Emergency cricothyrotomy--a systematic review.
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ABSTRACT: Background
An emergency cricothyrotomy is the last-resort in most airway management protocols and is performed when it is not possible to intubate or ventilate a patient. This situation can rapidly prove fatal, making it important to identify the best method to establish a secure airway. We conducted a systematic review to identify whether there exists superiority between available commercial kits versus traditional surgical and needle techniques.Methods
Medline, EMBASE and other databases were searched for pertinent studies. The inclusion criteria included manikin, animal and human studies and there were no restrictions regarding the professional background of the person performing the procedure.Results
In total, 1,405 unique references were identified; 108 full text articles were retrieved; and 24 studies were included in the review. Studies comparing kits with one another or with various surgical and needle techniques were identified. The outcome measures included in this systematic review were success rate and time consumption. The investigators performing the studies had chosen unique combinations of starting and stopping points for time measurements, making comparisons between studies difficult and leading to many conflicting results. No single method was shown to be better than the others, but the size of the studies makes it impossible to draw firm conclusions.Conclusions
The large majority of the studies were too small to demonstrate statistically significant differences, and the limited available evidence was of low or very low quality. That none of the techniques in these studies demonstrated better results than the others does not necessarily indicate that each is equally good, and these conclusions will likely change as new evidence becomes available.
SUBMITTER: Langvad S
PROVIDER: S-EPMC3704966 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:The surgical cricothyrotomy (CTT) has been recommended for emergency front of neck airway access (eFONA) during a cannot intubate, cannot oxygenate scenario for military working dogs (MWD) and civilian law enforcement working dogs (operational K9s). In prehospital and austere environments, combat medics and emergency medical service providers are expected to administer emergency medical care to working dogs and may only have emergency airway kits designed for humans at their disposal. The objective of this article is to provide a detailed description of the application of such devices in cadaver dogs and highlight potential alterations to manufacturer guidelines required for successful tube placement. The kits evaluated included the Portex® PCK, Melker universal cricothyrotomy kit and H&H® emergency cricothyrotomy kit. A novel technique for awake cricothyrotomy in the dog is also described, which can also be considered for in-hospital use, together with the open surgical method described for the H&H® kit. To the authors' knowledge, this is the first publication documenting and providing instruction on the application of commercial cricothyrotomy kits in dogs.
| S-EPMC8483268 | biostudies-literature
Project description:BackgroundEmergency cricothyrotomy training for non-surgeons is important as rare "cannot intubate or oxygenate events" may occur multiple times in a provider's career when surgical expertise is not immediately available. However, such training is highly variable and often infrequent, therefore, enhancing these experiences is important.Research questionIs bronchoscopy-enhanced cricothyrotomy training in cadavers feasible, and what are the potential benefits provided by this innovation for trainees?MethodsThis study was performed during implementation of a new program to train non-surgeon providers on cadaveric donors on our campus. Standard training with an instructional video and live coaching was enhanced by bronchoscopic visualization of the trachea allowing participants to review their technique after performing scalpel and Seldinger-technique procedures, and to review their colleagues' technique on live video. Feasibility was measured through assessing helpfulness for trainees, cost, setup time, quality of images, and operator needs. Footage from the bronchoscopy recordings was analyzed to assess puncture-to-tube time, safety errors, and evidence for a training effect within groups. Participants submitted pre- and post-session surveys assessing their levels of experience and gauging their confidence and anxiety with cricothyrotomies.ResultsThe training program met feasibility criteria for low costs (<200 USD/donor), setup time (<30 minutes/donor), and operator needs (1/donor). Furthermore, all participants rated the cadaveric session as helpful. Participants demonstrated efficient technique, with a median puncture-to-tube time of 48.5 seconds. Bronchoscopy recordings from 24 analyzed videos revealed eight instances of sharp instruments puncturing the posterior tracheal wall (33% rate), and two instances of improper tube placement (8% rate). Sharp instruments reached potentially dangerous insertion depths beyond the midpoint of the anterior-posterior diameter of the trachea in 58.3% of videos. Bronchoscopic enhancement was rated as quite or extremely helpful for visualizing the trachea (83.3%) and to assess depth of instrumentation (91.7%). There was a significant average increase in confidence (64.4%, P<0.001) and average decrease in performance anxiety (-11.6%, P = 0.0328) after the session. A training effect was seem wherein the last trainee in each group had no posterior tracheal wall injuries.InterpretationSupplementing cadaveric emergent cricothyrotomy training programs with tracheal bronchoscopy is feasible, helpful to trainees, and meets prior documented times for efficient technique. Furthermore, it was successful in detecting technical errors that would have been missed in a standard training program. Bronchoscopic enhancement is a valuable addition to cricothyrotomy cadaveric training programs and may help avoid real-life complications.
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Project description:ObjectivesCricothyrotomy is a high-stakes emergency procedure. Because the procedure is rare, simulation is often used to train residents. The Accreditation Council for Graduate Medical Education (ACGME) requires performance of three cricothyrotomies during residency, but the optimal number of training repetitions is unknown. Additional repetitions beyond three could increase proficiency, though it is unknown whether there is a threshold beyond which there is no benefit to additional repetition. The objective of this study was to establish a minimum number of simulated cricothyrotomy attempts beyond which additional attempts did not increase proficiency.MethodsThis was a prospective, observational study conducted over 3 years at the simulation center of an academic emergency medicine residency program. Participants were residents participating in a cricothyrotomy training as part of a longitudinal airway curriculum course. The primary outcome was time to successful completion of the procedure as first-year residents. Secondary outcomes included time to completion as second- and third-year residents. Procedure times were plotted as a function of attempt number. Data were analyzed using descriptive statistics, repeated-measures analysis of variance, and correlation analysis. Preprocedure surveys collected further data regarding procedure experience, confidence, and comfort.ResultsSixty-nine first-year residents participated in the study. Steady improvement in time to completion was seen through the first six attempts (from a mean of 75 to 41 sec), after which no further significant improvement was found. Second- and third-year residents initially demonstrated slower performance than first-year residents but rapidly improved to surpass their first-year performance. Resident mean times at five attempts were faster with each year of residency (first-year 48 sec, second-year 30 sec, third-year 24 sec). There was no statistically significant correlation between confidence and time to complete the procedure.ConclusionsAdditional repetition beyond the ACGME-endorsed three cricothyrotomy attempts may help increase proficiency. Periodic retraining may be important to maintain skills.
| S-EPMC10664393 | biostudies-literature
Project description:IntroductionIn a CICO (cannot intubate, cannot oxygenate) situation, anesthesiologists and acute care physicians must be able to perform an emergency surgical cricothyrotomy (front-of-neck airway procedure). CICOs are high-acuity situations with rare opportunities for safe practice. In COVID-19 airway management guidelines, bougie-assisted surgical cricothyrotomy is the recommended emergency strategy for CICO situations.MethodsWe designed a 4-hour procedural simulation workshop on surgical cricothyrotomy to train 16 medical residents. We provided prerequisite readings, a lecture, and a videotaped demonstration. Two clinical scenarios introduced deliberate practice on partial-task neck simulators and fresh human cadavers. We segmented an evidence-based procedure and asked participants to verbalize the five steps of the procedure on multiple occasions.ResultsThirty-two residents who participated in the workshops were surveyed, with a 97% response rate (16 of 16 from anesthesiology, 15 of 16 from emergency medicine). Participants commented positively on the workshop's authenticity, its structure, the quality of the feedback provided, and its perceived impact on improving skills in surgical cricothyrotomy. We analyzed narrative comments related to three domains: preparation for the procedure, performing the procedure, and maintaining the skills. Participants highlighted the importance of performing the procedure many times and mentioned the representativeness of fresh cadavers.DiscussionWe developed a surgical cricothyrotomy simulation workshop for anesthesiology and emergency medicine residents. Residents in the two specialities uniformly appreciated its format and content. We identified common pitfalls when executing the procedure and provided practical tips and material to facilitate implementation, in particular to face the COVID-19 pandemic.
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Project description:Ultrasound is an efficacious, versatile and affordable imaging technique in emergencies, but has limited utility without expert interpretation. Telesonography, in which experts may remotely support the use of ultrasound through a telecommunications link, may broaden access to ultrasound and improve patient outcomes, particularly in remote settings. This review assesses the literature regarding telesonography in emergency medicine, focussing on evidence of feasibility, diagnostic accuracy and clinical utility. A systematic search was performed for articles published from 1946 to February 2017 using the Cochrane, Medline, EMBASE, and CINAHL databases. Further searches utilising Scopus, Google Scholar, and citation lists were conducted. 4388 titles were identified and screened against inclusion criteria which resulted in the inclusion of 28 papers. These included feasibility, diagnostic accuracy and clinical pilot studies. Study design, methodology and quality were heterogeneous. There was good evidence of feasibility from multiple studies. Where sufficient bandwidth and high quality components were used, diagnostic accuracy was slightly reduced by image transmission. There was evidence of clinical utility in remote hospitals and low-resource settings, although reliability was infrequently reported. Further exploratory research is required to determine minimum requirements for image quality, bandwidth, frame rate and to assess diagnostic accuracy. Clinical trials in remote settings are justifiable. Telecommunication options will depend on local requirements; no one system conveys universal advantages. The methodological quality of research in this field must improve: studies should be designed to minimise bias, and must include details of their methods to allow replication. Analysis of cost effectiveness and sustainability should be provided.
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Project description:BackgroundEmergency general surgery practice is high risk. Surgery is a key part of treatment, with resultant catabolic stress and frequent need for nutritional support. The aim of this study was to examine the current methods of defining and determining malnutrition in emergency general surgery. This included examining the use of nutrition screening and assessment tools and other measures of malnutrition.MethodsMEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, trial registries, and relevant journals published between January 2000 and January 2022 were searched for studies of adult patients with any emergency general surgery diagnosis, managed conservatively or operatively, with an assessment of nutritional status. Mixed populations were included if more than 50 per cent of patients were emergency general surgery patients or emergency general surgery results could be separately extracted. Studies in which patients had received nutritional support were excluded. The protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42021285897).ResultsFrom 6700 studies screened, 324 full texts were retrieved and 31 were included in the analysis. A definition of malnutrition was provided in 23 studies (75 per cent), with nutritional status being determined by a variety of methods. A total of seven nutrition screening tools and a total of nine 'assessment' tools were reported. To define malnutrition, the most commonly used primary or secondary marker of nutritional status was BMI, followed by albumin level.ConclusionWide variation exists in approaches to identify malnutrition risk in emergency general surgery patients, using a range of tools and nutrition markers. Future studies should seek to standardize nutrition screening and assessment in the emergency general surgery setting as two discrete processes. This will permit better understanding of malnutrition risk in surgical patients.
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