title: Improvised cricothyrotomy provides reliable airway access in an unembalmed human cadaver model.
abstract: OBJECTIVE
  Patients with injuries requiring surgical airway management occurring far from medical care might benefit from the availability of a simple, reliable, improvisational method of cricothyrotomy with materials available in a wilderness or prehospital setting. We evaluated an improvised cricothyrotomy device in an experimental, unembalmed human cadaver model.
  
  
  METHODS
  A high-flow intravenous spike and drip chamber was cut through the drip chamber and used as the sole apparatus for performing cricothyrotomy on unembalmed cadavers whose anterior neck surfaces and deep tissues were warmed to or near body temperature. Correct placement in the trachea and damage to the posterior wall of the trachea were assessed by either fiberoptic bronchoscopy or neck dissection. Video recordings were used to time each procedure. Each operator was responsible for both device insertion and bag valve mask attachment and ventilation, modeling as the sole care provider for the patient.
  
  
  RESULTS
  One physician and 3 emergency medicine residents, all without previous, specific instruction, performed 10 procedures on 5 female and 5 male unembalmed cadavers weighing a mean of 65 kg (range 45-110 kg). All 10 attempts at placement of the intravenous tubing spike through the cricothyroid membrane were successful. On 2 attempts, the initial placement of the device was incorrect, but the error was immediately identified on attempt to ventilate the patient. Repositioning of the device resulted in appropriate cannulation of the trachea in both attempts. The median time span from manual identification of the cricothyroid membrane to percutaneous access and connection of the bag valve mask with successful ventilation was 27.3 seconds. Violation of the posterior tracheal wall was not seen on any of the 5 procedures in which fiberoptic visualization was available or in the 5 procedures evaluated by neck dissection.
  
  
  CONCLUSIONS
  Cricothyrotomy is the quickest and most effective method for obtaining airway access when nonsurgical methods of securing the airway are contraindicated or fail. Although frequently described, no improvised airway devices of this type have been tested in a systematic manner. We tested the reliability and utility of cricothyrotomy with a high-flow intravenous spike and drip chamber. Our results suggest that the spike and drip chamber is a plausible means of temporarily establishing airway access in patients with acute airway obstruction in a wilderness or prehospital environment.
authors.affiliation: Department of Emergency Medicine, University of California, San Francisco, Fresno, Fresno, CA 94143, USA.
authors.forename: Timothy F
authors.initials: TF
authors.lastname: Platts-Mills
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Lewin
authors.forename: Jesse
authors.initials: J
authors.lastname: Wells
authors.forename: Philip
authors.initials: P
authors.lastname: Bickler
mesh_terms: D000328:Adult; D000402:Airway Obstruction / Q000628:therapy*; D002102:Cadaver; D003413:Cricoid Cartilage / Q000601:surgery*; D004638:Emergency Treatment; D006801:Humans; D014140:Tracheotomy / Q000295:instrumentation* / Q000379:methods; D014741:Video Recording