Ultrasound-guided, Bougie-assisted cricothyroidotomy: a description of a novel technique in cadaveric models.

BACKGROUND: Ultrasound (US) has well-documented utility in critical procedures performed in the emergency department. It has been described as a "skill integral to the practice of emergency medicine" in the 2007 Model of Clinical Practice of Emergency Medicine. One of the ideal uses for US in critical care may be in the performance of emergent cricothyroidotomy. To the best of our knowledge there is currently no description of how to perform an US-guided open cricothyroidotomy in the literature.

OBJECTIVES: This study aimed to develop and describe an US-guided technique for emergent open cricothyroidotomy and evaluate the time to completion and failure rate of this technique.

METHODS: This study was performed in a cadaver lab on 21 cadavers. The procedure was performed by two independent operators with US guidance using a linear transducer in the longitudinal orientation placed on the anterior midline of the neck. The cricothyroid membrane was incised with a No. 20 scalpel and a bougie with a coude tip was inserted into the trachea. A 6.0 endotracheal tube was then advanced over the bougie and the cuff was inflated. Endotracheal tube placement was confirmed by dissection. The procedure was timed to evaluate the length of time to identification of the cricothyroid membrane and completion of the procedure. There was no control group for this study.

RESULTS: There were 12 female and nine male cadavers. The mean body mass index (BMI) was 21.9 (range=12.2 to 44.9). There was a median time to identification of the cricothyroid membrane of 3.6 seconds (interquartile range [IQR]=1.9 to 15.3 seconds) and median time to completion of the procedure of 26.2 seconds (IQR=10.7 to 50.7 seconds). The failure rate was 1 out of 21, with one incision placed between the cricoid cartilage and the first tracheal ring. In this case, the trachea was still cannulated. Similar completion times were obtained with high- and low-BMI cadavers.

CONCLUSIONS: Ultrasound-guided bougie-assisted cricothyroidotomy is a novel technique that may be beneficial in emergent open cricothyroidotomy. The data suggest that this technique is rapid, with a median time to completion of 26.2 seconds. The data also suggest that the procedure may have a low failure rate, with 20 of 21 cadavers undergoing successful cricothyroidotomy.