title: [Cricothyrotomy in emergency context: assessment of a cannot intubate cannot ventilate scenario].
abstract: OBJECTIVE
  The aim of this study was to assess airway management by emergency physicians in case of a simulated situation where intubation and ventilation were both impossible.
  
  
  METHODS
  Observational manikin study.
  
  
  METHODS
  A manikin (Airman®; Laerdal) allowing simulating difficult airway situations was used. The scenario assessed concerned a patient needing tracheal intubation for severe traumatic brain injury. The manikin was settled to make tracheal intubation under direct laryngoscopy impossible at the first attempt and to make facemask ventilation impossible after the second attempt. Manikin could initially be ventilated through the intubating laryngeal mask Airway (ILMA) but became impossible few seconds after its insertion. With impossible ventilation through the ILMA, arterial oxygen saturation decreased during 2 minutes before an hypoxic cardiac arrest occurred. Physicians could use classic laryngoscope with Macintosh blade, a Gum Elastic Bougie, an ILMA and a cricothyrotomy set. Adhesion to the national airway management algorithm was assessed. Time to cricothyroidotomy decision after ventilation through ILMA became impossible was measured.
  
  
  RESULTS
  Twenty-five emergency physicians were assessed. For 14 of them, national expert conference algorithm was perfectly followed. For ten physicians, cricothyroidotomy decision was taken after hypoxic cardiac arrest occurred.
  
  
  CONCLUSIONS
  Simulation with a manikin is useful to assess the adhesion rate to difficult intubation algorithms. Our study shows that the decision making process for cricothyrotomy is too often delayed as soon as ventilation became impossible and oxygenation compromized.
authors.affiliation: Samu-Smur 94, département d'anesthésie-réanimation chirurgicale, hôpital Henri-Mondor, 51 avenue du Maréchal-de-Lattre-de-Tassigny, Créteil, France. xavier.combes@hmn.aphp.fr
authors.forename: X
authors.initials: X
authors.lastname: Combes
authors.forename: P
authors.initials: P
authors.lastname: Jabre
authors.forename: R
authors.initials: R
authors.lastname: Amathieu
authors.forename: W
authors.initials: W
authors.lastname: Abdi
authors.forename: D
authors.initials: D
authors.lastname: Luis
authors.forename: J-L
authors.initials: JL
authors.lastname: Sebbah
authors.forename: B
authors.initials: B
authors.lastname: Leroux
authors.forename: G
authors.initials: G
authors.lastname: Dhonneur
mesh_terms: D000328:Adult; D058109:Airway Management / Q000379:methods*; D000465:Algorithms; D001930:Brain Injuries / Q000628:therapy; D002983:Clinical Competence; D003413:Cricoid Cartilage / Q000601:surgery*; D003657:Decision Making; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007442:Intubation, Intratracheal; D017214:Laryngeal Masks; D007828:Laryngoscopy; D008297:Male; D008348:Manikins; D008875:Middle Aged; D010092:Oximetry; D010100:Oxygen / Q000097:blood; D012121:Respiration, Artificial; D014139:Tracheostomy / Q000379:methods*
chemical_list: D010100:Oxygen