16/03/2023
Crico: Rare mais une des justifications de la médicalisation de l'avant.
Incidence of rescue surgical airways after attempted orotracheal intubation in the emergency department: A National Emergency Airway Registry (NEAR) Study
Offenbacher J. et Al. Am J Emerg Med. 2023 Feb 25;68:22-27.
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Il est fort probable qu'un médecin ou un infirmier militaire ne soit pas confronté à ce genre de situation. MAIS justement la présence d'un médecin ou d'un infirmier se justifie par la capacité à la réaliser. Il faut donc éviter de faire comme une autruche et ne pas se former et entretenir sa compétence en la matière.
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Background:
Cricothyrotomy is a critical technique for rescue of the failed airway in the emergency department (ED). Since the adoption of video laryngoscopy, the incidence of rescue surgical airways (those performed after at least one unsuccessful orotracheal or nasotracheal intubation attempt), and the circumstances where they are attempted, has not been characterized.
Objective:
We report the incidence and indications for rescue surgical airways using a multicenter observational registry.
Methods:
We performed a retrospective analysis of rescue surgical airways in subjects ≥14 years of age. We describe patient, clinician, airway management, and outcome variables.
Results:
Of 19,071 subjects in NEAR, 17,720 (92.9%) were ≥14 years old with at least one initial orotracheal or nasotracheal intubation attempt, 49 received a rescue surgical airway attempt, an incidence of 2.8 cases per 1000 (0.28% [95% confidence interval 0.21 to 0.37]). The median number of airway attempts prior to rescue surgical airways was 2 (interquartile range 1, 2). Twenty-five were in trauma victims (51.0% [36.5 to 65.4]), with neck trauma being the most common traumatic indication (n = 7, 14.3% [6.4 to 27.9]).
Conclusion:
Rescue surgical airways occurred infrequently in the ED (0.28% [0.21 to 0.37]), with approximately half performed due to a trauma indication. These results may have implications for surgical airway skill acquisition, maintenance, and experience.
| Tags : coniotomie
09/11/2022
Ouvrir le cou quand on ne voit rien
Definitive Management of a Traumatic Airway: Case Report
Fabich RA et Al. , MILITARY MEDICINE, 185, 1/2:e312, 2020
Maxillofacial and neck trauma from penetrating injuries present unique challenges for anesthesia providers and surgeons. In the austere conditions of a combat setting these challenges may be amplified due to limited resources and injury severity. Currently there is a lack of evidence and consensus on how to best manage a traumatized airway in this situation. The authors of this paper present the successful emergency management of a traumatized airway from a severe maxillofacial and neck-penetrating wound. A stepwise team approach using strong communication and a global mental model facilitated definitive airway management in this case allowing for safe transport to definitive care.
| Tags : coniotomie
28/06/2022
Coniotomie guidée par bougie
| Tags : coniotomie
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
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.
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
05/10/2018
Conio: Echo, cela se confirme
Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial.
BACKGROUND: Success of a cricothyrotomy is dependent on accurate identification of the cricothyroid membrane. The objective of this study was to compare the accuracy of ultrasonography versus external palpation in localizing the cricothyroid membrane.
METHODS:
In total, 223 subjects with abnormal neck anatomy who were scheduled for neck computed-tomography scan at University Health Network hospitals in Toronto, Canada, were randomized into two groups: external palpation and ultrasound. The localization points of the cricothyroid membrane determined by ultrasonography or external palpation were compared to the reference midpoint (computed-tomography point) of the cricothyroid membrane by a radiologist who was blinded to group allocation. Primary outcome was the accuracy in identification of the cricothyroid membrane, which was measured by digital ruler in millimeters from the computed-tomography point to the ultrasound point or external-palpation point. Success was defined as the proportion of accurate attempts within a 5-mm distance from the computed-tomography point to the ultrasound point or external-palpation point.
RESULTS:
The percentage of accurate attempts was 10-fold greater in the ultrasound than external-palpation group (81% vs. 8%; 95% CI, 63.6 to 81.3%; P < 0.0001). The mean (SD) distance measured from the external-palpation to computed-tomography point was five-fold greater than the ultrasound to the computed-tomography point (16.6 ± 7.5 vs. 3.4 ± 3.3 mm; 95% CI, 11.67 to 14.70; P < 0.0001).
Analysis demonstrated that the risk ratio of inaccurate localization of the cricothyroid membrane was 9.14-fold greater with the external palpation than with the ultrasound (P < 0.0001). There were no adverse events observed.
CONCLUSIONS:
In subjects with poorly defined neck landmarks, ultrasonography is more accurate than external palpation in localizing the cricothyroid membrane.
| Tags : airway, coniotomie
30/09/2018
US: Mieux que la main pour la conio
A multicentre prospective cohort study of the accuracy of conventional landmark technique for cricoid localisation using ultrasound scanning
Cricoid pressure is employed during rapid sequence induction to reduce the risk of pulmonary aspiration. Correct application of cricoid pressure depends on knowledge of neck anatomy and precise identification of surface landmarks. Inaccurate localisation of the cricoid cartilage during rapid sequence induction risks incomplete oesophageal occlusion, with potential for pulmonary aspiration of gastric contents. It may also compromise the laryngeal view for the anaesthetist. Accurate localisation of the cricoid cartilage therefore has relevance for the safe conduct of rapid sequence induction.
We conducted a multicentre, prospective cohort study to determine the accuracy of cricoid cartilage identification in 100 patients. The cranio‐caudal midpoint of the cricoid cartilage was identified by a qualified anaesthetic assistant using the conventional landmark technique and marked. While maintaining the patient in the same position, a second mark was made by identifying the midpoint of the cricoid cartilage using ultrasound scanning.
The mean (SD) distance between the two marks was 2.07 (8.49) mm. In 41% of patients the midpoint was incorrectly identified by a margin greater than 5 mm. This error was uniformly distributed both above and below the midpoint of the cricoid cartilage. The Pearson correlation coefficient of this error with respect to body mass index was 0.062 (p = 0.539) and with age was −0.020 (p = 0.843). There were also no significant differences in error between male and female patients.
Identification of cricoid position using a landmark technique has a high degree of variability and has little correlation with age, sex or body mass index. These findings have significant implications for the safe application of cricoid pressure in the context of rapid sequence induction.
| Tags : airway, coniotomie
15/09/2018
Coniotomie: Ne pas endommager le mandrin
Front-of-neck access and bougie trapping
| Tags : airway, coniotomie
15/10/2017
RFE 2017 In/Extubation en anesthésie
Clic sur l'image pour accéder au document
| Tags : intubation, coniotomie, airway
25/10/2016
Coniotomie chirurgicale: Spécialiste ? Non, mais formé spécifiquement OUI
The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective.
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
22/09/2016
Crico: Quelques rappels qui font du bien
Evidence Is Important: Safety Considerations for Emergency Catheter Cricothyroidotomy
Marshall SD et Al. Acad Emerg Med. 2016 Sep;23(9):1074-6
Il existe un regain d'intérêt concernant la pratique de l'oxygénation après ponction de la membrane cricoÏdienne. De large débats portent sur la meilleure méthode à utiliser. En pratique il n'est pas inutile de rappeler quelques vérités pratiques. C'est ce que propose ce document dont la lecture est fort utile. Cliquez sur la référence pour accéder au document et ici pour accéder à des vidéos complémentaires
| Tags : coniotomie
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 !
Surgical Procedures in Trauma Management. New York, NY: Thieme Inc; 1986:303
| Tags : airway, coniotomie
30/01/2016
Coniotomie: Modèle porcin
A porcine model for teaching surgical cricothyridootomy
Netto FA et Al. Rev Col Bras Cir. 2015 Jun;42(3):193-6
Le matériel nécessaire
Le montage
Un gant fixé derrière la peau va simuler la membrane
Le simulateur prêt à l'emploi.
| Tags : coniotomie
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
22/11/2015
Paroi postérieure: Rester à l'écart
Cricothyroidotomy catheters: an investigation of mechanisms of failure and the effect of a novel intracatheter stylet
Hebbard PD et Al. Anaesthesia. 2015 Oct 28. doi: 10.1111/anae.13269
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L'étude NAP4 a mis en avance l'importance de maîtriser les techniques d'oxygénation transtrachéale et la cricothyrotomie. Il n'est pas étonnant que, dans les démarches d'entrainement et de recherche en gestion des situations de CICO, apparaissent des interrogations sur la survenue des complications liées à ces techniques. Les atteintes de la paroi postérieures sont l'une d'entre elles. Elles s'observent aussi lors de l'emploi de simple cathéter et peuvent déboucher sur des complications grave notamment lors d'emploi de techniques de jet ventilation. C'est ce que rapporte le document proposé. D'après ce document il semble que l'on puisse réduire ce risque en orientant l'aiguille à 45° dès sa pénétration dans la lumière trachéale.
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Emergency catheter cricothyroidotomy often fails. Case reports have concentrated on kinking and displacement of the catheter as the major causes. We investigated catheter tip penetration of the trachea. Using insertion angles of 90°, 75°, 60°, 45° and 30° we advanced 14 G intravenous catheters into fresh isolated sheep tracheas during high pressure oxygen insufflation. At all angles, the catheter tip became blocked by pushing into the mucosa with submucosal gas injection on one or more attempts. Full thickness rupture with extratracheal gas also occurred on insertions at 90° and 60°. We then tested a Luer-mounted prototype wire stylet which remains in situ during insufflation. Using the same methodology, the stylet was able to be placed and prevented blockage at all angles of insertion. Mucosal trauma and submucosal gas injection occurred on insertions at 90° and 75°. Our results should guide further stylet design.
| Tags : coniotomie
Coniotomie: D'abord chirurgicale
Evaluation of novel Surgicric cricothyroidotomy device
King W et Al. Anaesthesia. 2015 Nov 17. doi: 10.1111/anae.13275
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Ce travail est intéressant car il met en avant l'intérêt des techniques chirurgicales par rapport à une technique de référence qui est l'emploi du set de Melker et d'un nouveau kit: le Surgicric. Il montre également que la survenue de lésions de la paroi postérieure n'est pas une vue de l'esprit, cette complication étant la plus fréquente avec ce nouveau kit.
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A can't intubate, can't ventilate scenario can result in morbidity and death. Although a rare occurrence (1:50 000 general anaesthetics), it is crucial that anaesthetists maintain the skills necessary to perform cricothyroidotomy, and are well-equipped with appropriate tools. We undertook a bench study comparing a new device, Surgicric® , with two established techniques; the Melker Emergency Cricothyroidotomy, and a surgical technique. Twenty-five anaesthetists performed simulated emergency cricothyroidotomy on a porcine model, with the primary outcome measure being insertion time. Secondary outcomes included success rate, tracheal trauma and ease of use.
The surgical technique was fastest. The median (IQR [range]) was 81 (62-126 [37-300]) s, followed by the Melker 124 (100-217 [71-300]) s, and the Surgicric 127 (68-171 [43-300]), p = 0.003. The Surgicric device was the most traumatic, as evaluated by a blinded Ear, Nose and Throat surgeon. Subsequently, the authors contacted the device manufacturer, who has now modified the kit in the hope that its clinical application might be improved. Further studies are required to evaluate the revised model.
| Tags : airway, coniotomie
30/10/2015
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)
| Tags : coniotomie
12/09/2015
Ouvrir un cou: Le doigt est important +++
| Tags : coniotomie