Cricothyrotomy technique: Standard versus the rapid four-step technique

Standard cricothyrotomy technique uses a tracheal hook cephalad to the open ing to stabilize the trachea during endotracheal (ET) tube passage. A newly described Rapid Four-Step Technique (RFST) uses the tracheal hook caudal t o the opening to stabilize the trachea during ET tube passage. This experim ental crossover trial compared standard cephalad tracheal hook traction to caudad traction as recommended by RFST in a cadaver model of cricothyrotomy , Outcome measures included the incidence of complications and the size of ET tube able to be passed with each technique. The anterior necks of 30 for malin-fixed cadavers were dissected to completely reveal the cricothyroid m embranes and surrounding structures. Two emergency medicine residents perfo rmed all cricothyrotomies. Each cadaver was randomly assigned to undergo ei ther standard open technique followed by RFST, or RFST followed by standard open technique. Standard open technique was performed using a #11 scalpel blade, a Trousseau dilator for widening the opening, and a tracheal hook he ld cephalad through the thyroid cartilage. RFST was performed using a #11 s calpel blade and a tracheal hook held caudad through the cricoid cartilage. Cuffed ET tubes without stylettes were passed in progressively larger size s until significant resistance was met as determined independently by two p hysicians. The size of the largest ET tube passed for each technique was re corded. After each attempt the trachea was inspected for evidence of struct ural damage and the balloon cuff was checked to assess for cuff rupture. Th ere were no complications with standard technique; five cadavers (16.7%) ha d complications with RFST including one (3.3%) with balloon cuff rupture an d four (13.3%) with cricoid cartilage fractures. Tracheal damage prevented standard technique performance on three of the cadavers, There was no signi ficant difference between maximal ET tube sizes for standard technique (med ian size 7.0, mean 6.95 mm internal diameter) versus RFST (median size 7.0, mean 6.82 mm internal diameter). We conclude that RFST may be associated w ith a higher incidence of complications than standard technique as demonstr ated by our cadaver model of cricothyrotomy, We were unable to demonstrate a difference between the two techniques with regards to size of ET tube abl e to be passed. (C) 1999 Elsevier Science Inc.