Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Emergency front-of-neck access may serve as a life-saving intervention when facing patients with difficult airways. Cricothyrotomy consists of needle and surgical techniques and is performed in approximately 0.2-0.5% of all airway management attempts. Our primary aim in this study was to compare procedural completion time and first-pass success of needle and surgical approaches to cricothyrotomy by civilian and military practitioners using a human cadaver model.

Methods: Emergency medicine (EM) attendings and residents and U.S. Air Force Pararescue specialists were randomized to perform either a needle or surgical cricothyrotomy on an unfixed human cadaver a single time following a 30-minute didactic session about both procedure types. We recorded procedural completion time, first-pass success, frequency and type of observed complications, and subject level of training. Our primary outcome measure was procedural completion time. Secondary outcome measures included first-pass success and complication rates. We used a Wilcoxon signed-rank test to compare the difference in median completion times between needle and surgical groups. We performed a Cox regression analysis to evaluate the relationship between technique and procedural completion time while adjusting for subject level of training. Chi-squared or Fisher exact tests were used to compare unadjusted first-pass success and complication frequencies between needle and surgical groups. Multivariable logistic regression analysis modeling the association between technique and first-pass success and complication events while adjusting for subject level of training was performed.

Results: A total of 99 subjects were enrolled, and 19 (19%), 68 (69%), and 12 (12%) were classified as EM attending, EM resident, and Pararescue specialist, respectively; 51 (52%) and 48 (48%) were randomized into the needle and surgical groups, respectively. The median time to procedural completion was shorter in the needle group than the surgical group (56.5 seconds [sec], 95% confidence interval, 54-66 sec vs 65 sec, 95% CI, 59-73 sec, respectively). The difference in median completion times was 8 sec (95% CI, -1.0 to 17 sec, P = .08). The hazard ratio comparing completion time of surgical to needle cricothyrotomy while adjusting for level of training was 1.41 (95% CI, 0.93-2.13, P = .11). First-pass success and complication rates were similar between the needle and surgical groups (94% vs 94%, P = .32, and 27% vs 33%, P = .52, respectively). The adjusted odds ratios comparing the likelihoods of first-pass success and complication between surgical and needle groups while adjusting for level of training were 1.06 (95% CI, 0.20-5.54, P = .95) and 1.40 (95% CI, 0.55-3.56, P = .48), respectively.

Conclusion: In this study using unfixed human cadavers, needle and surgical cricothyrotomy demonstrated comparable performance regarding procedural completion time, first-pass success, and complication rates. The 8-second difference in median completion time between groups was not found to be statistically significant and is unlikely to be clinically significant given the typical oxygen reserves in an apneic patient. These findings suggest that for practitioners in civilian and military settings, both needle and surgical cricothyrotomy remain viable options for emergency front-of-neck access, assuming adequate operator-level procedural proficiency and access to necessary equipment.