title: Cricoid ring integrity: implications for cricothyrotomy.
abstract: OBJECTIVE
  The rapid 4-step technique for cricothyrotomy was originally described as making use of a single traction hook on the cricoid ring. However, it is possible that such hook placement could lead to damage of the cricoid ring. As an alternative, a double-hook device was developed to augment the rapid 4-step technique by dispersing forces applied to the cricoid ring. The objectives of this study were to compare the requisite forces for intubation and the structural tolerances of the cricoid ring between the single- and double-hook techniques.
  
  
  METHODS
  We randomized 56 human cadaver specimens to undergo either cricothyrotomy with intubation followed by cricoid ring breakage or cricoid ring breakage alone. We randomized those cadaver specimens undergoing cricothyrotomy with intubation with respect to the initial hook technique used and then crossed over to the alternate technique for repeat intubation and subsequent cricoid ring breakage. We performed all cricothyrotomies in a similar manner with a consistent technique. We measured the intubation and breakage forces for the single- and double-hook techniques and calculated 95% confidence intervals (CIs).
  
  
  RESULTS
  The mean force to intubate with the single-hook technique was 18 N (95% CI 14 to 22 N), and the mean force to intubate with the double-hook technique was 23 N (95% CI 17 to 29 N). There was a significant difference between the mean forces required to break the cricoid ring with the single-hook technique (54 N; 95% CI 47 to 62 N) versus with the double-hook technique (101 N; 95% CI 89 to 113 N; difference in means 47 [95% CI 34 to 60 N]).
  
  
  CONCLUSIONS
  When applying the rapid 4-step technique for cricothyrotomy, the force required to intubate with either the single- or double-hook technique is small. The cricoid ring, however, tolerates significantly more force without breakage when the double-hook technique is used.
authors.affiliation: Division of Emergency Medicine, Department of Internal Medicine, University of California-Davis, 2315 Stockton Boulevard, PSSB #2100, Sacramento, CA 95817, USA. aebair@ucdavis.edu
authors.forename: Aaron E
authors.initials: AE
authors.lastname: Bair
authors.forename: Erik G
authors.initials: EG
authors.lastname: Laurin
authors.forename: Ari
authors.initials: A
authors.lastname: Karchin
authors.forename: John R
authors.initials: JR
authors.lastname: Richards
authors.forename: Nathan
authors.initials: N
authors.lastname: Kuppermann
mesh_terms: D000402:Airway Obstruction / Q000601:surgery; D002102:Cadaver; D003413:Cricoid Cartilage / Q000601:surgery*; D004638:Emergency Treatment / Q000379:methods; D006801:Humans; D007442:Intubation, Intratracheal / Q000295:instrumentation / Q000379:methods*; D011897:Random Allocation; D019616:Thoracic Surgical Procedures / Q000295:instrumentation / Q000379:methods*