cricothyroidotomy

Theme: 
Retrieval Medicine.

Participants: 

Dr Ruby Hsu, Dr Ruth Parsell, Dr Pramod Chandru, Shannon Townsend, Yelise Foon, Shreyas Iyer and Samoda Wilegoda Mudalige.

Discussion 1:
Benoit, J., Stolz, U., McMullan, J., & Wang, H. (2021). Duration of exposure to a prehospital advanced airway and neurological outcome for out-of-hospital cardiac arrest: A retrospective cohort study. Resuscitation, 160, 59-65. https://doi.org/10.1016/j.resuscitation.2021.01.009.

Presenter - Yelise Foon - ED senior resident medical officer.

Summary:

• This study was a retrospective cohort study that looked at adult, non-traumatic OOHCA patients with an advanced airway (supraglottic or endotracheal).
• The timing of airway placement (intra-arrest versus post-ROSC) and patient outcomes (with respect to the cerebral performance category, or CPC) were analyzed. 
• They observed a higher CPC in the group that had the advanced airway placed post-ROSC (i.e. 21.7% in post-arrest group versus 7.5% in intra-arrest group).
• They concluded that the timing of the airway placement was not associated with poor neurological outcomes. 

Discussion 2:
Aziz, S., Foster, E., Lockey, D., & Christian, M. (2021). Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review. Emergency Medicine Journal, 38(5), 349-354. https://doi.org/10.1136/emermed-2020-210305.

Presenter - Shannon Townsend, ED advanced trainee at Orange Health Service.

Summary & Take-Home Points:

• This was a retrospective observational study conducted from 2000 to 2019 using clinical records and aimed to (1) ascertain the rate of scalpel cricothyroidotomy and (2) understand indications for and factors associated with this procedure.
• They observed that the main indication for scalpel cricothyroidotomy was as a rescue airway (for failed laryngoscopy due to a large volume of blood in the airway).
• They noted high levels of procedural success, but the overall mortality in patients receiving this procedure was high (due to a number of factors). 
• The rate of scalpel cricothyroidotomy has decreased over the years due to factors such as the introduction of supraglottic airways and longer-acting muscle relaxants (rocuronium versus suxamethonium). 
• It is important to remember that, if we optimize our intubation conditions (e.g. improving patient position, carefully choosing drugs and equipment according to patient's clinical situation), we are likely to increase our first pass success with laryngoscopy. 
• It is important to (1) recognize the indications for scalpel cricothyroidotomy, (2) be familiar with the procedure itself, (3) overcome the mental barriers against performing it, and (4) perform it confidently and competently.

Discussion 3:
Sperry, J., Guyette, F., Brown, J., Yazer, M., Triulzi, D., & Early-Young, B. et al. (2018). Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. New England Journal Of Medicine, 379(4), 315-326. https://doi.org/10.1056/nejmoa1802345.

Presenter - Dr Ruth Parsell.

Summary:

• In this pragmatic, multi-center, cluster-randomized, phase 3 superiority trial, the efficacy of administering thawed plasma to patients at risk of haemorrhagic shock was studied. 
• The comparative arm was standard-care resuscitation (with crystalloid fluids).
• The primary outcome was mortality at the 30-day mark. 
• They concluded that administration of thawed plasma to patients at risk of haemorrhagic shock resulted in (1) lower 30-day mortality and (2) lower median prothrombin-time ratio. 

Interlude Segment 1:
Presenter - Dr Ruth Parsell.

Interlude Segment 2:
Presenter - Dr Ruby Hsu.

Credits:
The discussions were mediated by retrieval specialists and ED consultants, Dr Ruby Hsu and Dr Ruth Parsell and ED consultant Dr Pramod Chandru. 

This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney, Deepa Dasgupta, Cynthia De Macedo Franco, and Paul Scott.

Music/Sound Effects

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

In this follow-up episode to our discussion with Dr. Scott Weingart of EMCrit, we review the indications for performing a resuscitative thoracotomy, together with the potential application of a circulation first resuscitation strategy, and some intricacies regarding performing a surgical cricothyroidotomy. 

Knife. Finger. Tube. Sounds simple enough. And you read correctly....a bougie is both unnecessary and superfluous! In this episode I share you some tricks of the trade for performing a cric successfully, together with post-surgical airway considerations including hemorrhage control and the decision to convert to a formal tracheostomy.