title: Emergency cricothyroidotomy: a randomized crossover trial comparing percutaneous techniques: classic needle first versus "incision first".
abstract: OBJECTIVE
  Emergency cricothyroidotomy is potentially lifesaving in patients with airway compromise who cannot be intubated or ventilated by conventional means. The literature remains divided on the best insertion technique, namely, the open/surgical and percutaneous methods. The two are not mutually exclusive, and the study hypothesis was that an "incision-first" modification (IF) may improve the traditional needle-first (NF) percutaneous approach. This study assessed the IF technique compared to the NF method.
  
  
  METHODS
  A randomized controlled crossover design with concealed allocation was completed for 180 simulated tracheal models. Attending and resident emergency physicians were enrolled. The primary outcome was time to successful cannulation; secondary outcomes included needle insertion(s), incision, and dilatation attempts. Finally, proportions of intratracheal insertion on the first attempt and subjective ease of insertion were compared.
  
  
  RESULTS
  The IF technique was significantly faster than the standard NF technique (median = 53 seconds, interquartile range [IQR] = 45.0 to 86.4 seconds vs. median = 90 seconds, IQR = 55.2 to 108.6 seconds; p < 0.001). The median number of needle insertions was significantly higher for the NF technique (p = 0.018); there was no significant difference in dilation or incision attempts. Intratracheal insertion on the first attempt was documented in 90 and 93% of the NF and IF techniques, respectively (p = 0.317). All the study participants found the IF hybrid approach easier.
  
  
  CONCLUSIONS
  The IF modification allows faster access, fewer complications, and more favorable clinician endorsement than the classic NF percutaneous technique in a validated model of cricothyroidotomy. We suggest therefore that the IF technique be considered as an improved method for insertion of an emergency cricothyroidotomy.
authors.affiliation: Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Hussein
authors.initials: H
authors.lastname: Kanji
authors.forename: Warren
authors.initials: W
authors.lastname: Thirsk
authors.forename: Sandy
authors.initials: S
authors.lastname: Dong
authors.forename: Michael
authors.initials: M
authors.lastname: Szava-Kovats
authors.forename: Cristina
authors.initials: C
authors.lastname: Villa-Roel
authors.forename: Mira
authors.initials: M
authors.lastname: Singh
authors.forename: Brian H
authors.initials: BH
authors.lastname: Rowe
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D000818:Animals; D002983:Clinical Competence; D003413:Cricoid Cartilage / Q000601:surgery*; D018592:Cross-Over Studies; D004630:Emergencies; D006801:Humans; D007396:Internship and Residency; D008505:Medical Staff, Hospital; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D023421:Models, Animal; D017145:Models, Educational; D009339:Needles; D012867:Skin; D018709:Statistics, Nonparametric; D013552:Swine; D013965:Thyroidectomy / Q000193:education* / Q000379:methods*; D013997:Time Factors