Case Report

Cricothyroidotomy on the scene in a patient with severe facial trauma and difficult neck anatomy

Abstract

We present a case of a patient with severe facial trauma who was treated at the scene by a physician-staffed trauma life support team. Because of massive oropharyngeal bleeding in addition to a difficult neck anatomy in a very obese patient, a cannot-intubate, cannot-ventilate situation occurred. Control of the airway could finally be achieved by surgical cricothyroidotomy. The current literature concerning emergency cricothyroidotomy is discussed.

A correctly performed cricothyroidotomy is a potentially lifesaving procedure in a cannot-intubate, cannot-ventilate (CICV) situation. It is therefore an essential component of difficult airway algorithms [1-5]. However, most practicing emergency physicians have no practical experience with cricothyroidotomy, and may not have received training in models. Cricothyroidotomy can be performed using a needle or cannula or surgical technique. Although a number of studies have attempted to compare the efficacy of different emergency airway equipment, there is no consensus in the literature as to which technique or device is superior. We report a case of a patient who sustained severe facial trauma with subsequent massive oropharyngeal bleeding, where prehospital airway management proved extremely difficult, but control of the airway could finally be achieved by surgical cricothyroidotomy.

A 50-year-old man was struck by a truck while riding his bicycle. A physician-staffed ambulance was dispatched to the scene. The emergency physician found a very obese patient with a Glasgow Coma Score of 7, binocular hematoma, an open nasal fracture, multiple contused lacerations on his head, and Massive bleeding from the mouth and nose. The patient was hemodynamically stable and breathing sponta- neously, but was tachypneic, gurgling, and bubbling loudly. There were no further visible signs of injury. Thorax and pelvis were stable. After rapid sequence induction and thorough suctioning, direct laryngoscopy was performed. Despite ongoing massive hemorrhaging the epiglottis was briefly visible, but it could not be lifted. A second attempt to visualize the laryngeal inlet with the fiberoptic intubating bronchoscope (FOB) proved impossible because copious

amounts of blood in the oropharynx obscured the FOB’s tip despite the use of 2 suction instruments, one connected to the FOB and the second for regular oral suctioning. In a situation highly suggestive of massive aspiration of blood and a suggestion of additional hypopharyngeal injury, the emer- gency physician, a trauma surgeon with considerable experience in cervical spine surgery, did not attempt to improve oxygenation by inserting a laryngeal mask airway (LMA) when the Pulse oximeter indicated that the patient was becoming hypoxemic. Instead, he immediately decided to perform surgical cricothyroidotomy. As the patient had a very short and fat neck, the procedure proved extremely difficult. Only by dissecting strictly along the anatomical landmarks cricoid and thyroid cartilage the emergency physician succeeded in localizing the Cricothyroid membrane. To minimize bleeding, he made a horizontal incision as recommended by Greaves et al [6] over the lower half of the cricothyroid membrane, thus avoiding the cricothyroid artery that runs transversely across the upper third. The incision was extended laterally, a 7.0-mm-inner-diameter tube was inserted into the cricothyroid membrane incision (Fig. 1), directed distally into the trachea, and the cuff was inflated. After bronchoscopic suctioning, the patient could be adequately ventilated and was well oxygenated on arrival in the emergency department of our facility. cranial computed tomography revealed frontal and ethmoidal sinus fractures, a zygomatic arch and orbital fracture, a maxillary and nasal fracture, as well as a Temporal bone fracture and a fracture of the pterygoid process. Long-term ventilation was necessary because of severe craniocerebral trauma, but after 5 weeks in the intensive care unit, the patient was able to walk out of the clinic without neurologic impairment (Fig. 2).

Early access to and control of the airway is one of the few Prehospital interventions that have been shown to improve outcome significantly for the severely injured patient [7-10]. Most emergency ambulances providing advanced life support carry at least 1 supraglottic airway device and an emergency Surgical airway access kit in addition to the standard equipment consisting of bag-valve mask, orophar- yngeal or nasopharyngeal airways for basic airway manage- ment, and standard tracheal tubes. The use of an FOB in the prehospital setting is not widespread, as fiberoptic intubation is a sophisticated and costly technique, and requires the operator to have considerable skills and experience [11]. Failure to establish a patent upper airway by nonsurgical

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Fig. 1 Cranial computed tomographic scan with tube in place.

means is a rare complication in anesthesia and emergency care. In such a situation where the oral and nasal route is impossible, cricothyroidotomy is a lifesaving skill.

Indications for immediate placement of a definitive airway in our case included: the presence of a severe closed head injury (Glasgow Coma Score, b8), impending com- promise of the airway because of severe maxilloFacial fractures, and need to protect the airway from aspiration of blood [12]. In the patient described previously, airway management was expected to be difficult for 3 reasons: (1) a short fat neck in a very obese patient, (2) severe facial trauma, and (3) massive oropharyngeal bleeding. Two potential hazards are related to severe oropharyngeal hemorrhage: first, compromise of the airway with the risk of laryngeal soiling and aspiration of blood; second, interference with visualization of the laryngeal inlet and the vocal cords during endotracheal intubation. After 2 unsuccessful intubation attempts in an emergency patient where face mask ventilation is impossible, rescue techniques for maintenance of oxygenation in the field include esophageal-tracheal combitube ventilation, insertion of an LMA, and transtracheal jet ventilation (TTJV). Placement of a combitube was not an option, as our local emergency ambulance does not carry combitubes. Insertion of an LMA as an intubating conduit and subsequent fiberoptic intubation would have been an alternative, but with the patient’s oxygen saturation plummeting, the emergency physician opted for a procedure he knew he could perform reliably. Rapid recourse to surgical tracheal access was essential to restore the patient’s oxygenation and accounts largely for his excellent neurologic outcome. Scoop and run was definitely not an option with the estimated transport time exceeding half an hour. Once the decision to perform an invasive technique is

made, it is essential to use an effective technique. Although ventilation is certainly suboptimal using needle/cannula TTJV, it may be enough to adequately oxygenate the patient for about 30 minutes [12]. When longer ambulance transport times can be expected, the needle cricothyroidotomy, especially if used with low pressure ventilation systems, is certainly inferior to a surgical cricothyroidotomy with a cuffed tube.

All current airway guidelines [1-5] recommend manage- ment of the CICV situation using cannula cricothyroidotomy with percutaneous TTJV or surgical cricothyroidotomy. A variety of commercial kits are now available for percuta- neous cricothyroidotomy. The different methods to create a percutaneous cricothyroidotomy can be broadly divided into catheter-over-needle and wire-guided techniques. Although a number of studies [13-20] exist comparing the efficacy of different emergency airway equipment in simulated patients, cadavers, and animal models, there is no consensus in the literature as to which technique or device is superior. The literature search found no prospective study directly comparing needle and surgical airways in either the clinical or preclinical setting. This is not surprising given the infrequency of use and the immediately life-threatening situations in which cricothyroidotomies are performed. Several retrospective studies showed that surgical cricothyr- oidotomy can be performed in the field by ambulance paramedics and flight nurse personnel with a high success rate (89%-98.5%) and an acceptable complication rate [21-25]. Studies comparing the speed and ease of insertion of wire-guided vs standard surgical techniques have found conflicting results. Chan et al [14] found that insertion times were similar (in formalin-preserved cadavers), but there were more complications with the surgical approach. Eisenburger

Fig. 2 Three-dimensional reconstruction of the cranium.

et al [17], in contrast, demonstrated that the wires could kink and surgical access was quicker (in unembalmed cadavers). The participants in a study by Schaumann et al [19] performed Seldinger technique emergency cricothyroidot- omy significantly faster as compared with standard surgical cricothyroidotomy. In a recently conducted study by Sulaiman et al [16] using an airway mannequin and artificial lung model, surgical cricothyroidotomy proved significantly faster. However, as none of the trials was carried out by more than 27 physicians, we are discussing a very limited amount of data. Keane et al [26] compared the speed and success rates of placement for percutaneous cricothyroidotomy vs surgical cricothyroidotomy in a pig model timing 22 paramedics. The surgical route was significantly faster and had a 100% success rate. Johnson et al [27] found that the standard surgical approach was significantly faster compared with a percutaneous techni- que. Moreover, the 44 paramedic students who partici- pated in the study judged the traditional surgical approach to be significantly easier to perform. Success with infraglottic airway techniques perhaps relies more on the operator’s experience, practice, and skill than on the tools themselves [28].

Cricothyroidotomy in a live patient is associated with high complication rates arguably because it is usually performed for very critically injured patients under stressful conditions. Each method has its own peculiar set of problems. Whereas the needle method is associated with problems related to ventilation, for example, hyper- capnia, barotraumas, subcutaneous emphysema, and obs- truction of the cannula because of kinking [18,27,29-32], the surgical method is associated with complications on insertion, in particular, bleeding. The prehospital scenario of a real airway emergency is a high-stress situation, especially for somebody lacking adequate training and experience. The data suggest that experience in using infraglottic techniques on mannequins is correlated with Comfort level in use and thus may be associated with improved performance in CICV situations [33]. Wong et al

[33] recommend that training in percutaneous cricothyr- oidotomy should consist of a minimum of 5 practice attempts to attain a sufficient level of competency. In a recent study comparing a New indicator-guided with a conventional wire-guided percutaneous cricothyroidotomy device in mannequins, Assmann et al [20] also report that insertion times reached a plateau after the fourth attempt with the indicator-guided device and after the fifth attempt with the wire-guided device.

It has been demonstrated that Prehospital personnel can be trained to perform cricothyroidotomies with a reasonable degree of proficiency [22,27]. In countries where physi- cians are involved in prehospital emergency care, there is much to commend a technique that is intrinsically familiar, such as the Seldinger approach. However, whatever tech- nique is chosen, it is essential that adequate training has taken place.

Sylvia Archan MD Gerhard Prause MD

Department of Anesthesiology and Intensive Care Medicine Medical University of Graz 8036 Graz, Austria

E-mail address: [email protected]

Rainer Gumpert MD Franz Joseph Seibert MD Department of Traumatology Medical University of Graz 8036 Graz, Austria

Bernhard Kugler MD Sanatorium Hansa 8010 Graz, Austria

doi:10.1016/j.ajem.2008.05.005

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