Insertion of a tracheal tube via cricothyrotomy is one of the final airway management options in a cannot-ventilate/cannot-intubate scenario. However, because this tends to be a rare occurrence, many physicians have little experience with either the conventional surgical or blind Seldinger technique of cricothyrotomy.
Accordingly, Eisenburger et al. recruited 20 intensive care unit physicians, each of whom had performed numerous conventional endotracheal intubations but had no previous cricothyrotomy experience. The aim of the team was to compare methods of cricothyrotomy vis a vis speed and reliability in first-time performers. The physicians participated in a 60-min training session using slides detailing neck anatomy and written instructions regarding the methods of both conventional surgical and Seldinger techniques.
The study was performed in 40 consecutive unembalmed adult human cadavers. Physicians were assigned to perform cricothyrotomies in random order and were allowed only one attempt per procedure and cadaver. One member of the research team watched each attempt and put participants under stress by constantly reminding them of the time constraints. Three time intervals were measured with a stop watch: from start of the procedure to location of the cricothyroid membrane, from start of the procedure to either tracheal puncture or penetration with scalpel (depending on method being evaluated), and from start of procedure to first ventilation with a breathing bag.
Participants rated the difficulty of the cadavers’ anatomic situations and of using both cricothyrotomy methods using a visual analog scale. A pathologist dissected the neck after each procedure and assessed correct placement of cannulae in the trachea and any potential injury inflicted by the procedure.
Tracheal placement was achieved in 70% of group 1 (surgical) procedures and in 60% of group 2 (Seldinger) procedures. Failures in group 1 were caused by paratracheal, esophageal, or subcutaneous misplacement; failures in group 2 were attributed mainly to kinking of the guidewire during insertion. Incidence of tissue injury was similar for both methods. The researchers concluded that although cadavers do not reflect real-life clinical situations, the incidence of failure in these first-time performers underscores the need for further studies to define the learning curve for both techniques and to determine more effective methods for teaching such critically important techniques.