Chandler Hill

Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab

OBJECTIVES The objective was to compare time to completion, failure rate, and subjective difficulty of a new cricothyrotomy technique to the standard technique. The new bougie-assisted cricothyrotomy technique (BACT) is similar to the rapid four-step technique (RFST), but a bougie and endotracheal tube are inserted rather than a Shiley tracheostomy tube. METHODS This was a randomized controlled trail conducted on domestic sheep. During a 3-month period inexperienced residents or students were randomized to perform cricothyrotomy on anesthetized sheep using either the standard technique or the BACT. Operators were trained with an educational video before the procedure. Time to successful cricothyrotomy was recorded. The resident or student was then asked to rate the difficulty of the procedure on a five-point scale from 1 (very easy) to 5 (very difficult). RESULTS Twenty-one residents and students were included in the study: 11 in the standard group and 10 in the BACT group. Compared to the standard technique, the BACT was significantly faster with a median time of 67 seconds (interquartile range [IQR] = 55-82) versus 149 seconds (IQR = 111-201) for the standard technique (p = 0.002). The BACT was also rated easier to perform (median = 2, IQR = 1-3) than the standard technique (median = 3, IQR = 2-4; p = 0.04). The failure rate was 1/10 for the BACT compared to 3/11 for the standard method (p = NS). CONCLUSIONS This study demonstrates that the BACT is faster than the standard technique and has a similar failure rate when performed by inexperienced providers on anesthetized sheep.

Retrograde Intubation for Ace Inhibitor–Induced Angioedema

R.C. is a 49-year-old man who presented to triage with complaints of lip and tongue swelling. He noted symptoms upon awakening with progression over the next 2 hours. Medical history is significant for hypertension. His medications are lisinopril and hydrochlorothiazide. On examination, the patient was afebrile, mildly tachypneic, and sitting upright on the cart. He was speaking in short sentences with a hoarse voice and complaining of dysphagia. The head, eyes, and ear ⁄ nose ⁄ throat exam revealed significant edema of his lips and his posterior oropharynx. His lungs were clear and there was no stridor. An IV was established and he was given 0.3 mg of epinephrine subcutaneously and 125 mg of Solu-Medrol intravenously. Fiber-optic–assisted nasotracheal intubation and subsequent RSI and direct laryngoscopy were unsuccessful. Because the patient maintained oxygen saturations greater than 99% with bag-valve mask ventilation, the decision was made to perform a retrograde intubation (Figure 1). The retrograde intubation was successfully completed with one attempt (available as supporting information in the online version of this paper). Oxygen saturations remained above 90% for the entire case.