Emergency Cricothyroidotomy: A Randomized Crossover Trial Comparing Percutaneous Techniques: Classic Needle First Versus “Incision First”
Academic Emergency Medicine 2012; 19:1061–1067
Emergency cricothyroidotomy is potentially lifesaving in patients with airway compromise who cannot be intubated, ventilated or oxygenated by conventional means. According to the authors, the literature remains divided on the best insertion technique, namely, the open/surgical and percutaneous methods. The two are not mutually exclusive, and the study hypothesis was that an “incision-first” modification (IF) may improve the traditional needle-first (NF) percutaneous approach. This study assessed the IF technique compared to the NF method. While the study is not associated with paramedics or pre-hospital emergency care, the skill of cricothyroidotomy is one performed by paramedics and the identification of the most appropriate approach should be of interest.
A randomised controlled crossover design with concealed allocation was completed for 180 simulated tracheal models. Attending and resident emergency physicians were enrolled. The primary outcome was time to successful cannulation; secondary outcomes included needle insertion(s), incision, and dilatation attempts. Finally, proportions of intratracheal insertion on the first attempt and subjective ease of insertion were compared.
The IF technique was significantly faster than the standard NF technique (median = 53 seconds, interquartile range [IQR] = 45.0 to 86.4 seconds vs. median = 90 seconds, IQR = 55.2 to 108.6 seconds; p < 0.001). The median number of needle insertions was significantly higher for the NF technique (p = 0.018); there was no significant difference in dilation or incision attempts. Intratracheal insertion on the first attempt was documented in 90 and 93% of the NF and IF techniques, respectively (p = 0.317). All the study participants found the IF hybrid approach easier.
The IF modification allows faster access, fewer complications, and more favorable clinician endorsement than the classic NF percutaneous technique in a validated model of cricothyroidotomy. The authors suggest therefore that the IF technique be considered as an improved method for insertion of an emergency cricothyroidotomy. This study, however, was performed on simulated tracheal models with attending and resident emergency physicians. As cricothyroidotomy is often a ‘once in a career’ procedure for the average paramedic it could be interesting to compare the two procedures for pre-hospital providers. Paramedics who do not regularly undertake the skill may find the increased confidence of performing NF cricothyroidotomy first the easier approach in a stressful situation.
http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2012.01436.x/abstract