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Three Part Question

In an [adult requiring emergency cricothyroidotomy] is the [the standard surgical approach more effective than a percutaneous dilation method] at [achieving an open airway and minimising complications]?

Clinical Scenario

A paramedic ambulance is dispatched to a 24-year-old male who has been ejected through the windscreen of his car. On arrival at the scene the patient is found to have major maxillofacial injuries a seriously compromised airway. Airway control cannot be achieved by manual techniques and endotracheal intubation is not possible. You decide to attempt cricothyroidotomy and wonder whether the surgical technique is more preferable to the percutaneous dilatation technique.

Search Strategy

Medline 1966-06/02 using the OVID interface.
[{cricothyroid.mp OR surgical airway.mp} AND {percutaneous.mp OR needle.mp OR surgical}] LIMIT to human AND English.

Search Outcome

144 papers found of which 142 were irrelevant to the study. The two remaining papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Johnson DR et al, 1993, USA	Human adult cadavers. SA vs PD	Controlled trial	Insertion success:	86% vs 73% (P = 0.186)	The use of pig skin instead of human skin. Some of the procedures performed on violated cricothyroid membranes due to lack of cadavers
			Insertion times:	55+/- 35 sec vs 148+/- 96 sec(p<0.01)
			Ease of method (0 to 10 scale)	3.0+/- 1.5 vs5.1+/- 3.3 (p<0.01)
Eisenburger P et al, 2000, Austria	40 consecutive unembalmed adult human cadavers, who had died 4-24 hours previously SA vs Seldinger cricothyroidotomies	Controlled trial	Insertion success:	70% vs 60%	Limited size of the trial
			Insertion times:	102+/-42 vs 100+/-46
			Ease of method (1 to 5 scale)	2.2 vs 2.4

Comment(s)

The Johnson et al study found statistically significant differences in the insertion times and the subjective ease of use of the procedure, which were both in favour of the surgical approach. This study was of a lower quality than the Eisenburger study which found no statistically significant differences between the techniques.

Clinical Bottom Line

There is no convincing evidence that either technique is superior in the prehospital environment. The operator should use the technique with which they are most familiar.

References

1. Johnson DR, Dunlap A, McFeely P et al. Cricothyrotomy performed by prehospital personnel: A comparison of two techniques in a human cadaver model. Am J Emerg Med 1993;11(3):207-209.
2. Eisenburger P, Laczika K, List M et al. Comparison of conventional surgical versus Seldinger technique emergency cricothyrotomy performed by inexperienced clinicians. Anesthesiology 2000;92(3):687-690.