The Emergent Surgical Airway
Content
Int. J. Oral Maxillofac. Surg. 2013; 42: 204–208 http://dx.doi.org/10.1016/j.ijom.2012.10.021, available online at http://www.sciencedirect.com
Clinical Paper Trauma
The emergent surgical airway: cricothyrotomy vs tracheotomy
J.K. Dillon, B. Christensen, T. Fairbanks, G. Jurkovich, K.S. Moe: The emergent surgical airway: cricothyrotomy vs tracheotomy. Int. J. Oral Maxillofac. Surg. 2013; 42: 204–208. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The American Society of Anesthesiologists difficult airway algorithm identifies two acceptable emergency surgical airways in the ‘cannot intubate, cannot ventilate’ scenario: cricothyrotomy and tracheotomy. Little has been published regarding the emergency surgical airway practices at different institutions. The authors investigated whether the primary choice of emergency surgical airway at a major level I trauma centre was cricothyrotomy or tracheotomy. A retrospective chart review was conducted of emergency airways performed over 6 years using relevant current procedural terminology codes. The electronic medical records obtained were reviewed to ensure accurate coding and verify the emergent nature of the procedure. Over the study period, there were 4312 documented emergent airways. 3197 (74.1%) were field intubated by paramedics, 1081 (25.1%) were hospital intubated by anaesthesia, 34 (0.008%) required emergency surgical access of which 24 were tracheotomies and 10 cricothyrotomies. Despite the emphasis in resident training and Advanced Trauma Life Support, there was a paucity of cricothyrotomies during the study period. At the authors’ institution, tracheotomy is preferentially used as the emergency surgical airway. A multicentre prospective study is recommended to evaluate current practice in emergency surgical airway and to include the emergency open tracheotomy in residency training and continuing education if needed.
J. K. Dillon1,2,, B. Christensen1, T. Fairbanks1,2, G. Jurkovich3, K. S. Moe4
University of Washington School of Dentistry, Seattle, WA, USA; 2Department of Oral & Maxillofacial Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA; 3Department of Surgery, University of Colorado, Denver Health Medical Center, Boulder, CO, USA; 4Department of Otolaryngology Head and Neck Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
1
Key words: emergency surgical airway; tracheotomy; cricothyrotomy. Accepted for publication 19 October 2012 Available online 21 December 2012
The recommended technique for obtaining an emergency airway is, according to the current literature, straightforward. The American Society of Anesthesiologists (ASA) has developed a ‘difficult airway algorithm’,1 which recommends either surgical or percutaneous tracheotomy or cricothyrotomy if intubation fails. The Advanced Trauma Life Support (ATLS) manual specifies that ‘a surgical cricothyroidotomy is preferable to a tracheotomy for most patients requiring an emergency surgical airway’.2 This
0901-5027/020204 + 05 $36.00/0
recommendation is based on the perception that: cricothyrotomy is easier to perform than open (standard) tracheotomy; is safer; is associated with less bleeding; and requires less surgical time.2–4 For these reasons, cricothyrotomy receives the most emphasis during didactic teaching, training, and surgical simulations. The ATLS manual devotes an entire chapter to cricothyrotomy, while tracheotomy is not taught in the protocol. While teaching cricothyrotomy as the primary technique for obtaining a surgical
airway is straightforward and based on sound logic, the literature simply contains recommendations and no definitive information on actual practices. On evaluation of their practice, it is the perception of the authors that cricothyrotomy is not the technique most often used in the surgical management of the emergency airway. Given the decreasing time and assets available for training and the desire to direct assets towards current clinical practice, a need was identified for a multidisciplinary investigation of the actual
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Cricothyrotomy vs tracheotomy
emergency airway practices at a major level I trauma and medical centre.
Materials and methods
Table 1. Indications for emergency airways in the emergency department. Procedural indications for emergency airway In any of these situations, the patient should progress to an emergent surgical airway Three total attempts at endotracheal intubation, including at least one by the anaesthesiology attending 10 min has elapsed since start of rapid sequence induction and injection of induction agents Oxygen saturation falls to <65% during airway management, after the first or second attempt Status indications for emergency airway In either of these situations, the progression to emergent surgical airway should be considered or hastened, regardless of above indications Rapid desaturation or difficult maintaining oxygen saturation while bagging Anaesthesiology attending decides a surgical airway is necessary and addition intubation attempts would be futile
205
After receiving Institutional Review Board approval, a retrospective cohort study was performed of all emergency surgical airways performed from 1 July 2004 to 30 June 2010 at the authors’ hospital. This hospital is the sole level I adult and paediatric trauma and burn centre serving over 10 million people across a five-state area. A list of medical records with the current procedural terminology (CPT) codes for an emergency tracheotomy (31603) and an emergency cricothyrotomy (31605) was studied. The list was cross-referenced with the trauma registry database for completeness. Medical records were reviewed to ensure accurate coding and to verify the emergent nature of the procedure. For the purposes of this study, ‘emergent’ or ‘emergency’ were defined using the following criteria: an emergent definitive airway was required; the patient received a surgical airway within minutes of airway compromise or emergency department arrival; there was no time to obtain consent from the patient or next of kin; and other feasible airway avenues had already been attempted and failed. In each case identified, the ASA difficult airway algorithm was followed and emergency surgical airway was attempted only after efforts at securing an endotracheal airway were attempted by paramedics and/or the anaesthesia service. In addition to the criteria listed above, institutional guidelines specify criteria that must be met in order to designate surgical airway access as an ‘emergency surgical airway’. These include oxygen desaturation and multiple failed attempts at intubation (Table 1). Over the 6-year review period, 34 surgical airway procedures were determined to be ‘emergent’ and were included in the study. Age, gender, surgical indication, location of procedure within the hospital, surgical specialty involved, perioperative complications, and the type of surgical procedure were all recorded.
Results
Of the 34 emergency surgical airways, the patients’ ages ranged from 17 to 70 years (mean 44.9 Æ 15.4 years). There were 25 male patients and 9 female. The underlying pathology included multiple facial fractures (n = 11), airway obstruction from bleeding or oedema (n = 10), gunshot wounds to the head and neck (n = 9), penetrating neck injury (n = 2), and head and neck carcinoma (n = 2) (Table 2). The surgical airway was obtained by cricothyrotomy in 10 cases and by tracheotomy in 24 cases (Table 3). 12 tracheotomies were performed by the otolaryngology-head and neck surgery (Oto-HNS) department, 11 by general surgery/trauma (GS), and one in the field by paramedics (Table 3). Six cricothyrotomies were performed by GS, two by paramedics in the field, one by internal
Table 2. Patient demographics and indication for emergency surgical airway. Patients, n Age (mean Æ SD) Gender (male; female) Indications Multiple facial fractures Airway obstructions Gunshot wound to head/neck Penetrating neck injury Head/neck carcinoma 34 44.9 Æ 15.4 years 25; 9 n 11 10 9 2 2
medicine, and one by oral and maxillofacial surgery (OMFS) (Table 3). Table 4 summarizes the patient data. There were 16 obese patients in this cohort (body mass index (BMI) > 30).5 The 10 cricothyrotomies included seven obese patients and one patient described as ‘a large, heavy-set gentleman with virtually no neck’ (thus included in the obese category despite his BMI of 28.3). Of the 10 cricothyrotomies performed, eight of the patients were considered obese (80%). In contrast, obesity was present in only 33% (8 of 24) of patients who had tracheotomies. Cricothyrotomies, therefore, were more likely to be performed on obese patients in this study (p < 0.05, Fisher’s exact test, two-tailed) (Fig. 1). No perioperative complications were noted in the procedures in this study. Nine of the 10 cricothyrotomies were converted to tracheotomies after the patients had been stabilized. The tenth patient died due to other injuries prior to stabilization.
Discussion
During the study period there were 4312 documented emergent airways. Of these, 3197 (74.1%) were intubated by paramedics in the field, 1081 (25.1%) were intubated by the anaesthesia service on arrival and 34 (0.008%) required emergency surgical access.
Table 3. Cricothyrotomies and tracheotomies by service. Cricothyrotomies General surgery 6 Paramedics 2 OMFS 1 Internal medicine 1 Total 10 Tracheotomies Otolaryngology 12 General surgery 11 Paramedics 1 Total 24
This multidisciplinary evaluation of the technique for surgically obtaining an emergent airway at a large, well-established level I trauma centre and teaching institution demonstrates that, unlike the current standard teaching, tracheotomy rather than cricothyrotomy is the most common procedure. While the practices at the authors’ facility may not be generalized to every institution, it is unlikely that their institution is greatly different in this regard. There is no definitive information on the choice of emergency airways in the literature, but the same surgical specialties practice at the authors’ facility as at other institutions and similar protocols are used for evaluation of trauma and management of pathologies. General surgery/trauma, OMFS, and emergency medicine residents are mandated to complete the American College of Surgeon’s ATLS course, in which emphasis is
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Dillon et al.
possess the technical skills, knowledge of pertinent anatomy, and must be available to treat associated complications. The burden of this training could be achieved by incorporating training in tracheotomy techniques to specialties that do not currently offer it, followed by reinforcement through continuing education. That this is a retrospective chart review is a limitation of the study. The authors used stringent requirements for the determination of surgical airways that were ‘emergent’ in nature, or ‘emergencies,’ but despite their best efforts to maintain accuracy in this review, they were not present during the procedures and the possibility of inaccurate or misleading records cannot be ruled out. Another study limitation relates to the transferability of a level I trauma centre protocol to the general hospital population. At the authors’ trauma centre, when a patient goes into respiratory arrest either in the field or after arrival at the emergency department, a ‘trauma code’ is activated. This mobilizes a team consisting of an emergency department attending physician, anaesthesiologist, general surgery attending or fellow, general surgery second, third and fifth-year residents and nursing/support staff. While this team approach has been beneficial in ensuring rapid and efficient progression through the difficult airway algorithm, to suggest its replication at a smaller community-based hospital is impractical. What is potentially transferrable is that the open tracheotomy has been shown to be a safe and effective means of securing the airway in an emergent setting. With proper training and protocol, this may be a technique applied by any appropriately trained provider in the appropriate setting. At their institution, the authors noted a very high success rate of intubation in the setting of emergency airway management. When surgical airway access was necessary at the authors’ institution, tracheotomy is the emergency surgical airway of choice despite the ATLS recommendation of cricothyrotomy. Although tracheotomies may be more challenging to perform in the emergent setting, the authors found no immediate complications from the procedure. The most striking finding in this study is the relative paucity of cricothyrotomies at the authors’ institution; this suggests the tracheotomy is a viable option for an emergency surgical airway. If there is an opportunity to establish a more definitive and stable airway for a patient immediately, doing so will obviate another surgical procedure to convert the
Fig. 1. Obesity and emergency surgical airways. *p < 0.05.
placed on cricothyrotomy as the preferred emergency surgical airway. Oto-HNS residents at the University of Washington no longer participate in ATLS. OMFS residents who usually take ATLS certification in the senior years only do so once during their residency because ATLS certification is renewed every 4 years. General surgery/trauma residents complete and renew it every 4 years, along with attending general surgery/trauma surgeons and emergency medicine physicians. OMFS and Oto-HNS attendings usually have completed ATLS training, but they are not required to renew it. 11 of the 24 tracheotomies (46%) and six of the 10 cricothyrotomies (60%), were performed by the general surgery/trauma service. Over the study period, there were no emergency cricothyrotomies performed by Oto-HNS and most of the cricothyrotomies were performed by the general surgery/trauma department, as expected from their ATLS training. During the study period, 3197 patients were intubated by paramedics in the field. This is not surprising as Seattle is home to the Medic One paramedic program, a pioneer in pre-hospital emergency response for over 50 years.6 These paramedics are highly trained in airway assessment and management and their interventions are able to intercept airway compromise in the field.7,8 An additional 1081 patients were intubated on arrival at the emergency department by a welltrained anaesthesia service. The skill and efficiency of the paramedics and anaesthesiologists, coupled with an efficient evaluation system consistent with ATLS leads to successful airway intervention prior to encountering the ‘can’t intubate, can’t ventilate’ scenario. Thus, a higher rate of tracheotomies and cricothyrotomies could reflect less-thanideal management of the airway and
inappropriate application of the difficult airway algorithm. This study highlights several important exceptions to the use of tracheotomies as a primary emergency surgical airway. Obese patients were more likely to receive a cricothyrotomy. With normal anatomical landmarks obscured by subcutaneous fat, the cricothyroid membrane is the most superficial portion of the airway and is more readily identifiable after initial incision and dissection in the obese patient.9 Despite this plausible explanation, the authors cannot eliminate the presence of confounding variables in these patients, who are likely to have multiple comorbidities. In addition to obese patients, patients requiring emergency airway access in the field are more likely to receive a cricothyrotomy. This is consistent with the local paramedic training and quality assurance program reinforcement of their teaching. The lone tracheotomy performed by paramedics in this study was a case of severe anaphylaxis for which a cricothyrotomy had already been attempted unsuccessfully and an airway was secured with a tracheotomy incision. The incidence of tracheotomy at this major trauma centre appears to suggest a role for training in tracheotomy in the curricula of surgical specialties and disciplines more likely to perform them. Tracheotomy can provide an additional procedure for use in the event that cricothyrotomy is contraindicated or fails. When it is determined by the attending surgical staff that a tracheotomy is required for long-term airway management, the initial placement of a tracheotomy may save the patient from the risks and costs associated with an additional invasive airway procedure with the conversion of the cricothyrotomy. Although tracheotomy has several advantages, to perform a tracheotomy the surgeon must
Table 4. Patients included in the study. Age 53 55 69 33 62 50 59 30 60 55 53 33 55 17 27 30 44 69 56 23 23 55 27 70 58 35 37 62 47 22 22 45 41 51 Gender M M M M M M F F M F M F M M M M F M F M M M M M M M M M F M M F M F BMI 28.3 31.6 25.4 45.7 30.0 45.5 20.4 30.0 36.3 34.3 27.9 37.0 30.0 21.0 29.3 21.7 45.0 28.1 27.0 21.0 29.6 24.1 17.6 23.4 37.0 21.0 20.0 32.9 31.6 20.8 21.0 13.2 39.6 42.7 Procedure Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy MVC GSW MVC MVC MVC MVC Epistaxis MVC GSW MVC MVC Admitted for sepsis GSW GSW GSW MVC MVC Bicycle crash MVC MVC Penetrating Neck Injury – stab wounds Penetrating Neck Injury – stab wounds Airway oedema secondary to bronchoscopy C spinal fracture Epiglottitis and laryngitis Necrotizing fasciitis of neck, chest GSW GSW GSW GSW GSW Recurrent SCC of throat Head/Neck Carcinoma Severe anaphylaxis Patient history Indication Airway obstruction Airway obstruction Multiple facial injuries Multiple facial injuries Multiple facial injuries Multiple facial injuries Airway obstruction Multiple facial injuries GSW Multiple facial injuries Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Multiple facial injuries Multiple facial injuries Multiple facial injuries Multiple facial injuries Multiple facial injuries Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway Airway Airway Airway obstruction obstruction compromise compromise Service General General General General General General surgery surgery surgery surgery surgery surgery Setting ER ER OR ER ER ICU/bedside Bedside OR Field Field ER ICU/bedside ICU/bedside OR ER ER ER OR OR ER OR ER ICU/bedside Bedside OR OR OR ER OR OR OR OR OR Field Re-intubation failed Worsening oedema in airway led to acute respiratory distress Acute respiratory failure Scheduled procedure, altered anatomy. Failed intubation Bronchoscopy indicated for visualization of tracheal wounds, reintubation failed Rapid growth and bleed Cervical adenopathy with respiratory distress Slash tracheotomy following unsuccessful cricothyrotomy Comment
Internal medicine Oral maxillofacial surgery Paramedics Paramedics General Surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Paramedics
Intubation failed and vomitus noted in airway Severe bleed in oropharynx
Acute respiratory failure
Cricothyrotomy vs tracheotomy
Airway obstruction
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References
1. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269–77. 2. Advanced trauma life support for doctors ATLS: manuals for coordinators and faculty. 8th ed. Chicago: American College of Surgeons; 2008. 3. Gillespie MB, Eisele DW. Outcomes of emergency surgical airway procedures in a hospital-wide setting. Laryngoscope 1999;109: 1766–9. 4. Goldstein B, Goldenberg D. The difficult airway: implications for the otolaryngologist– head and neck surgeon. Oper Tech Otolaryngol Head Neck Surg 2007;18:72–6. 5. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. National Institutes of Health. Obes Res 1998;6 Suppl 2:51S–209S. 6. Medic One Foundation Website: History. Available at: http://www.mediconefoundation. org/who-we-are/history/ [accessed 27.04.12]. 7. Warner KJ, Carlbom D, Cooke CR, Bulger EM, Copass MK, Sharar SR. Paramedic training for proficient prehospital endotracheal intubation. Prehosp Emerg Care 2010; 14:103–8. 8. Warner KJ, Sharar SR, Copass MK, Bulger EM. Prehospital management of the difficult airway: a prospective cohort study. J Emerg Med 2009;36:257–65. 9. Rehm CG, Wanek SM, Gagnon EB, Pearson SK, Mullins RJ. Cricothyroidotomy for elective airway management in critically ill trauma patients with technically challenging neck anatomy. Crit Care 2002;6: 531–5.
airway, if it is indicated. However, without knowledge of the exact surgical procedure involved and sufficient practice and experience with tracheotomy, tracheotomy is not an option. There is currently little available in the literature regarding the surgical practices for emergency airway management at different institutions. This study highlights the need for further evaluation of these techniques in the form of a multi-institutional prospective study to confirm the findings and determine if change to the emergency airway management component of resident training and continuing education is indicated.
Funding
None.
Competing interests
None.
Ethical approval
Address: Jasjit K. Dillon Department of Oral and Maxillofacial Surgery Harborview Medical Center University of Washington 325 Ninth Ave. Box 359893 Seattle WA 98104 USA Tel.: +1 206 744 4124 Fax: +1 206 744 2810 E-mail: [email protected]
Human subjects application # 38776 approved by the institutional review board
Clinical Paper Trauma
The emergent surgical airway: cricothyrotomy vs tracheotomy
J.K. Dillon, B. Christensen, T. Fairbanks, G. Jurkovich, K.S. Moe: The emergent surgical airway: cricothyrotomy vs tracheotomy. Int. J. Oral Maxillofac. Surg. 2013; 42: 204–208. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The American Society of Anesthesiologists difficult airway algorithm identifies two acceptable emergency surgical airways in the ‘cannot intubate, cannot ventilate’ scenario: cricothyrotomy and tracheotomy. Little has been published regarding the emergency surgical airway practices at different institutions. The authors investigated whether the primary choice of emergency surgical airway at a major level I trauma centre was cricothyrotomy or tracheotomy. A retrospective chart review was conducted of emergency airways performed over 6 years using relevant current procedural terminology codes. The electronic medical records obtained were reviewed to ensure accurate coding and verify the emergent nature of the procedure. Over the study period, there were 4312 documented emergent airways. 3197 (74.1%) were field intubated by paramedics, 1081 (25.1%) were hospital intubated by anaesthesia, 34 (0.008%) required emergency surgical access of which 24 were tracheotomies and 10 cricothyrotomies. Despite the emphasis in resident training and Advanced Trauma Life Support, there was a paucity of cricothyrotomies during the study period. At the authors’ institution, tracheotomy is preferentially used as the emergency surgical airway. A multicentre prospective study is recommended to evaluate current practice in emergency surgical airway and to include the emergency open tracheotomy in residency training and continuing education if needed.
J. K. Dillon1,2,, B. Christensen1, T. Fairbanks1,2, G. Jurkovich3, K. S. Moe4
University of Washington School of Dentistry, Seattle, WA, USA; 2Department of Oral & Maxillofacial Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA; 3Department of Surgery, University of Colorado, Denver Health Medical Center, Boulder, CO, USA; 4Department of Otolaryngology Head and Neck Surgery, University of Washington, Harborview Medical Center, Seattle, WA, USA
1
Key words: emergency surgical airway; tracheotomy; cricothyrotomy. Accepted for publication 19 October 2012 Available online 21 December 2012
The recommended technique for obtaining an emergency airway is, according to the current literature, straightforward. The American Society of Anesthesiologists (ASA) has developed a ‘difficult airway algorithm’,1 which recommends either surgical or percutaneous tracheotomy or cricothyrotomy if intubation fails. The Advanced Trauma Life Support (ATLS) manual specifies that ‘a surgical cricothyroidotomy is preferable to a tracheotomy for most patients requiring an emergency surgical airway’.2 This
0901-5027/020204 + 05 $36.00/0
recommendation is based on the perception that: cricothyrotomy is easier to perform than open (standard) tracheotomy; is safer; is associated with less bleeding; and requires less surgical time.2–4 For these reasons, cricothyrotomy receives the most emphasis during didactic teaching, training, and surgical simulations. The ATLS manual devotes an entire chapter to cricothyrotomy, while tracheotomy is not taught in the protocol. While teaching cricothyrotomy as the primary technique for obtaining a surgical
airway is straightforward and based on sound logic, the literature simply contains recommendations and no definitive information on actual practices. On evaluation of their practice, it is the perception of the authors that cricothyrotomy is not the technique most often used in the surgical management of the emergency airway. Given the decreasing time and assets available for training and the desire to direct assets towards current clinical practice, a need was identified for a multidisciplinary investigation of the actual
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Cricothyrotomy vs tracheotomy
emergency airway practices at a major level I trauma and medical centre.
Materials and methods
Table 1. Indications for emergency airways in the emergency department. Procedural indications for emergency airway In any of these situations, the patient should progress to an emergent surgical airway Three total attempts at endotracheal intubation, including at least one by the anaesthesiology attending 10 min has elapsed since start of rapid sequence induction and injection of induction agents Oxygen saturation falls to <65% during airway management, after the first or second attempt Status indications for emergency airway In either of these situations, the progression to emergent surgical airway should be considered or hastened, regardless of above indications Rapid desaturation or difficult maintaining oxygen saturation while bagging Anaesthesiology attending decides a surgical airway is necessary and addition intubation attempts would be futile
205
After receiving Institutional Review Board approval, a retrospective cohort study was performed of all emergency surgical airways performed from 1 July 2004 to 30 June 2010 at the authors’ hospital. This hospital is the sole level I adult and paediatric trauma and burn centre serving over 10 million people across a five-state area. A list of medical records with the current procedural terminology (CPT) codes for an emergency tracheotomy (31603) and an emergency cricothyrotomy (31605) was studied. The list was cross-referenced with the trauma registry database for completeness. Medical records were reviewed to ensure accurate coding and to verify the emergent nature of the procedure. For the purposes of this study, ‘emergent’ or ‘emergency’ were defined using the following criteria: an emergent definitive airway was required; the patient received a surgical airway within minutes of airway compromise or emergency department arrival; there was no time to obtain consent from the patient or next of kin; and other feasible airway avenues had already been attempted and failed. In each case identified, the ASA difficult airway algorithm was followed and emergency surgical airway was attempted only after efforts at securing an endotracheal airway were attempted by paramedics and/or the anaesthesia service. In addition to the criteria listed above, institutional guidelines specify criteria that must be met in order to designate surgical airway access as an ‘emergency surgical airway’. These include oxygen desaturation and multiple failed attempts at intubation (Table 1). Over the 6-year review period, 34 surgical airway procedures were determined to be ‘emergent’ and were included in the study. Age, gender, surgical indication, location of procedure within the hospital, surgical specialty involved, perioperative complications, and the type of surgical procedure were all recorded.
Results
Of the 34 emergency surgical airways, the patients’ ages ranged from 17 to 70 years (mean 44.9 Æ 15.4 years). There were 25 male patients and 9 female. The underlying pathology included multiple facial fractures (n = 11), airway obstruction from bleeding or oedema (n = 10), gunshot wounds to the head and neck (n = 9), penetrating neck injury (n = 2), and head and neck carcinoma (n = 2) (Table 2). The surgical airway was obtained by cricothyrotomy in 10 cases and by tracheotomy in 24 cases (Table 3). 12 tracheotomies were performed by the otolaryngology-head and neck surgery (Oto-HNS) department, 11 by general surgery/trauma (GS), and one in the field by paramedics (Table 3). Six cricothyrotomies were performed by GS, two by paramedics in the field, one by internal
Table 2. Patient demographics and indication for emergency surgical airway. Patients, n Age (mean Æ SD) Gender (male; female) Indications Multiple facial fractures Airway obstructions Gunshot wound to head/neck Penetrating neck injury Head/neck carcinoma 34 44.9 Æ 15.4 years 25; 9 n 11 10 9 2 2
medicine, and one by oral and maxillofacial surgery (OMFS) (Table 3). Table 4 summarizes the patient data. There were 16 obese patients in this cohort (body mass index (BMI) > 30).5 The 10 cricothyrotomies included seven obese patients and one patient described as ‘a large, heavy-set gentleman with virtually no neck’ (thus included in the obese category despite his BMI of 28.3). Of the 10 cricothyrotomies performed, eight of the patients were considered obese (80%). In contrast, obesity was present in only 33% (8 of 24) of patients who had tracheotomies. Cricothyrotomies, therefore, were more likely to be performed on obese patients in this study (p < 0.05, Fisher’s exact test, two-tailed) (Fig. 1). No perioperative complications were noted in the procedures in this study. Nine of the 10 cricothyrotomies were converted to tracheotomies after the patients had been stabilized. The tenth patient died due to other injuries prior to stabilization.
Discussion
During the study period there were 4312 documented emergent airways. Of these, 3197 (74.1%) were intubated by paramedics in the field, 1081 (25.1%) were intubated by the anaesthesia service on arrival and 34 (0.008%) required emergency surgical access.
Table 3. Cricothyrotomies and tracheotomies by service. Cricothyrotomies General surgery 6 Paramedics 2 OMFS 1 Internal medicine 1 Total 10 Tracheotomies Otolaryngology 12 General surgery 11 Paramedics 1 Total 24
This multidisciplinary evaluation of the technique for surgically obtaining an emergent airway at a large, well-established level I trauma centre and teaching institution demonstrates that, unlike the current standard teaching, tracheotomy rather than cricothyrotomy is the most common procedure. While the practices at the authors’ facility may not be generalized to every institution, it is unlikely that their institution is greatly different in this regard. There is no definitive information on the choice of emergency airways in the literature, but the same surgical specialties practice at the authors’ facility as at other institutions and similar protocols are used for evaluation of trauma and management of pathologies. General surgery/trauma, OMFS, and emergency medicine residents are mandated to complete the American College of Surgeon’s ATLS course, in which emphasis is
206
Dillon et al.
possess the technical skills, knowledge of pertinent anatomy, and must be available to treat associated complications. The burden of this training could be achieved by incorporating training in tracheotomy techniques to specialties that do not currently offer it, followed by reinforcement through continuing education. That this is a retrospective chart review is a limitation of the study. The authors used stringent requirements for the determination of surgical airways that were ‘emergent’ in nature, or ‘emergencies,’ but despite their best efforts to maintain accuracy in this review, they were not present during the procedures and the possibility of inaccurate or misleading records cannot be ruled out. Another study limitation relates to the transferability of a level I trauma centre protocol to the general hospital population. At the authors’ trauma centre, when a patient goes into respiratory arrest either in the field or after arrival at the emergency department, a ‘trauma code’ is activated. This mobilizes a team consisting of an emergency department attending physician, anaesthesiologist, general surgery attending or fellow, general surgery second, third and fifth-year residents and nursing/support staff. While this team approach has been beneficial in ensuring rapid and efficient progression through the difficult airway algorithm, to suggest its replication at a smaller community-based hospital is impractical. What is potentially transferrable is that the open tracheotomy has been shown to be a safe and effective means of securing the airway in an emergent setting. With proper training and protocol, this may be a technique applied by any appropriately trained provider in the appropriate setting. At their institution, the authors noted a very high success rate of intubation in the setting of emergency airway management. When surgical airway access was necessary at the authors’ institution, tracheotomy is the emergency surgical airway of choice despite the ATLS recommendation of cricothyrotomy. Although tracheotomies may be more challenging to perform in the emergent setting, the authors found no immediate complications from the procedure. The most striking finding in this study is the relative paucity of cricothyrotomies at the authors’ institution; this suggests the tracheotomy is a viable option for an emergency surgical airway. If there is an opportunity to establish a more definitive and stable airway for a patient immediately, doing so will obviate another surgical procedure to convert the
Fig. 1. Obesity and emergency surgical airways. *p < 0.05.
placed on cricothyrotomy as the preferred emergency surgical airway. Oto-HNS residents at the University of Washington no longer participate in ATLS. OMFS residents who usually take ATLS certification in the senior years only do so once during their residency because ATLS certification is renewed every 4 years. General surgery/trauma residents complete and renew it every 4 years, along with attending general surgery/trauma surgeons and emergency medicine physicians. OMFS and Oto-HNS attendings usually have completed ATLS training, but they are not required to renew it. 11 of the 24 tracheotomies (46%) and six of the 10 cricothyrotomies (60%), were performed by the general surgery/trauma service. Over the study period, there were no emergency cricothyrotomies performed by Oto-HNS and most of the cricothyrotomies were performed by the general surgery/trauma department, as expected from their ATLS training. During the study period, 3197 patients were intubated by paramedics in the field. This is not surprising as Seattle is home to the Medic One paramedic program, a pioneer in pre-hospital emergency response for over 50 years.6 These paramedics are highly trained in airway assessment and management and their interventions are able to intercept airway compromise in the field.7,8 An additional 1081 patients were intubated on arrival at the emergency department by a welltrained anaesthesia service. The skill and efficiency of the paramedics and anaesthesiologists, coupled with an efficient evaluation system consistent with ATLS leads to successful airway intervention prior to encountering the ‘can’t intubate, can’t ventilate’ scenario. Thus, a higher rate of tracheotomies and cricothyrotomies could reflect less-thanideal management of the airway and
inappropriate application of the difficult airway algorithm. This study highlights several important exceptions to the use of tracheotomies as a primary emergency surgical airway. Obese patients were more likely to receive a cricothyrotomy. With normal anatomical landmarks obscured by subcutaneous fat, the cricothyroid membrane is the most superficial portion of the airway and is more readily identifiable after initial incision and dissection in the obese patient.9 Despite this plausible explanation, the authors cannot eliminate the presence of confounding variables in these patients, who are likely to have multiple comorbidities. In addition to obese patients, patients requiring emergency airway access in the field are more likely to receive a cricothyrotomy. This is consistent with the local paramedic training and quality assurance program reinforcement of their teaching. The lone tracheotomy performed by paramedics in this study was a case of severe anaphylaxis for which a cricothyrotomy had already been attempted unsuccessfully and an airway was secured with a tracheotomy incision. The incidence of tracheotomy at this major trauma centre appears to suggest a role for training in tracheotomy in the curricula of surgical specialties and disciplines more likely to perform them. Tracheotomy can provide an additional procedure for use in the event that cricothyrotomy is contraindicated or fails. When it is determined by the attending surgical staff that a tracheotomy is required for long-term airway management, the initial placement of a tracheotomy may save the patient from the risks and costs associated with an additional invasive airway procedure with the conversion of the cricothyrotomy. Although tracheotomy has several advantages, to perform a tracheotomy the surgeon must
Table 4. Patients included in the study. Age 53 55 69 33 62 50 59 30 60 55 53 33 55 17 27 30 44 69 56 23 23 55 27 70 58 35 37 62 47 22 22 45 41 51 Gender M M M M M M F F M F M F M M M M F M F M M M M M M M M M F M M F M F BMI 28.3 31.6 25.4 45.7 30.0 45.5 20.4 30.0 36.3 34.3 27.9 37.0 30.0 21.0 29.3 21.7 45.0 28.1 27.0 21.0 29.6 24.1 17.6 23.4 37.0 21.0 20.0 32.9 31.6 20.8 21.0 13.2 39.6 42.7 Procedure Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Cricothyrotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy Tracheotomy MVC GSW MVC MVC MVC MVC Epistaxis MVC GSW MVC MVC Admitted for sepsis GSW GSW GSW MVC MVC Bicycle crash MVC MVC Penetrating Neck Injury – stab wounds Penetrating Neck Injury – stab wounds Airway oedema secondary to bronchoscopy C spinal fracture Epiglottitis and laryngitis Necrotizing fasciitis of neck, chest GSW GSW GSW GSW GSW Recurrent SCC of throat Head/Neck Carcinoma Severe anaphylaxis Patient history Indication Airway obstruction Airway obstruction Multiple facial injuries Multiple facial injuries Multiple facial injuries Multiple facial injuries Airway obstruction Multiple facial injuries GSW Multiple facial injuries Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Multiple facial injuries Multiple facial injuries Multiple facial injuries Multiple facial injuries Multiple facial injuries Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway obstruction Airway Airway Airway Airway obstruction obstruction compromise compromise Service General General General General General General surgery surgery surgery surgery surgery surgery Setting ER ER OR ER ER ICU/bedside Bedside OR Field Field ER ICU/bedside ICU/bedside OR ER ER ER OR OR ER OR ER ICU/bedside Bedside OR OR OR ER OR OR OR OR OR Field Re-intubation failed Worsening oedema in airway led to acute respiratory distress Acute respiratory failure Scheduled procedure, altered anatomy. Failed intubation Bronchoscopy indicated for visualization of tracheal wounds, reintubation failed Rapid growth and bleed Cervical adenopathy with respiratory distress Slash tracheotomy following unsuccessful cricothyrotomy Comment
Internal medicine Oral maxillofacial surgery Paramedics Paramedics General Surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery General surgery Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Otolaryngology Paramedics
Intubation failed and vomitus noted in airway Severe bleed in oropharynx
Acute respiratory failure
Cricothyrotomy vs tracheotomy
Airway obstruction
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References
1. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003;98:1269–77. 2. Advanced trauma life support for doctors ATLS: manuals for coordinators and faculty. 8th ed. Chicago: American College of Surgeons; 2008. 3. Gillespie MB, Eisele DW. Outcomes of emergency surgical airway procedures in a hospital-wide setting. Laryngoscope 1999;109: 1766–9. 4. Goldstein B, Goldenberg D. The difficult airway: implications for the otolaryngologist– head and neck surgeon. Oper Tech Otolaryngol Head Neck Surg 2007;18:72–6. 5. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. National Institutes of Health. Obes Res 1998;6 Suppl 2:51S–209S. 6. Medic One Foundation Website: History. Available at: http://www.mediconefoundation. org/who-we-are/history/ [accessed 27.04.12]. 7. Warner KJ, Carlbom D, Cooke CR, Bulger EM, Copass MK, Sharar SR. Paramedic training for proficient prehospital endotracheal intubation. Prehosp Emerg Care 2010; 14:103–8. 8. Warner KJ, Sharar SR, Copass MK, Bulger EM. Prehospital management of the difficult airway: a prospective cohort study. J Emerg Med 2009;36:257–65. 9. Rehm CG, Wanek SM, Gagnon EB, Pearson SK, Mullins RJ. Cricothyroidotomy for elective airway management in critically ill trauma patients with technically challenging neck anatomy. Crit Care 2002;6: 531–5.
airway, if it is indicated. However, without knowledge of the exact surgical procedure involved and sufficient practice and experience with tracheotomy, tracheotomy is not an option. There is currently little available in the literature regarding the surgical practices for emergency airway management at different institutions. This study highlights the need for further evaluation of these techniques in the form of a multi-institutional prospective study to confirm the findings and determine if change to the emergency airway management component of resident training and continuing education is indicated.
Funding
None.
Competing interests
None.
Ethical approval
Address: Jasjit K. Dillon Department of Oral and Maxillofacial Surgery Harborview Medical Center University of Washington 325 Ninth Ave. Box 359893 Seattle WA 98104 USA Tel.: +1 206 744 4124 Fax: +1 206 744 2810 E-mail: [email protected]
Human subjects application # 38776 approved by the institutional review board
