American Journal of Emergency Medicine (2012) 30, 1429-1432

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 Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA

^bJackson Memorial Hospital/Ryder Trauma Center, University of Miami School of Medicine,

Division of Trauma Surgery, Miami, FL 33136, USA

^cMassachusetts General Hospital and Harvard Medical School, Division of Emergency Medicine, 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) physician training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by surgeons.

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 injury 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 blunt trauma. The most common primary operator was a surgeon (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 physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.

(C) 2012

Introduction

Emergent cricothyroidotomy remains the criterion-stan- dard procedure for airway access when other orotracheal or nasotracheal methods of airway control fail. The need for this

* Corresponding author. Tel.: +1 617 643 2433.

E-mail address: [email protected] (D.R. King).

emergent surgical intervention can arise rapidly and unexpectedly during the evaluation of trauma patients in the emergency department (ED). The 2 most common physician groups exposed to this scenario in the United States are emergency medicine (EM) and surgery.

Because of the relative rareness [1-5] of the procedure, technical expertise is required to safely access the airway under duress. This expertise may be obtained through either

0735-6757/$ - see front matter (C) 2012 doi:10.1016/j.ajem.2011.10.026

training program. We hypothesized that although both groups are present for initial intake and evaluation of trauma patients, EM physicians rarely perform the procedure in the trauma setting.

Methods

Following institutional review board approval, medical records from all the patients of 2 large urban level I trauma centers that underwent emergent cricothyroidotomies from 2000 to 2010 were retrospectively reviewed. Both in- stitutions are sites of Accreditation Council for Graduate Medical Education (ACGME)-approved EM and surgery training programs and together serve over 7000 trauma patients annually. Emergency medicine trainees (postgrad- uate year [PGY] 3 or 4) and surgery trainees (PGY 3-10) are both routinely represented at the initial intake and evaluation of trauma patients at both institutions. Patients were identified through a medical records search for Interna- tional Statistical Classification of Diseases and Related Health Problems, Version 10 (ICD), codes identifying cricothyroidotomy or emergent tracheostomy. Individual records were reviewed to exclude those patients who underwent surgical airway access less urgently in the operating room. Patients were limited to those who had an emergent surgical airway intervention in the ED. If records were unclear, patients were excluded.

Patient demographics, Glasgow Coma Scale, mechanism of injury, cricothyroidotomy operator, cricothyroidotomy assistant, operator and assistant specialties, PGY level of operator and assistant, complications, and subsequent conversion to tracheostomy were noted. The primary operator was defined as the individual performing most of the technical portions of the cricothyroidotomy, whereas the assistant was defined as the individual providing immediate supervision to the primary operator or as providing immediate technical assistance critical to the performance of the procedure. A serious complication was defined as any complication resulting from cricothyroidotomy that neces- sitated an additional surgical procedure at the cricothyr- oidotomy site. Data are presented as mean and SD for continuous and discrete variables and as percent frequency for categorical variables. Where appropriate, statistical analysis was conducted using Mantel-Haenszel ?2 tests to compare complication rates using SPSS (IBM, Inc, Armonk, NY, USA).

Results

Over 10 years, 59 371 trauma patients were screened, and 84 emergent cricothyroidotomies were identified. Of these, only 54 complete records were available for analysis. Both institutions contributed approximately equally to the

Surgeon operator		EM operator	EMS operator
No. of cricothyroidotomies	47	1	6
No. of complications	5	0	6 ?
No. of serious complications	3	0	6 ?
Mean PGY level	6.4	4	0
* P b .0001 difference in complications.

data pool (30 patients from one institution and 24 from the other). Patients had a mean age of 50 +- 15 years, 80% were male, and 90% presented as a result of blunt trauma. Of those presenting with blunt trauma, motor vehicle crash was the inciting Traumatic event in 95%. Patients had a presenting Glasgow Coma Scale of 8 +- 5, and 85% had prehospital loss of consciousness. All patients had at least 2 in-hospital failed direct laryngoscopic orotracheal intuba- tion attempts, except those who underwent cricothyroidot- omy in the prehospital environment. Prehospital documentation was not adequate to determine number of orotracheal intubation attempts before prehospital cricothyr- oidotomy was attempted.

Results are summarized in Table 1. In 47 (87%) cases, the primary operator was an attending surgeon or surgical trainee. Of these 47 cases, an attending surgeon was the primary operator in 13 cases and a PGY 6.4 +- 1.2 surgical trainee in 34 cases. Assistants were attending surgeons in 40 cases and PGY 6.2 +- 1.1 surgical trainees in 7 cases. The complication rate was 10% in this group: 2 minor Wound infections and 3 surgical site bleeding events requiring surgical control (suture ligation of an injured vein). Emergency medical services (EMS) performed 6 prehospi- tal cricothyroidotomies, all resulting in a complication: 2 pretracheal airways placements (airway placed outside the tracheal into the pretracheal cervical fascia), 1 inadvertent tracheostomy, and 3 surgical site bleeding events requiring surgical control upon arrival to the trauma center. One cricothyroidotomy was performed by a PGY 4 EM trainee as primary operator without complications. The serious complication rate for prehospital cricothyroidotomies was higher than in-hospital-performed procedures (P b .0001). There were no differences in nonserious complications, such as wound infection. Twenty-four cricothyroidotomies were eventually converted to tracheostomies to facilitate long-term respiratory care. The remainder underwent primary decannulation.

Table 1 Complications and training

Discussion

Although emergent cricothyroidotomy is a relatively simple procedure, it is very uncommon, with rates varying from 0.2% to 1.2% considering all tracheal intubations [1-5], and it is generally performed under the most

undesirable and unexpected of circumstances. Both EM physicians and surgeons may be called upon to perform the procedure on trauma patients. This analysis demon- strates that, despite the simultaneous presence of both physician groups during initial trauma intake and evaluation in the ED, EM physicians rarely perform the procedure at these 2 level I academic trauma centers. Among the surgeon operators and assistants, the level of training (PGY year) of the surgical trainees performing the airway procedure was quite advanced. We have additionally demonstrated that the cricothyroidotomies performed in the prehospital environment by EMS providers universally resulted in a serious complication.

Both EM and surgical training programs have procedural requirements mandated by the ACGME, American Board of Surgery, and the American Board of Emergency Medicine [6-8]. The ACGME cricothyroidotomy procedural training requirement for EM residents is 3 procedures, inclusive of patient care and laboratory simulation [6]. The American Board of Emergency Medicine requires 3 procedures to be eligible for initial board certification in emergency medicine [8]. For surgical residents, the ACGME and American Board of Surgery are less specific with regard to this procedure, requiring 24 head and neck operative cases, 44 vascular cases, and 10 trauma cases, without concessions for simulations [6,7]. The 24 head and neck cases may include cricothyroidotomies but may also include tracheostomies, radical neck dissections, parotidectomies, and others [6]. The 44 vascular and 10 trauma cases may include neck surgery, such as carotid endarterectomy and Neck exploration for trauma, resulting in any variety of neck and tracheal operative experiences [6]. This poses an unusual training difficulty for both specialties because it is entirely likely that both trainees will graduate having never performed a cricothyroidotomy on an actual patient.

The discussion is further complicated by the data generated in this study, which suggests that even when the opportunity and necessity for a cricothyroidotomy arises, EM trainees rarely perform the procedure. Such a difference was not found in previous studies. In one analysis of the failed intubations of the National Emergency Airway Registry II database [9], 58% of the 21 surgical cricothyroidotomies were performed by EM physicians. Another report [3] from the same database, of all surgical airways (including tracheotomies as well as needle cricothyroidotomies) for either primary or rescue airway management, showed that EM physicians carried out 50.7% of the 75 procedures. It is important to note, though, that the National Emergency Airway Registry database includes trauma and medical indications for intubation. Regional variations may also play a role because in one small series

[4] of the United Kingdom, no cricothyroidotomy was performed by trauma or general surgery specialists or trainees. In addition, these studies include all reporting hospitals and centers, most of which are nontrauma centers with no formal postgraduate training programs in either

specialty. Consequently, the EM physician is likely the only provider present to perform the life-saving procedure at most hospitals in the United States.

In our series, the procedure is clearly dominated, for a variety of reasons, by surgeons and surgical trainees. We suggest, possibly, that surgical trainees are more comfortable operating in the neck because of their prior experience operating on the same anatomy during related elective procedures. As compared with more complicatED operations performed on the same anatomical region, such as an elective tracheostomy, a carotid endarterectomy, or a neck explora- tion for trauma, an emergent cricothyroidotomy is a technically simpler procedure.

Orotracheal airway control is absolutely within the confines of the EM physician and trainees, something supported by a survey of residency directors throughout the country [10]. Consequently, these physicians are usually at the head of the bed attempting orotracheal airway control when the need develops for surgical airway access. This suggests another reason for the preponderance of surgical airway procedures performed by surgeons in this series: the EM trainee may likely continue to manage the airway from the head of the bed by providing Bag-mask ventilations or attempting a temporizing supraglottic airway device or reattempting orotracheal intubation as the neck incision is being made.

The teaching of emergent surgical airways epitomizes the debate of training vs the service to the patient. From the trainee perspective, it is unlikely the PGY 6 surgical trainee with 60 or more neck cases will have significant educational benefit from performing a cricothyroidotomy because this operator has far more experience operating in the neck. The EM trainee, alternatively, stands to benefit dramatically from performance of even a single cricothyr- oidotomy because this is likely to be this trainee’s only experience at surgical airway control in a real patient during their entire residency.

From a patient-centered perspective, when the necessity arises for emergent airway access, those most experienced and knowledgeable of the neck anatomy may be the best operators to perform a stressful, time-sensitive procedure. This operator is far more likely to be an advanced-level surgical trainee than an EM trainee. In this series, the operators, on average, were PGY 6-level surgical trainees or greater. Because these procedures are uncommon, one must question which trainee should be performing cricothyroido- tomies when the opportunities present themselves. Some consideration to this topic should be given in advance, likely individualized to each training program and even each trainee when appropriate.

At an academic level I trauma center, an attending surgeon’s presence during the performance of an emergent surgical airway is clearly valuable with both training and clinical benefits. What remains unclear, however, is which trainees the attending surgeon should be taking through the procedure. Should surgical faculty be making a conscious

effort to engage EM physicians when the need for this uncommon procedure arises, insisting the EM trainee to abandon their orotracheal intubation attempts to redirect attention to the neck? What represents an equitable distribution of training between the 2 specialties? Should attending surgeons stand aside while EM attendings perform the procedure with their trainees? There are a variety of questions developed here, and most have no good answers.

Complications from prehospital cricothyroidotomy were 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 analysis from the National Emergency Medical Services Information System data, the largest EMS database currently available, does not mention the complications to each specific airway method but reported 87% of the cricothyr- oidotomies as successful [11]. Prehospital surgical airway management has been reported to have an associated mortality rate as high as 87% [12-14], but this probably relates to the severity of the cases that required prehospital airway management, and in one of the series, most patients died on the scene. Other authors suggest that prehospital intubation failures should be ventilated by bag valve mask alone until definitive airway management can be undertaken after arrival to the hospital [15]. Clearly, this particular issue requires additional investigation.

There are several obvious limitations of this study. The retrospective nature of this study, as with all retrospective studies, is a limitation. In addition, an enrollment attrition of 30 cases (36%) caused by incomplete medical records could affect the results. Patient enrollment for the study was by ICD billing codes; therefore, if the physician performing the procedure failed to create a bill for the procedure, then those patients would not be captured in this study population. Another possible limitation (al- though the specific intent of this particular investigation was to examine emergent airway access for trauma patients) is the fact that this series was taken exclusively from trauma patients only. Consequently, results cannot be extrapolated to other patient populations, such as medical indications for emergent airway access. This, however, may be attenuated by the fact that most of the surgical airway opportunities for trainees arise from trauma presentations, as shown by other studies [3,4,9,10,16]. Another global limitation is that the number of cricothyr- oidotomies has notably declined over recent years, which may be related to establishment of EM residency programs and more ubiquitous presence of ED providers formally trained in rapid sequence intubation technique, which increases the first-attempt success of intubations [1]. Finally, the evolving routine availability of adjuncts to oral airway management (such as fiber optic cameras, Supraglottic airway devices) may limit the number of cricothyroidotomies in any situation.

This series demonstrates a serious training divide in performance of an uncommon, but lifesaving, procedure that all surgery and EM trainees must master. Attending surgeons, for a variety of reasons, appear to be performing or immediately supervising nearly every ED cricothyroidot- omy in this series. This places surgeons in a position to facilitate training across specialties. Emergency physicians and trauma surgeons must collaborate to develop a means of providing emergency surgical airway training for EM physicians while still providing excellent patient care.

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