Cricothyrotomy Education QI Project 2016-17 Ben Abrams Justin Merkow Julius Ngaile Maung HlainG Tony Oliva

Outline Background Fishbone and Smart Aim Intervention PDSA cycle Conclusions Future considerations

Background “Can’t intubate, can’t ventilate” scenario is one of the most common causes of morbidity and mortality in anesthesia Percutaneous Emergency Cricothyrotomy (PEC) is a rarely performed but potentially life saving procedure in these situations Studies have shown high failure rate, prolonged procedure time, and significant complications during PEC attempts with devastating consequences Correct identification of the CTM found to be less 50% among both anesthesiologists and surgeons in one study UK registry of airway complications found greater than 60% failure rate of PEC (100% failure in ED) -According to the Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (NAP4), emergency percutaneous airway occurs in 1/12,500-50,000 general anesthetics -failure to correctly identify the CTM is a common cause of failure

Background Common complications include: Failure Injury to posterior tracheal wall Penetration into the esophagus Injury to thyroid/cricoid cartilage Significant improvement in both success rate and speed has been shown with training and simulation By the 5th attempt during simulation study, 96% (n = 102) of participants performed successful PEC in <40 seconds Just 5 attempts needed to reach successful plateau in performing cric

Fishbone Individual/staff Factors: -Rushed -Stressed -Untrained -Likely first time performed on real patient (possibly first time opening the kit) Fishbone Team Factors: -Effective teamwork impossible with poor understanding of procedure -Multiple teams possibly involved -Unclear tasks/ responsibilities Patient Factors: -Unanticipated difficult airway -Emergency -In extremis -Not cooperative/responsive -Impatient -Difficult -Complex patient (delay/unpredictable timing) Communication Factors: -Communication breakdown in emergency -Likely many people in room, noise -Limited time to communicate -Difficult to communicate if unfamiliar with procedure   Problem or issue (CDP/SDP) Task Factors: -Limited time -High stakes scenario -People involved (docs, nurses, respiratory) likely unfamiliar with procedure Anesthesia providers unprepared to reliably perform needle cricothyrotomy. Education/Training Factors: -Minimal training/ simulation -Difficult to simulate real life situation - Academic institution  ENT/General surgery always available Working Condition Factors: -High pressure/stakes environment -High stress -Emergency, participants likely unprepared Equipment/ Resources: -Limited access to training -Lack of familiarity with equipment Organizational, Strategic Factors: -Algorithm, surgical vs. needle cric -Who to perform (ENT, anesthesia, gen surg, ED) -Where to perform 

SMART aim Provider knowledge/skills Provider confidence Goal: to improve anesthesia provider knowledge and skills with respect to performing cricothyrotomy, including knowledge of anatomy, procedure kit contents, and proper technique Provider confidence Goal: to improve confidence with performing cricothyrotomy to prevent delays in intervention and decrease provider stress  increase likelihood of timely, successful cricothyrotomy

Intervention Pre-test/survey Education Post-test/survey

Q1: Have you ever performed a cricothyrotomy? Answered: 121 Skipped: 0

Q2: Have you received formal training in proper cricothyrotomy technique at any point in your career? Answered: 121 Skipped: 0

Q3: Would you feel comfortable performing a cricothyrotomy in an emergency? Answered: 121 Skipped: 0

Q4: Cricothyrotomy always involves a “cut down” technique with a scalpel. Answered: 121 Skipped: 0

Education

Education Here we describe the Seldinger technique for cricothyrotomy (aka Melker cricothyrotomy), as recommended for anesthesia providers over the traditional surgical cut down technique (also refer to diagrams below): 1. Identify the cricothyroid membrane: - located between the prominent thyroid cartilage superiorly (“Adam’s Apple”) and the cricoid cartilage inferiorly - for difficult anatomy (e.g. obesity), the typical adult cricothyroid membrane is roughly four finger breadths above the sternal notch - an ultrasound with a linear probe can also be useful for identifying difficult anatomy 2. Insert the 18-gauge over-the-needle catheter into the skin at the level of the cricothyroid membrane with the syringe attached to the needle. While maintaining negative pressure on the syringe, advance the needle at a 45 degree angle until air is aspirated. At this point, the needle tip has entered the airway. - it may be useful to fill the syringe with saline, as bubbles will appear in the fluid upon entry into the airway Advance the catheter over the needle, and then remove the needle. - similar technique to placement of an intravenous catheter 4. Thread the guidewire through the catheter into the airway, then remove the catheter. 5. Make a small skin incision at the point of wire entry. - this should be a small skin nick, similar to central line placement - the scalpel should NOT be used to dissect down to the airway 6. With the dilator inside the airway catheter, advance the entire apparatus over the wire until the airway hub is flush with the skin. Then remove the wire and dilator, inflate the cuff, and confirm placement in the airway.

Q5: Having reviewed the above material, would you feel more comfortable performing a cricothyrotomy in an emergency? Answered: 112 Skipped: 9

Q6: A cricothyrotomy does not require a surgical cut down, and can instead be performed using a Seldinger technique over a wire. Answered: 111 Skipped: 10

Q7: (optional) My current position in the department is: Answered: 107 Skipped: 14

PDSA Cycle

Conclusions Improved provider knowledge Improved provider confidence (Provider skills not assessed)

Future Considerations Cadaver lab Lamb trachea Jet ventilation cases Transtracheal approach

References 1. Helm M, Hossfeld B, Jost C, Lampl L, Bockers T. Emergency cricothyroidotomy performed by inexperienced clinicians--surgical technique versus indicator-guided puncture technique. Emerg Med J. 2013;30(8):646-9. 2. John B, Suri I, Hillermann C, Mendonca C. Comparison of cricothyroidotomy on manikin vs. simulator: a randomised cross-over study. Anaesthesia. 2007;62(10):1029-32. 3. Wong DT, Prabhu AJ, Coloma M, Imasogie N, Chung FF. What is the minimum training required for successful cricothyroidotomy?: a study in mannequins. Anesthesiology. 2003;98(2):349-53. 4. Hiller KN, Karni RJ, Cai C, Holcomb JB, Hagberg CA. Comparing success rates of anesthesia providers versus trauma surgeons in their use of palpation to identify the cricothyroid membrane in female subjects: a prospective observational study. Can J Anaesth. 2016;63(7):807-17. 5. Kanji H, Thirsk W, Dong S, Szava-Kovats M, Villa-Roel C, Singh M, et al. Emergency cricothyroidotomy: a randomized crossover trial comparing percutaneous techniques: classic needle first versus "incision first". Acad Emerg Med. 2012;19(9):E1061-7. 6. Cook TM, Woodall N, Frerk C, Fourth National Audit P. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617-31.