de santé ayant la pratique de gestes de réanimation préhospitalière et capable de les mettre en oeuvre de faon opportune. La gestion des voies aériennes en est l'exemple. 

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OBJECTIVES:

Airway compromise is the third leading cause of potentially preventable combat death. Pre-hospital airway management has lower success rates than in hospital. This study reviewed advanced airway management focusing on cricothyroidotomies and supraglottic airway devices in combat casualties prior to admission to a Role 3 Hospital in Afghanistan.

METHODS:

This was a retrospective review of all casualties who required advanced airway management prior to arrival at the Role 3 Hospital, Bastion, Helmand Province over a 30-week period identified by the US Joint Theatre Trauma Registry. The notes and relevant X-rays were analysed. The opinions of US and UK clinical Subject Matter Experts (SME) were then sought.

RESULTS:

Fifty-seven advanced airway interventions were identified. 45 casualties had attempted intubations, 37 (82%) were successful and of those who had failed intubations, one had a King LT Airway (supraglottic device) and seven had a rescue cricothyroidotomy. The other initial advanced airway interventions were five attempted King LT airways and seven attempted cricothyroidotomies. In total, 14 cricothyroidotomies were performed; in this group, there were nine complications/significant events.

airwayway

CONCLUSIONS:

The SMEs suggested that dedicated surgical airway kits should be used and students in training should be taught to secure the cricothyroidotomy tube as well as how to insert it. This review re-emphasises the need to 'ensure the right person, with the right equipment and the right training, is present at the right time if we are to improve the survival of patients with airway compromise on the battlefield'. The audit reference number is RCDM/Res/Audit/1036/12/0368.

| Tags : airway

24/07/2015

Crico: Plutôt avec une canule à ballonet

The Efficacy of Spontaneous and Controlled Ventilation With Various Cricothyrotomy Devices: A Quantitative In Vitro Assessment in a Model Lung

Michalek-Sauberer M et Al. J Trauma. 2011;71: 886 – 892

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La procédure du sauvetage au combat indique la réalisation d'une coniotomie en cas d'obstruction des voies aériennes. Le minitrach portex II doit être considéré plutôt comme un dispositif d'oxygénation. En effet il est rarissime que les obstructions soient complètes. Dans de telles conditions les fuites sont telle qu'une ventilation effective n'est pas possible sauf à utiliser un dispositif de jet ventilation de type manujet. L'article présenté exprime très bien les limites des dispositifs sans ballonet

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Background:

Guidelines for the management of a difficult airway recommend performing a cricothyrotomy in a “can’t intubate/can’t ventilate” situation. We investigated the tidal volumes delivered by controlled and spontaneous ventilation by seven commercially available cricothyrotomy sets (cuffed: Quicktrach II, Portex Cricothyroidotomy Kit, and Melker cuffed cannula and uncuffed: Airfree, 4.0-mm ID Quicktrach, 6.0-mm inner diameter Melker, and 13-gauge Ravussin cannula) and two improvised devices (14-gauge intravenous cannula and spike and drip chamber device).

Methods:

A LS800 model lung, set at different values for compliance and resistance and modified with different upper airway diameter, was ventilated via the respective cricothyrotomy device mechanically and using a selfinflating bag. With the 13-gauge Ravussin cannula and the 14-gauge intravenous cannula, a Manujet injector was used for jet ventilation. Spontaneous ventilation was simulated with a Michigan 560i lung.

Results:

During controlled or manual ventilation, all cuffed cricothyrotomy devices yielded adequate tidal volumes. Uncuffed devices provided tidal volumes 300 mL only with an upper airway diameter of 3 mm. With a Manujet injector, adequate tidal volumes required an upper airway diameter between 3 mm and 5 mm. A spike and drip chamber device does not provide suitable emergency airway access. Spontaneous ventilation at adequate inspiratory pressure levels required a device inner diameter of at least 4 mm.

 

 

ConioVentilationVariousDevices.jpgConclusion:

As expected, cuffed cricothyrotomy devices yield the best results during controlled, manual, and spontaneous ventilation. With uncuffed cricothyrotomy devices, ventilation becomes ineffective when the upper airway obstruction allows for an upper airway diameter 3 mm.

 

| Tags : coniotomie, airway

03/07/2015

Coniotomie: improviser ?

coniotomie.jpg

| Tags : coniotomie

22/06/2015

Coniotomie: Pas si simple à enseigner

 Cricothyroidotomy Bottom–Up Training Review: Battlefield Lessons Learned

Benett BL et Al. Military Medicine, 176, 11:1311, 2011 

Challenges with surgical cricothyroidotomy on the battlefi eld can be attributed to limited frequency of use, procedure unfamiliarity, and limited knowledge base of anatomical landmarks of which is further heighten in the tactical environment. The objective was to identify ways to enhance the cricothyroidotomy training to minimize potential preventable procedural errors. A training review was conducted to determine the gaps in the cricothyroidotomy training in a 4-day Tactical Combat Casualty Care course at the Naval Medical Center Portsmouth. An ad hoc Working Group team identified five specific gap areas in the cricothyroidotomy training: 1) limited gross airway anatomy review; 2) lack of “hands-on” human laryngeal anatomy; 3) nonstandardized step-by-step surgical incision skill procedure; 4) inferior standards for anatomically correct cricothyroid mannequins; 5) lack of standardized refresher training frequency. Specific training enhancements are recommended across each day in the classroom, simulation laboratory, and field exercise. 

| Tags : coniotomie, airway

20/06/2015

Coniotomie sur le terrain: La vraie vie

An analysis of battlefield cricothyrotomy in Iraq and Afghanistan

J Spec Oper Med. 2012 Spring;12(1):17-23

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Pouvoir oxygéner est fondamental. Mais il existe de très nombreuses situations où l'oxygénation par masque ou ballon n'est pas possible ou insuffisante. Il faut alors contrôler les voies aériennes, en particulier la la réalisation d'une coniotomie (1). Ce travail est un des rares actuellement publiés qui fasse le point sur la réalisation de ce geste en conditions de combat (2,3,). Il met en avant la réalité de sa réalisation y compris par les medic, qui ont cependant un taux d'échec double de celui des médecins. Il suggère également tout l'intérêt des ateliers de formation et de séjours au bloc opératoire pour améliorer cet état de fait.

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OBJECTIVES:

Historical review of modern military conflicts suggests that airway compromise accounts for 1,2% of total combat fatalities. This study examines the specific intervention of pre-hospital cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls. The goal of this paper is to help define optimal airway management strategies, tools and techniques for use in the military pre-hospital setting.

METHODS:

This retrospective chart review examined all patients presenting to combat support hospitals following prehospital cricothyrotomy during combat operations in Iraq and Afghanistan during a 22-month period. A PC was determined successful if it was documented as functional on arrival to the hospital. All PC complications that were documented in the patient's record were also noted in the review.

RESULTS:

Two thirds of the patients died. The most common injuries were caused by explosions, followed by gunshot wounds (GSW) and blunt trauma. Eighty-two percent of the casualties had injures to face, neck or head. Those injured by gunshot wounds to the head or thorax all died. The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Pre-hospital cricothyrotomy was documented as successful in 68% of the cases while 26% of the PCs failed to cannulate the trachea. In 6% of cases the patient was pronounced dead on arrival without documentation of PC function. The majority of PCs (62%) were performed by combat medics at the point of injury. Physicians and physician assistants (PA) were more successful performing PC than medics with a 15% versus a 33% failure rate. Complications were not significantly different than those found in civilian PC studies, including incorrect anatomic placement, excessive bleeding, air leak and right main stem placement.

CONCLUSIONS:

The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC. However the failure rate for military medics is three to five times higher than comparable civilian studies. Further study is required to define the optimal equipment, technique, and training required for combat medics to master this infrequently performed but lifesaving procedure.

04/04/2015

Crico: Pour en savoir plus en 5 min ?

Large-bore cricothyroidotomy devices

Patel B. et Al. Contin Educ Anaesth Crit Care Pain(2008) (5): 157-160

 

L'article proposé fait une revue simple des divers équipements permettant la réalisation d'une coniotomie. Il apporte par ailleurs quelques compléments d'informations sur les facteurs de réussite de cette pratique dont l'éventualité d'occurrence est faible mais à laquelle il faut se préparer.

| Tags : coniotomie

23/11/2014

Coniotomie: Quel diamètre ?

Morphometric analysis and clinical application of the working dimensions of cricothyroid membrane in south Indian adults: With special relevance to surgical cricothyroidotomy

 Prithishkumar IJ et Al. Emergency Medicine Australasia (2010) 22, 13–20

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L'anatomie de la membrane cricoïdienne fait l'objet de nombreuses description. Un des intérêts de ces dernières est de préciser la taille de cette dernière et d'en déduire le diamètre de canule/sonde le plus adapté pour une insertion intratrachéale. Il existe de grandes variations selon les populations étudiées, ici indienne. On peut retenir pour  notre population militaire essentiellement masculine une hauteur de  6 mm pour une largeur de 8 mm. C'est pourquoi la taille maximale des canules insérées à ce niveau ne doit excéder ces dimensions.

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Objective: To measure the working dimensions of the cricothyroid membrane in the adult south Indian population and to establish the association between the working dimensions and the appropriate endotracheal tube size for the purpose of cricothyroidotomy.

Methods: Cross-sectional evaluation of 50 fresh adult autopsy cases (35 men, 15 women) in a medical university teaching hospital in South India.

Results: Age ranged from 17.0 to 83.0 years. Working dimensions of the membrane in neutral position of neck, in men: width = 8.41  2.11 mm, height = 6.57  1.87 mm; in women: width = 6.30  1.29 mm, height = 5.80  1.56 mm. Depth of the subglottic larynx at the level of cricoid cartilage: men = 20.73  1.97 mm, women = 15.62  1.71 mm. Distance of the lower border of cricothyroid membrane from suprasternal notch in neutral position of neck, in men = 5.18  1.76 cm, women = 4.72  1.55 cm; in passively extended neck, men = 7.86  1.25 cm, women = 8.05  1.28 cm. Regression equations have been derived to determine endotracheal tube size for cricothyroidotomy, based on distance between sternal  notch and chin, and height of the individual (P < 0.05).

CricoSize.jpeg

Conclusions: Working dimensions are smaller in the Indian group compared with western publications. Endotracheal tubes ranging from size 3.0 to 6.0 might be used for cricothyroidotomy in the adult south Indian population. 

| Tags : coniotomie, airway

21/11/2014

Simuler 1 fois par an: Suffisant ?

Complex procedural skills are retained for a minimum of 1 yr after a single high-fidelity simulation training session

Boet S.et All. Br. J. Anaesth. (2011) 107 (4): 533-539

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Certaines procédures de mise en condition de survie sont rarement réalisées en conditions réelles. Pourtant leur maîtrise par le personnel qui intervient doit être acquise. Se pose dès lors le problème de l'acquisition et du maintien de ces compétences techniques. la simulation est un moyen d'y parvenir.  La coniotomie fait partie des ces gestes. Récemment il a été mis en avant que 5 réalisations simulées par des professionnels de l'urgence permettaient d'obtenir une relative maîtrise techniqe mais que cette dernière ne se maintenait pas au delà de  6 mois. (1). Le travail présenté confirme ces données.

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Background. Simulation has been shown to be effective in teaching complex emergency procedural skills. However, the retention of these skills for a period of up to 1 yr has not been studied. We aimed to investigate the 6 month and 1 yr retention of the complex procedural skill of cricothyroidotomy in attending anaesthetists using a high-fidelitysimulated cannot intubate, cannot ventilate (CICV) scenario.

Methods. Thirty-eight attending anaesthetists participated individually in a high-fidelitysimulated CICV scenario (pretest) that required a cricothyroidotomy for definitive airway management. Immediately after a debriefing and structured teaching session on cricothyroidotomy insertion, subjects managed a second identical CICV scenario (posttest). Each anaesthetist was randomized to either a ‘6 month retention’ or a ‘12 month retention’ group. No further teaching occurred. At their respective retention times, each anaesthetist managed a third identical CICV scenario (retention post-test). Two blinded experts independently rated videos of all performances in a random order, using a specific checklist (CL) score, a global-rating scale (GRS) score, and procedural time (PT).

skillRetention.jpeg

Results. Subjects from both groups improved on their cricothyroidotomy skill performances from pretest to immediate post-test and from pretest to retention post-test, irrespective of the retention interval; CL mean (SD) 8.00 (2.39) vs 8.88 (1.53), P¼0.49; GRS 28.00 (7.80) vs 31.25 (5.31), P¼0.25; PT 102.83 (63.81) s vs 106.88 (36.68) s, P¼0.73.

Conclusions. After a single simulation training session, improvements in cricothyroidotomy skills are retained for at least 1 yr. These findings suggest that high-fidelity simulation training, along with practice and feedback, can be used to maintain complex procedural skills for at least 1 yr

| Tags : simulateurs

06/09/2014

Coniotomie: Comment en situation isolée ?

Optimizing Emergent Surgical Cricothyrotomy for use in Austere Environments.
 
Etre en capacité d'ouvrir le cou en cas d'instruction des voies aériennes est un savoir faire essentiel à la médicalisation de l'avant. Il n'est pas nécessaire de disposer de kit sophistiqué pour cela. une lame de bistouri de 20, un mandrin et une canule/sonde de 6 mm suffisent. C'est ce qu'exprime ce document. 
 
Emergent cricothyrotomy is an infrequently performed procedure used in the direst of circumstances on the most severely injured patients. Austere environments present further unique challenges to effective emergency medical practice. Recently, military trauma registry data were searched for the frequency of cricothyrotomy use and success rates during a 22-month period. These data revealed that cricothyrotomy performed in the most rigorous austere environment (ie, battlefield) had many successes, but also a large number of failed (33%) attempts by medics owing to many factors. Thus, the aim of this review article is to present what is known about cricothyrotomy and apply this knowledge to any austere environment for qualified providers. The National Library of Medicine’s PubMed was used to conduct a thorough search using the terms “prehospital,” “cricothyroidotomy,” “cricothyrotomy,” and “surgical airway.” The findings were further narrowed by applicability to the austere environment. This review presents relevant airway anatomy, incidences, indications, contraindications, procedures, and equipment, including improvised devices, success rates, complications, and training methods. Recommendations are proffered for ways to optimize procedures, equipment, and training for successful application of this emergent skill set in the austere environment.
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| Tags : airway, coniotomie