1. Emergency Cricothyrotomy: Comparing Four Methods Summary and Comment by Aaron E. Bair, MD, MSc, FAAEM, FACEP Published in Journal Watch Emergency Medicine October 24, 2008Journal Watch Emergency Medicine Pick a method and practice it! CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

2. Covering Dimitriadis JC and Paoloni R. Emergency cricothyroidotomy: A randomised crossover study of four methods. Anaesthesia 2008 Nov; 63:1204. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

3. Background Despite the advent of new devices and techniques for emergency airway management, cricothyrotomy remains an essential skill. However, opinions differ regarding the best way to achieve an emergency surgical airway. These authors compared time to ventilation, success rates, and user preference among four emergency cricothyrotomy techniques: percutaneous Minitrach II kit (not available in the U.S.), single-step trocar-based Quicktrach kit, Seldinger-based percutaneous Melker kit, and an open surgical method. In a prospective study, 23 Australian emergency physicians and trainees performed cricothyrotomy on a manikin (developed by the authors) using each technique in random order. Participants were inexperienced in cricothyrotomy (average, 1.5 previous attempts) and did not receive training in use of the techniques before the study. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

4. The Research Overall, median time to ventilation was fastest with the open surgical method (34 seconds); followed by the Quicktrach and Minitrach II kits (48 seconds each); and last, the Melker kit (126 seconds). The procedure failed (ventilation not established in 210 seconds) 26% of the time with the Melker kit and in no cases with the other three techniques. Most operators rated the Minitrach II and Quicktrach techniques as their first or second preference (70% and 78%, respectively). The study did not investigate trauma associated with use of the devices. The authors concluded that the Quicktrach or Minitrach II kits should be available in emergency practice. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

5. Comment In a “can’t intubate, can’t ventilate” scenario, the immediate goal is to oxygenate the patient, and the secondary aim is to protect the airway with a cuffed endotracheal tube. In this manikin model for surgical airway management by untrained providers, the Quicktrach and Minitrach II techniques were preferred by participants and were faster than the Melker Seldinger–based technique. However, these findings might not translate to performance on actual (bleeding) patients. Previous studies have found that trocar-based methods, such as the Quicktrach and Minitrach II, are associated with more airway trauma and higher failure rates than either open surgical or Seldinger-based methods. Despite the findings of this manikin-based study, the Seldinger- based and open surgical techniques are probably the best for emergency cricothyroidotomy. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

6. Comment Ultimately, personal choice might determine which technique is best for emergency surgical airway management. Clearly, however, providers responsible for emergency airway management must be familiar with one technique or device, and the equipment should be readily available. CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society

7. About Journal Watch Journal Watch helps physicians and allied heath professionals save time and stay informed by providing brief, clearly written, clinically focused perspectives on the medical developments that affect practice. Journal Watch is an independent, trustworthy source, from the publishers of the New England Journal of Medicine. These slides were derived from Journal Watch Emergency Medicine.Journal Watch Emergency Medicine The best way to stay informed with Journal Watch, is through our alerts. To sign up, visit the My Alerts page.My Alerts page CopyrightCopyright © 2008. Massachusetts Medical Society. All rights reserved.Massachusetts Medical Society