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.
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’, 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’. This 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. 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 emergency airway practices at a major level I trauma and medical centre.
Materials and methods
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.
| 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 |
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
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.
Of the 34 emergency surgical airways, the patients’ ages ranged from 17 to 70 years (mean 44.9 ± 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 ).
| Patients, n | 34 |
| Age (mean ± SD) | 44.9 ± 15.4 years |
| Gender (male; female) | 25; 9 |
| Indications | n |
|---|---|
| Multiple facial fractures | 11 |
| Airway obstructions | 10 |
| Gunshot wound to head/neck | 9 |
| Penetrating neck injury | 2 |
| Head/neck carcinoma | 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 medicine, and one by oral and maxillofacial surgery (OMFS) ( Table 3 ). Table 4 summarizes the patient data.
| Cricothyrotomies | |
| General surgery | 6 |
| Paramedics | 2 |
| OMFS | 1 |
| Internal medicine | 1 |
| Total | 10 |
| Tracheotomies | |
| Otolaryngology | 12 |
| General surgery | 11 |
| Paramedics | 1 |
| Total | 24 |
| Age | Gender | BMI | Procedure | Patient history | Indication | Service | Setting | Comment |
|---|---|---|---|---|---|---|---|---|
| 53 | M | 28.3 | Cricothyrotomy | MVC | Airway obstruction | General surgery | ER | |
| 55 | M | 31.6 | Cricothyrotomy | GSW | Airway obstruction | General surgery | ER | |
| 69 | M | 25.4 | Cricothyrotomy | MVC | Multiple facial injuries | General surgery | OR | |
| 33 | M | 45.7 | Cricothyrotomy | MVC | Multiple facial injuries | General surgery | ER | |
| 62 | M | 30.0 | Cricothyrotomy | MVC | Multiple facial injuries | General surgery | ER | |
| 50 | M | 45.5 | Cricothyrotomy | MVC | Multiple facial injuries | General surgery | ICU/bedside | Intubation failed and vomitus noted in airway |
| 59 | F | 20.4 | Cricothyrotomy | Epistaxis | Airway obstruction | Internal medicine | Bedside | Severe bleed in oropharynx |
| 30 | F | 30.0 | Cricothyrotomy | MVC | Multiple facial injuries | Oral maxillofacial surgery | OR | |
| 60 | M | 36.3 | Cricothyrotomy | GSW | GSW | Paramedics | Field | |
| 55 | F | 34.3 | Cricothyrotomy | MVC | Multiple facial injuries | Paramedics | Field | |
| 53 | M | 27.9 | Tracheotomy | MVC | Airway obstruction | General Surgery | ER | |
| 33 | F | 37.0 | Tracheotomy | Admitted for sepsis | Airway obstruction | General surgery | ICU/bedside | Acute respiratory failure |
| 55 | M | 30.0 | Tracheotomy | GSW | Airway obstruction | General surgery | ICU/bedside | |
| 17 | M | 21.0 | Tracheotomy | GSW | Airway obstruction | General surgery | OR | |
| 27 | M | 29.3 | Tracheotomy | GSW | Airway obstruction | General surgery | ER | |
| 30 | M | 21.7 | Tracheotomy | MVC | Multiple facial injuries | General surgery | ER | |
| 44 | F | 45.0 | Tracheotomy | MVC | Multiple facial injuries | General surgery | ER | |
| 69 | M | 28.1 | Tracheotomy | Bicycle crash | Multiple facial injuries | General surgery | OR | |
| 56 | F | 27.0 | Tracheotomy | MVC | Multiple facial injuries | General surgery | OR | |
| 23 | M | 21.0 | Tracheotomy | MVC | Multiple facial injuries | General surgery | ER | |
| 23 | M | 29.6 | Tracheotomy | Penetrating Neck Injury – stab wounds | Airway obstruction | General surgery | OR | |
| 55 | M | 24.1 | Tracheotomy | Penetrating Neck Injury – stab wounds | Airway obstruction | General surgery | ER | |
| 27 | M | 17.6 | Tracheotomy | Airway oedema secondary to bronchoscopy | Airway obstruction | Otolaryngology | ICU/bedside | Re-intubation failed |
| 70 | M | 23.4 | Tracheotomy | C spinal fracture | Airway obstruction | Otolaryngology | Bedside | Worsening oedema in airway led to acute respiratory distress |
| 58 | M | 37.0 | Tracheotomy | Epiglottitis and laryngitis | Airway obstruction | Otolaryngology | OR | Acute respiratory failure |
| 35 | M | 21.0 | Tracheotomy | Necrotizing fasciitis of neck, chest | Airway obstruction | Otolaryngology | OR | Scheduled procedure, altered anatomy. Failed intubation |
| 37 | M | 20.0 | Tracheotomy | GSW | Airway obstruction | Otolaryngology | OR | |
| 62 | M | 32.9 | Tracheotomy | GSW | Airway obstruction | Otolaryngology | ER | |
| 47 | F | 31.6 | Tracheotomy | GSW | Airway obstruction | Otolaryngology | OR | Bronchoscopy indicated for visualization of tracheal wounds, reintubation failed |
| 22 | M | 20.8 | Tracheotomy | GSW | Airway obstruction | Otolaryngology | OR | |
| 22 | M | 21.0 | Tracheotomy | GSW | Airway obstruction | Otolaryngology | OR | |
| 45 | F | 13.2 | Tracheotomy | Recurrent SCC of throat | Airway compromise | Otolaryngology | OR | Rapid growth and bleed |
| 41 | M | 39.6 | Tracheotomy | Head/Neck Carcinoma | Airway compromise | Otolaryngology | OR | Cervical adenopathy with respiratory distress |
| 51 | F | 42.7 | Tracheotomy | Severe anaphylaxis | Airway obstruction | Paramedics | Field | Slash tracheotomy following unsuccessful cricothyrotomy |
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