Emergency Cricothyrotomy: Standard or Seldinger?

abstract & commentary

Source: Eisenburger P, et al. Comparison of conventional surgical versus Seldinger technique in emergency cricothyrotomy performed by inexperienced clinicians. Anesthesiology 2000;92:687-690.

The authors compared the first-time performance of surgical (group 1) vs. Seldinger technique (group 2) for cricothyrotomy. Twenty critical care physicians with significant prior intubating experience were randomized to perform each procedure on two adult human cadavers. None had ever performed a cricothyrotomy. Participants completed a 60-minute training session, reviewing the pertinent anatomy and the tools/steps required to complete each procedure. Both procedures were performed using standard methods previously described in the literature. Times to location of the cricothyroid membrane (CTM), tracheal puncture, and first ventilation were recorded. Each participant was allowed only one attempt per procedure.

Tracheal placement was successful for 70% of group 1 vs. 60% of group 2 (P = NS). Failure in group 1 resulted from unsuccessful attempts to locate the CTM (n = 1), abortion of the procedure due to incorrectly presumed esophageal placement (n = 1), and cannula misplacement (paratracheal = 1, esophageal = 1, subcutaneous = 2). Failure in group 2 resulted from kinking of the guide wire (n = 5) and cannula misplacement (paratracheal = 1, esophageal = 1, subcutaneous = 1). Time intervals (mean ± SD) were as follows: 7 ± 9 sec (group 1) vs. 8 ± 7 sec (group 2) for location of the CTM; 46 ± 37 sec (group 1) vs. 30 ± 28 sec (group 2) for tracheal puncture; and 102 ± 42 sec (group 1) vs. 100 ± 46 sec (group 2) for first ventilation. There was no statistical difference between groups for any of the time points measured.

Comment by michael a. gibbs, MD, facep

Rapid sequence intubation (RSI) is now the standard for emergency airway management. Success rates are high (97-99%), and surgical airway rescue is rarely required (0.5-2%).1-3 An inevitable consequence of successful RSI is that most emergency physicians will have very limited (if any) experience with surgical airway management. The introduction of other airway rescue devices (e.g., Combitube, laryngeal mask airway, retrograde intubation, lighted stylet) make the need for cricothyrotomy even less likely. Yet, the final pathway for all failed airway algorithms remains the surgical airway.

The results of this study bring out several important points. First, it is difficult to perform cricothyrotomy after didactic training alone. It is unrealistic to perform a life-saving procedure on a dying patient having only read about it in a textbook! Emergency physicians must seek out opportunities to perfect this crucial skill on realistic models (e.g., animal, human cadaver, post-mortem).

Second, the success rate of surgical and Seldinger cricothyrotomy is similarly unsatisfactory in inexperienced hands. Selecting one of the techniques and learning to perform it well is probably more important than which technique is chosen. Third, there is a significant risk of cannula misplacement with both techniques, and guide wire kinking is a common problem with the Seldinger technique.

The "cannot ventilate/cannot intubate" patient is the most feared clinical scenario in emergency medicine. All emergency physicians using neuromuscular blockade must become familiar with alternative airway rescue techniques, as well as cricothyrotomy, be it surgical or Seldinger.

References

1. Sakles JC, et al. Airway management in the emergency department: A one year study of 610 tracheal intubations. Ann Emerg Med 1998;31:398-400.

2. Tayal VS, et al. Rapid-sequence intubation at an emergency medicine residency: Success rates and adverse events during a two-year period. Acad Emerg Med 1999;6:31-37.

3. Walls RM, et al. 2,392 emergency department intubations: First report of the ongoing National Emergency Airway Registry Study (NEAR 97). Ann Emerg Med 1999;34:814 (abstract).

33. The most common reason for failed Seldinger cricothyrotomy is:

a. inability to locate the cricothyroid membrane.

b. placement of the cannula in the esophagus.

c. kinking of the guide wire.

d. excessive bleeding.