sign in sign up
<<
Home , Trauma surgery

American Journal of Emergency (2011) xx, xxx–xxx

www.elsevier.com/locate/ajem

Original Contribution Emergent cricothyroidotomies for trauma: training considerations David R. King MD a,⁎, Michael P. Ogilvie MD b, George Velmahos MD, PhD a, Hasan B. Alam MD a, Marc A. deMoya MD a, Susan R. Wilcox MD c, Ali Y. Mejaddam MD a, Gwendolyn M. Van Der Wilden MD a, Oscar A. Birkhan MD a, Karim Fikry MD a aDivision of Trauma, Emergency , and Surgical Critical Care, Massachusetts General and Harvard , Boston, MA 02114, USA bJackson Memorial Hospital/Ryder , University of Miami School of Medicine, Division of Trauma Surgery, Miami, FL 33136, USA cMassachusetts General Hospital and Harvard Medical School, Division of , Boston, MA, USA

Received 11 July 2011; revised 28 October 2011; accepted 29 October 2011

Abstract Background: Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by . Methods: We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of and patient demographics were examined. Results: Fifty-four cricothyroidotomies were analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of . The most common primary operator was a (n = 47, 87%), followed by an emergency medical services (EMS) provider (n = 6, 11%) and an EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared with in-hospital procedures (P b .0001). Conclusions: (1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement. © 2011 Published by Elsevier Inc.

1. Introduction emergent surgical intervention can arise rapidly and unexpectedly during the evaluation of trauma patients in Emergent cricothyroidotomy remains the criterion-stan- the emergency department (ED). The 2 most common dard procedure for airway access when other orotracheal or physician groups exposed to this scenario in the United nasotracheal methods of airway control fail. The need for this States are emergency medicine (EM) and surgery. Because of the relative rareness [1-5] of the procedure, ⁎ Corresponding author. Tel.: +1 617 643 2433. technical expertise is required to safely access the airway E-mail address: [email protected] (D.R. King). under duress. This expertise may be obtained through either

0735-6757/$ – see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.ajem.2011.10.026 2 D.R. King et al. training program. We hypothesized that although both Table 1 Complications and training groups are present for initial intake and evaluation of trauma Surgeon EM EMS patients, EM physicians rarely perform the procedure in the operator operator operator trauma setting. No. of cricothyroidotomies 47 1 6 No. of complications 5 0 6 ⁎ No. of serious complications 3 0 6 ⁎ 2. Methods Mean PGY level 6.4 4 0 ⁎ P b .0001 difference in complications. Following institutional review board approval, medical records from all the patients of 2 large urban level I trauma centers that underwent emergent cricothyroidotomies from data pool (30 patients from one institution and 24 from the 2000 to 2010 were retrospectively reviewed. Both in- other). Patients had a mean age of 50 ± 15 years, 80% were stitutions are sites of Accreditation Council for Graduate male, and 90% presented as a result of blunt trauma. Of (ACGME)–approved EM and surgery those presenting with blunt trauma, motor vehicle crash training programs and together serve over 7000 trauma was the inciting traumatic event in 95%. Patients had a patients annually. Emergency medicine trainees (postgrad- presenting Glasgow Coma Scale of 8 ± 5, and 85% had uate year [PGY] 3 or 4) and surgery trainees (PGY 3-10) are prehospital loss of consciousness. All patients had at least 2 both routinely represented at the initial intake and evaluation in-hospital failed direct laryngoscopic orotracheal intuba- of trauma patients at both institutions. Patients were tion attempts, except those who underwent cricothyroidot- identified through a medical records search for Interna- omy in the prehospital environment. Prehospital tional Statistical Classification of Diseases and Related documentation was not adequate to determine number of Health Problems, Version 10 (ICD), codes identifying orotracheal attempts before prehospital cricothyr- cricothyroidotomy or emergent tracheostomy. Individual oidotomy was attempted. records were reviewed to exclude those patients who Results are summarized in Table 1. In 47 (87%) cases, underwent surgical airway access less urgently in the the primary operator was an attending surgeon or surgical operating room. Patients were limited to those who had an trainee. Of these 47 cases, an attending surgeon was the emergent surgical airway intervention in the ED. If records primary operator in 13 cases and a PGY 6.4 ± 1.2 surgical were unclear, patients were excluded. trainee in 34 cases. Assistants were attending surgeons in 40 Patient demographics, Glasgow Coma Scale, mechanism cases and PGY 6.2 ± 1.1 surgical trainees in 7 cases. The of injury, cricothyroidotomy operator, cricothyroidotomy complication rate was 10% in this group: 2 minor wound assistant, operator and assistant specialties, PGY level of and 3 surgical site bleeding events requiring operator and assistant, complications, and subsequent surgical control (suture ligation of an injured vein). conversion to tracheostomy were noted. The primary Emergency medical services (EMS) performed 6 prehospi- operator was defined as the individual performing most of tal cricothyroidotomies, all resulting in a complication: 2 the technical portions of the cricothyroidotomy, whereas the pretracheal airways placements (airway placed outside the assistant was defined as the individual providing immediate tracheal into the pretracheal cervical fascia), 1 inadvertent supervision to the primary operator or as providing tracheostomy, and 3 surgical site bleeding events requiring immediate technical assistance critical to the performance surgical control upon arrival to the trauma center. One of the procedure. A serious complication was defined as any cricothyroidotomy was performed by a PGY 4 EM trainee complication resulting from cricothyroidotomy that neces- as primary operator without complications. The serious sitated an additional surgical procedure at the cricothyr- complication rate for prehospital cricothyroidotomies was oidotomy site. Data are presented as mean and SD for higher than in-hospital–performed procedures (P b .0001). continuous and discrete variables and as percent frequency There were no differences in nonserious complications, for categorical variables. Where appropriate, statistical such as wound . Twenty-four cricothyroidotomies analysis was conducted using Mantel-Haenszel χ2 tests to were eventually converted to tracheostomies to facilitate compare complication rates using SPSS (IBM, Inc, long-term respiratory care. The remainder underwent Armonk, NY, USA). primary decannulation.

3. Results 4. Discussion

Over 10 years, 59 371 trauma patients were screened, Although emergent cricothyroidotomy is a relatively and 84 emergent cricothyroidotomies were identified. Of simple procedure, it is very uncommon, with rates varying these, only 54 complete records were available for analysis. from 0.2% to 1.2% considering all tracheal Both institutions contributed approximately equally to the [1-5], and it is generally performed under the most Fifty-four emergent cricothyroidotomies 3 undesirable and unexpected of circumstances. Both EM specialty. Consequently, the EM physician is likely the physicians and surgeons may be called upon to perform only provider present to perform the life-saving procedure the procedure on trauma patients. This analysis demon- at most in the United States. strates that, despite the simultaneous presence of both In our series, the procedure is clearly dominated, for a physician groups during initial trauma intake and variety of reasons, by surgeons and surgical trainees. We evaluation in the ED, EM physicians rarely perform the suggest, possibly, that surgical trainees are more comfortable procedure at these 2 level I academic trauma centers. operating in the neck because of their prior experience Among the surgeon operators and assistants, the level of operating on the same anatomy during related elective training (PGY year) of the surgical trainees performing procedures. As compared with more complicated operations the airway procedure was quite advanced. We have performed on the same anatomical region, such as an elective additionally demonstrated that the cricothyroidotomies tracheostomy, a carotid endarterectomy, or a neck explora- performed in the prehospital environment by EMS tion for trauma, an emergent cricothyroidotomy is a providers universally resulted in a serious complication. technically simpler procedure. Both EM and surgical training programs have procedural Orotracheal airway control is absolutely within the requirements mandated by the ACGME, American Board of confines of the EM physician and trainees, something Surgery, and the American Board of Emergency Medicine supported by a survey of directors throughout [6-8]. The ACGME cricothyroidotomy procedural training the country [10]. Consequently, these physicians are usually requirement for EM residents is 3 procedures, inclusive of at the head of the bed attempting orotracheal airway control patient care and laboratory simulation [6]. The American when the need develops for surgical airway access. This Board of Emergency Medicine requires 3 procedures to be suggests another reason for the preponderance of surgical eligible for initial board certification in emergency medicine airway procedures performed by surgeons in this series: the [8]. For surgical residents, the ACGME and American Board EM trainee may likely continue to manage the airway from of Surgery are less specific with regard to this procedure, the head of the bed by providing bag-mask ventilations or requiring 24 head and neck operative cases, 44 vascular attempting a temporizing supraglottic airway device or cases, and 10 trauma cases, without concessions for reattempting orotracheal intubation as the neck incision is simulations [6,7]. The 24 head and neck cases may include being made. cricothyroidotomies but may also include tracheostomies, The teaching of emergent surgical airways epitomizes radical neck dissections, parotidectomies, and others [6]. The the debate of training vs the service to the patient. From the 44 vascular and 10 trauma cases may include neck surgery, trainee perspective, it is unlikely the PGY 6 surgical trainee such as carotid endarterectomy and neck exploration for with 60 or more neck cases will have significant trauma, resulting in any variety of neck and tracheal educational benefit from performing a cricothyroidotomy operative experiences [6]. This poses an unusual training because this operator has far more experience operating in difficulty for both specialties because it is entirely likely that the neck. The EM trainee, alternatively, stands to benefit both trainees will graduate having never performed a dramatically from performance of even a single cricothyr- cricothyroidotomy on an actual patient. oidotomy because this is likely to be this trainee's only The discussion is further complicated by the data experience at surgical airway control in a real patient during generated in this study, which suggests that even when their entire residency. the opportunity and necessity for a cricothyroidotomy From a patient-centered perspective, when the necessity arises, EM trainees rarely perform the procedure. Such a arises for emergent airway access, those most experienced difference was not found in previous studies. In one and knowledgeable of the neck anatomy may be the best analysis of the failed intubations of the National Emergency operators to perform a stressful, time-sensitive procedure. Airway Registry II database [9], 58% of the 21 surgical This operator is far more likely to be an advanced-level cricothyroidotomies were performed by EM physicians. surgical trainee than an EM trainee. In this series, the Another report [3] from the same database, of all surgical operators, on average, were PGY 6–level surgical trainees or airways (including tracheotomies as well as needle greater. Because these procedures are uncommon, one must cricothyroidotomies) for either primary or rescue airway question which trainee should be performing cricothyroido- management, showed that EM physicians carried out 50.7% tomies when the opportunities present themselves. Some of the 75 procedures. It is important to note, though, that consideration to this topic should be given in advance, likely the National Emergency Airway Registry database includes individualized to each training program and even each trauma and medical indications for intubation. Regional trainee when appropriate. variations may also play a role because in one small series At an academic level I trauma center, an attending [4] of the United Kingdom, no cricothyroidotomy was surgeon's presence during the performance of an emergent performed by trauma or specialists or surgical airway is clearly valuable with both training and trainees. In addition, these studies include all reporting clinical benefits. What remains unclear, however, is which hospitals and centers, most of which are nontrauma centers trainees the attending surgeon should be taking through the with no formal postgraduate training programs in either procedure. Should surgical faculty be making a conscious 4 D.R. King et al. effort to engage EM physicians when the need for this This series demonstrates a serious training divide in uncommon procedure arises, insisting the EM trainee to performance of an uncommon, but lifesaving, procedure that abandon their orotracheal intubation attempts to redirect all surgery and EM trainees must master. Attending attention to the neck? What represents an equitable surgeons, for a variety of reasons, appear to be performing distribution of training between the 2 specialties? Should or immediately supervising nearly every ED cricothyroidot- attending surgeons stand aside while EM attendings omy in this series. This places surgeons in a position to perform the procedure with their trainees? There are a facilitate training across specialties. Emergency physicians variety of questions developed here, and most have no and trauma surgeons must collaborate to develop a means of good answers. providing emergency surgical airway training for EM Complications from prehospital cricothyroidotomy were physicians while still providing excellent patient care. universal in this series, and this is controversial compared with complication rates reported by others for these prehospital procedures and may be regionally related. The References analysis from the National Emergency Medical Services Information System data, the largest EMS database currently [1] Chang RS, Hamilton RJ, Carter WA. Declining rate of cricothyrotomy available, does not mention the complications to each in trauma patients with an emergency medicine residency: implications specific airway method but reported 87% of the cricothyr- for skills training. Acad Emerg Med 1998;5:247-51. [2] Sagarin MJ, Barton ED, Chng YM, Walls RM. National Emergency oidotomies as successful [11]. Prehospital surgical airway Airway Registry Investigators. Airway management by US and management has been reported to have an associated Canadian emergency medicine residents: a multicenter analysis of mortality rate as high as 87% [12-14], but this probably more than 6,000 endotracheal intubation attempts. Ann Emerg Med relates to the severity of the cases that required prehospital 2005;46(4):328-36. airway management, and in one of the series, most patients [3] Collins JJ, Brown CA, Walls RM, Surgical airways in emergency department patients: a report of 75 cases from the National Emergency died on the scene. Other authors suggest that prehospital Airway Registry (II). intubation failures should be ventilated by bag valve mask [4] Reid LA, Dunn M, Mckeown DW, Oglesby AJ. Surgical airway in alone until definitive airway management can be undertaken emergency department intubation. Eur J Emerg Med 2011;18(3): after arrival to the hospital [15]. Clearly, this particular issue 168-71. requires additional investigation. [5] Walls RM, Brown III CA, Bair AE, Pallin DJ. NEAR II Investigators. Emergency airway management: a multi-center report of 8937 There are several obvious limitations of this study. The emergency department intubations. J Emerg Med 2010;41(4):347-54. retrospective nature of this study, as with all retrospective [6] Accreditation Council for Graduate Medical Education (1 July 2011) studies, is a limitation. In addition, an enrollment attrition Emergency Medicine Program Requirements, and General Surgery of 30 cases (36%) caused by incomplete medical records Program Requirements. 6 January 2011. ACGME. Retrieved 23 Nov could affect the results. Patient enrollment for the study 2011 Available at: http://www.acgme.org/. [7] American Board of Surgery (26 February 2011). Case Requirements. was by ICD billing codes; therefore, if the physician ABS. Retreived 6 July 2011. Available at: http://www.absurgery.org/. performing the procedure failed to create a bill for the [8] American Board of Emergency Medicine (4 April 2004). Emergency procedure, then those patients would not be captured in Medicine Training Overview. Retrieved Available 16 March 2011. this study population. Another possible limitation (al- Available at http://www.abem.org/public/. though the specific intent of this particular investigation [9] Bair AE, Filbin MR, Kulkarni RG, Walls RM. The failed intubation attempt in the emergency department: analysis of prevalence, rescue was to examine emergent airway access for trauma techniques, and personnel. J Emerg Med 2002. patients) is the fact that this series was taken exclusively [10] Reeder TJ, Brown CK, Norris DL. Managing the difficult airway: from trauma patients only. Consequently, results cannot be a survey of residency directors and a call for change. J Emerg Med extrapolated to other patient populations, such as medical 2005;28(4):473-8. indications for emergent airway access. This, however, [11] Wang HE, Mann NC, Mears G, Jacobson K, Yealy DM. Out-of- hospital airway management in the United States. may be attenuated by the fact that most of the surgical 2011;82(4):378-85 [Epub 2011 Feb 1]. airway opportunities for trainees arise from trauma [12] Warner KJ, Sharar SR, Copass MK, Bulger EM. Prehospital presentations, as shown by other studies [3,4,9,10,16]. management of the difficult airway: a prospective cohort study. J Another global limitation is that the number of cricothyr- Emerg Med 2009;36(3):257-65. oidotomies has notably declined over recent years, which [13] Wong E, Ng YY. The difficult airway in the emergency department. Int J Emerg Med 2008;1(2):107-11. may be related to establishment of EM residency programs [14] Gerich TG, Schmidt U, Hubrich V, Lobenhoffer HP, Tscherne H. and more ubiquitous presence of ED providers formally Prehospital airway management in the acutely injured patient: the trained in rapid sequence intubation technique, which role of surgical cricothyrotomy revisited. J Trauma 1998;45(2):312-4. increases the first-attempt success of intubations [1]. [15] Cobas MA, De la Peña MA, Manning R, Candiotti K, Varon AJ. Finally, the evolving routine availability of adjuncts to Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg 2009;109(2):489-93. oral airway management (such as fiber optic cameras, [16] Bair AE, Panacek EA, Wisner DH, Bales R, Sakles JC. Cricothyr- supraglottic airway devices) may limit the number of otomy: a 5-year experience at one institution. J Emerg Med 2003;24 cricothyroidotomies in any situation. (2):151-6.