Seldinger vs Surgical Approach to Emergency Cricothyroidotomy in Cadaver Models

Abstract & Commentary

Commentary by Michael Gibbs, MD, FACEP, Chief, Department of Emergency Medicine, Maine Medical Center, Portland. Dr. Gibbs is on the Editorial Board of Emergency Medicine Alert.

Source: Schaumann N, et al. Evaluation of Seldinger technique: Emergency cricothyroidotomy versus standard surgical cricothyroidotomy in 200 cadavers. Anesthesiology 2005; 102:7-11.

The purpose of this study was to compare the proficiency of emergency physicians (EPs) in the performance of Seldinger and surgical approaches to cricothyroidotomy using a human cadaver model. Twenty novice EPs completed a standardized 30-minute didactic training session. During the subsequent four months, participants performed each procedure five times in random order. Outcome measurement included three time intervals (i.e., time to location of the cricothyroid membrane [CTM]; time to tracheal puncture and tube insertion; and time to first ventilation), successful tube placement, and the presence or absence of injuries to airway structures upon post-procedure anatomic dissection.

The results in 13 cadavers were excluded because of incomplete data. The airway was placed accurately in 82 of 93 cases (88%) in the Seldinger group, and in 79 of 94 cases (84%) in the surgical group. Time to location of the CTM was not significantly different between groups (7.9 ± 11 sec Seldinger; 8.2 ± 9.7 sec surgical [p = NS]). Time to tracheal puncture was significantly longer in the surgical group (98.7 ± 58.3 sec Seldinger; 119.2 ± 61.2 sec surgical [p < 0.01]), as was the time to first ventilation (108.6 ± 59.5 sec Seldinger; 136 ± 66.3 sec surgical [p < 0.001]). The procedure was aborted seven times in the Seldinger group due to kinking of the wire and six times in the surgical group due to inability to advance the tube.

No injuries were observed in the Seldinger group; there were six punctures of the thyroid vessels among those using the surgical approach.

Commentary

Acknowledging the limitations of a cadaver model, this is the largest investigation to date examining the success rates and complications of Seldinger vs surgical cricothyroidotomy. Although EPs in this study were able to perform the Seldinger technique more rapidly, with comparable success rates and less injury to the airway, I believe it is our responsibility as experts in airway management to become proficient with both techniques. We should take advantage of every training opportunity available to us to achieve this goal. In clinical practice, the performance of an emergency surgical cricothyroidotomy is unfortunately not likely to be a one-technique-fits-all experience. Remember, the last box on every failed airway algorithm ever published says the same thing: surgical airway.