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.

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".

Coniotomie: l'insertion de la canule !

 

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)

 

 

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.

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.

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.

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.

 

 

Conclusion:

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.

 

Coniotomie: improviser ?

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. 

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.

Crico: Pour en savoir plus en 5 min ?

Large-bore cricothyroidotomy devices

Patel B. et Al. Contin Educ Anaesth Crit Care Pain(2008) 8 (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.

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).

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. 

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).

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

Coniotomie: Comment en situation isolée ?

Optimizing Emergent Surgical Cricothyrotomy for use in Austere Environments.

Wilderness Environ Med. 2013 Mar;24(1):53-66 Hessert J et all.

 

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. 

 

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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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Clic sur l'image pour accéder à l'article

Maîtrise de la coniotomie en environnement austère: Une nécessité.

Optimizing Emergent Surgical Cricothyrotomy for use in Austere Environments

HessertMJ et Al. Wilderness Environ Med. 2013 Mar;24(1):53-66

" Although cricothyrotomy is becoming less common as other alternative airway devices are introduced, such as the laryngeal mask airway, King LT-D (King Systems Corp, Noblesville, IN), and other supraglottic devices, there is, and likely always will be, a role for cricothy- rotomy in a subsection of patients with difficult airways, especially in environments in which such devices are unlikely to be available. A common emergency medicine aphorism is: “If you do one cricothyrotomy, you’re a hero; if you do two, work on your airway skills.” True perhaps in a hospital, but in an austere environment many factors besides failed ET intubation lead to early cricothyrotomy. Wilderness providers must be not only technically skilled, but also adequately trained to recognize the key indications and situational decision triggers for cricothyrotomy that differ from in-hospital practice."

Rupture cricotrachéale: Que faire ?

Cricotracheal Separation after Gunshot to the Neck: Report of a Survivor with Recovery of Bilateral Vocal Fold Function.

Vivero RJ et Al. http://dx.doi.org/10.1016/j.jemermed.2013.08.090

Il s'agit d'une éventualité rarissime mais cette observation montre qu'en situation d'isolement extrême il peut être possible d'agir si la partie distale est visible. Encore faut il connaître l'existence de cette conduite à tenir.

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Initial appropriate airway management is imperative to improve survival. Numerous case reports in the literature demonstrate incidental findings of airway injury after routine workup of the patient or the advent of ominous clinical findings (1,2) . At this stage in patient management, it can become difficult to adequately secure the airway, which places the patient at increased risk. A careful physical examination is therefore critical, with fiberoptic laryngoscopy used, as necessary, in the stable patient. A CT scan can be a useful adjunct in the clinical workup, but it should not be relied upon solely, as it can be inconclusive (3) . When cricotracheal separation is identified and the patient is stable, the airway should be secured surgically in the operating room or trauma bay. The proximal stump of the airway should be grasped and secured with a clamp, and then an awake tracheotomy performed (under local anesthesia if possible) distal to the injury. In the event that the patient is unstable or that intubation fails, the distal stump of the trachea should be identified either visually or by palpation. The stump of trachea should then be grasped with a clamp and pulled superficially (out of the wound toward the skin surface), and an appropriately sized endotracheal tube is placed as a temporary measure and secured. The clamp should not be removed from the airway, as the distal tracheal stump can retract into the mediastinum. The patient should then be taken to the operating room emergently for formal tracheotomy or maturation of the airway tracheostoma. In general, cricothyrotomy should not be performed, as this is usually proximal to the site of airway separation.

Oxygénation transtrachéale de sauvetage

Viable oxygenation with cannula-overneedle cricothyrotomy for asphyxial airway occlusion

Kofke WA et Al. Br. J. Anaesth. (2011) 107 (4): 642-643.

Le recours à un cathéter veineux et une seringue pour la réalisation d'une coniotomie est souvent présenté comme un simple gadget.

Cette technique a été mise en oeuvre dans le cadre de la prise en charge d'un arrêt circulatoire dans un bloc opéatoire. L'usage d'un cathéter de 14g, d'une seringue de 3ml associé à l'application continue doxygène à une pression de 35 à 4O mmHg a permis la restauration d'une oxygénation suffisante contribuant ainsi au succès des  manoeuvres de prise en charge de l'arrêt circulatoires.

Le fait d'avoir à disposition une machine d'anesthésie permettant de générer une pression d'insufflation continue et élevée est certainement un élément essentiel à prendre en compte. Il n'est pas certain que ceci puisse être réalisé avec un BAVU sauf à bien obturer la valve notamment celle de surpression si elle existe. 

Coniotomie: Chirurgicale avec un mandrin

Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists

Nakstad et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:59

Background: A large number of techniques and devices for cricothyroidotomy have been developed. In this study, the Portex™ Cricothyroidotomy Kit (PCK, Smiths Medical Ltd, Hythe, UK) was compared with the bougie assisted emergency surgical cricothyrotomy technique (BACT).

Methods: Twenty air ambulance anaesthesiologists performed emergency cricothyrotomy on a cadaveric porcine airway model using both PCK and BACT. Baseline performance and performance after the intensive training package were recorded. Success rate, time to secured airway and tracheal damage were the primary endpoints, and confidence rating was a secondary endpoint.

Results: During baseline testing, success rates for PCK and BACT were 60% and 95%, respectively. Tracheal injury rate with PCK was 60% while no such injury was found in BACT. A lecture was given and skills were trained until the participants were able to perform five consecutive successful procedures with both techniques. In the posttraining test, all participants were successful with either technique. The mean time to successful insertion was reduced by 15.7 seconds (from 36.3 seconds to 20.6 seconds, p< 0.001) for PCK and by 7.8 seconds (from 44.9 seconds to 37.1 seconds, p=0.021) for BACT. In the post-training scenario, securing the airway with PCK was significantly faster than with BACT (p<0.001). Post-training tracheal laceration occurred in six (30%) of the PCK procedures and in none of the BACT procedures (p=0.028). The self-evaluated confidence level was measured both pre- and post-training using a confidence scale with 10 indicating maximum amount of confidence. The median values increased from 4 to 8 for PCK and from 6.5 to 9.5 for BACT. All participants reported that BACT was their preferred technique.

Conclusions: Testing the base-line PCK skills of prehospital anaesthesiologists revealed low confidence, sub-optimal performance and a very high failure rate. The BACT technique demonstrated a significantly higher success rate and no tracheal damage. In spite of PCK being a significantly faster technique in the post-training test, the anaesthesiologists still reported a higher confidence in BACT. Limitations of the cadaveric porcine airway may have influenced this study because the airway did not challenge the clinicians with realistic tissue bleeding.

Coniotomie: On fait le point

Emergency cricothyrotomy - A systematic review 

Langvad F. et Al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013 21:43

Une revue exhaustive de ce qui est publié sur le sujet. Il en ressort qu'il n'existe pas vraiment d'avantages d'une technique sur une autre, qu'en condition extrême une technique chirurgicale semble préférable. Le point clé est l'expérience et l'entraînement de celui qui la réalise.

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Background: An emergency cricothyrotomy is the last-resort in most airway management protocols and is performed when it is not possible to intubate or ventilate a patient. This situation can rapidly prove fatal, making it important to identify the best method to establish a secure airway. We conducted a systematic review to identify whether there exists superiority between available commercial kits versus traditional surgical and needle techniques.

Methods: Medline, EMBASE and other databases were searched for pertinent studies. The inclusion criteria included manikin, animal and human studies and there were no restrictions regarding the professional background of the person performing the procedure.

Results: In total, 1,405 unique references were identified; 108 full text articles were retrieved; and 24 studies were included in the review. Studies comparing kits with one another or with various surgical and needle techniques were identified. The outcome measures included in this systematic review were success rate and time consumption. The investigators performing the studies had chosen unique combinations of starting and stopping points for time measurements, making comparisons between studies difficult and leading to many conflicting results. No single method was shown to be better than the others, but the size of the studies makes it impossible to draw firm conclusions.

Conclusions: The large majority of the studies were too small to demonstrate statistically significant differences, and the limited available evidence was of low or very low quality. That none of the techniques in these studies demonstrated better results than the others does not necessarily indicate that each is equally good, and these conclusions will likely change as new evidence becomes available

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Coniotomie: Un nouveau set

A Comparison of Two Open Surgical Cricothyroidotomy Techniques by Military Medics Using a Cadaver Model

Mabry RL et All., Ann EmergMed. 2013;-:1-5

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Le taux d'échec observé est d'environ 33%. Aussi est on toujours à la recherche de dispositifs d'aide à la réalisation de ce geste considéré comme essentiel. L'originalité du kit présenté ici tient à son guide qui a une forme particulière censée améliorer la performance des combat medics. Relisez la fiche technique de la coniotomie en sachant que vous pouvez vous servir du mandrin d'eschmann comme guide d'insertion si vous avez recours à la technique chirurgicale ce qui est recommandé.

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Study objective: The CricKey is a novel surgical cricothyroidotomy device combining the functions of a tracheal hook, stylet, dilator, and bougie incorporated with a Melker airway cannula. This study compares surgical cricothyroidotomy with standard open surgical versus CricKey technique.

Methods: This was a prospective crossover study using human cadaveric models. Participants included US Army combat medics credentialed at the emergency medical technician–basic level. After a brief anatomy review and demonstration, participants performed in random order standard open surgical cricothyroidotomy and CricKey surgical cricothyroidotomy. The primary outcome was first-pass success, and the secondary outcome measure was procedural time.

Results: First-attempt success was 100% (15/15) for CricKey surgical cricothyroidotomy and 66% (10/15) for open surgical cricothyroidotomy (odds ratio 16.0; 95% confidence interval 0.8 to 326). Surgical cricothyroidotomy insertion was faster for CricKey than open technique (34 versus 65 seconds; median time difference 28 seconds; 95% confidence interval 16 to 48 seconds).

Conclusion: Compared with the standard open surgical cricothyroidotomy technique, military medics demonstrated faster insertion with the CricKey. First-pass success was not significantly different between the techniques

Coniotomie: Avant tout de bons repères

La réalisation d'une coniotomie en conditions extrêmes n'est pas une chose si aisée que cela. Bien souvent l'opérateur peut être obnubilé par le fait de faire pénétrer un tuyau dans un trou alors que ce qui est important c'est le trou au bon endroit et de taille suffisamment large pour admettre le tuyau. Au final ce qui est FONDAMENTAL c'est donc de prendre ses repères et de vérifier le diamêtre de l'ouverture faite.

C'est ce qu'exprime ce document intéressant et très pratique dont l'un des auteurs est un des inventeurs d'une technqiue de trachéotomie percutanée.

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The first step of the ‘scalpel–finger–tube’ method is to stabilize the larynx with the non-dominant hand, identify the cricothyroid membrane visually and by palpation, and to incise horizontally all the way through skin and cricothyroid membrane into the laryngeal lumen in one motion (Fig. 1).

In the emergency situation, neither skin antiseptics nor local anaesthesia are used.Any suitable blade can be used, either on or off the handle. The incision is extended laterally until judgedlarge enough to accommodate the tip of the operator’s gloved little finger, that is, approximately 15 mm. The second step is to remove the scalpel and insert the tip of the operator’s little finger into the incision (Fig. 2), confirming by palpation that the incision has penetratedinto the laryngeal lumen, and that the incision is large enough to accommodate the finger, and therefore, an endotracheal tube.

Finally, in the third step, a cuffed oral endotracheal tube is fed through the hole into the trachea, directed somewhat caudally (Fig. 3)

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