A stab in the dark! Are you ready to perform needlecricothyroidotomy?

Phil Davies*

Cheltenham General Hospital, Sandford Road, Cheltenham GL5 7AN, UK

Accepted 24 April 1999

Abstract

The objective of this study was to assess the availability of pre-prepared equipment for needle cricothyroidotomy, and the

knowledge of sta� in its use in Accident and Emergency (A&E) departments in Great Britain. A telephone survey wasundertaken of all A&E departments seeing more than 30 000 new patients per year. 184 hospitals were contacted. 98% of thedoctors agreed to be interviewed. 47% of the departments had made provision for immediate use of needle cricothyroidotomy.

45% of the doctors interviewed were fully conversant in the use of needle cricothyroidotomy. Provision of equipment forimmediate use of needle cricothyroidotomy in A&E departments is generally inadequate. All departments should ensure thatsuch equipment is immediately accessible, and that the sta� is regularly trained in its use. # 1999 Published by Elsevier Science

Ltd. All rights reserved.

1. Introduction

Management of the airway is a priority in the resus-citation of the critically ill [1]. In the majority ofpatients this can be achieved by either basic or moreadvanced airway manoeuvres. In a minority, however,these procedures will fail to secure an airway andrecourse to a surgical method will be required [2].

Needle cricothyroidotomy is established as a safeand rapid method for securing a surgical airway in theemergency setting [3]. Theoretical and practical aspectsof the technique are described in various emergencytextbooks [4±6] and taught on a variety of resuscita-tion courses including advanced life support (ALS) [7],advanced trauma life support (ATLS) [8], advancedpaediatric life support (APLS)[9].

This study attempts to establish both the provisionfor performing needle cricothyroidotomy in A&Edepartments and the knowledge of senior doctors inthe use of this technique.

2. Method

A con®dential telephone survey was undertaken ofall A&E departments in Great Britain seeing morethan 30 000 new patients per year (as identi®ed by theBritish Association of Accident and EmergencyDirectory, 1996) [10]. Departments were contacted ran-domly over a two month period and medical sta� ofspecialist registrar grade or higher on duty were inter-viewed. Interviewees were asked to describe the equip-ment they would use to perform a needlecricothyroidotomy on a patient with an injury to theneck. Their answers were compared with a modelanswer, which was constructed after studying variousemergency medical texts [4±9] describing needle cri-cothyroidotomy. This answer encompassed ®ve pointsall the texts considered essential for the correct use ofthis technique (see Table 1). Interviewees were given ascore between 0 and 5. Non-speci®c prompts wereused to guide them into covering all aspects of thetechnique, if necessary. The interviewee's previous ex-perience and training was noted. A pre-set list ofclosed questions was then used to establish the depart-ment's provision for emergency surgical airway pro-

Injury, Int. J. Care Injured 30 (1999) 659±662

0020-1383/99/$ - see front matter # 1999 Published by Elsevier Science Ltd. All rights reserved.

PII: S0020-1383(99 )00154 -0

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* Tel.: +44-1242-222-2222; fax: +44-1242-273-651.

E-mail address: carophil@primex.co.uk (P. Davies)

cedures. Other members of sta� were interviewed inthe event of the initial interviewee not being able tosupply this information.

3. Results

184 departments were contacted; four declined totake part. 33 consultants (19%), 87 sta� grades (48%)and 60 specialist registrars or equivalent (33%) wereinterviewed. All had worked in their department for atleast one month.

Only 70 doctors (39%) correctly identi®ed all ®vesteps thought necessary to adequately oxygenate apatient using a needle cricothyroidomy technique (seeTable 1). 65 (36%) were able to describe the mainsteps of a jet insu�ation technique, but lacked detailedknowledge in one or two areas. The most commonomissions were an inability to describe a method ofconnecting oxygen tubing to the cannula and the ratioof timing for insu�ation. The rest (25%) showed poorknowledge of the technique or described wrongmethods, such as placing two cannulae through the cri-cothyroid membrane or using a self-in¯ating bag forventilation. Consultant and specialist registrar gradeswere nearly three times as likely as sta� grades to cor-rectly identify all steps of the procedure (see Table 2).

42 doctors had personal experience of needle cri-cothyroidotomy in an emergency setting. Of these, 35felt that needle cricothyroidotomy had provided ade-quate oxygenation as a temporary manoeuvre whilstmore formal arrangements were made for a de®nitivesurgical airway.

84 departments (47%) have pre-assembled equip-ment for performing needle cricothyroidomy. Of these,four departments use a commercial jet insu�ator,

whilst 80 rely on adapted anaesthetic or medical equip-ment (see Fig. 1).

66 departments (36%) rely on commercially avail-able kits, preferring surgical to needle cricothyroid-omy.

The remaining 30 departments (17%) contactedfailed to locate any emergency equipment speci®callydesignated for provision of a surgical airway at thetime of interview.

The majority of departments include teaching ses-sions on advanced airway management in their teach-ing programme, although these are generally aimed atsenior house o�cers. Most doctors interviewed were ofthe opinion that knowledge of the technique for per-forming needle cricothyroidotomy was assumedthrough their attendance on advanced resuscitationcourses. 94% of those interviewed had attended atleast one of these courses and 29% were instructors onone or more courses. Instructors demonstrated a betterknowledge of needle cricothyroidotomy, with only 4%scoring poorly in the questionnaire.

4. Discussion

Telephone surveys have previously been criticisedfor their poor objectivity and ability to bias the re-sponse of a respondent through prompting and inter-action [11]. We felt this method was justi®ed for oursurvey as it tested immediate retention of core knowl-edge and simulated decision making in real time, asmight be expected when dealing with an emergency.Our questionnaire was designed to be neutral and non-suggestive and was validated prior to use on sta� inour own department. We chose to interview sta� ofspecialist registrar grade or above, as they are most

Table 1

Five points considered essential for the correct use of needle cricothyroidotomy apparatus

1 An oxygen source with a ¯ow at 10±15 l/min is necessary

2 Non-collapsible oxygen tubing must be used to connect the oxygen source and the cannula

3 A connection between oxygen tubing and cannula must be formed

4 A ventilation port must be incorporated in the system

5 A ventilation rate of one second insu�ation with four seconds break is appropriate

Table 2

Questionnaire score according to status

Total (%) Consultant (%) SpRa (%) Sta� grade (%) Instructorb (%)

All correct 39 55 54 20 66

3±4 correct 36 27 27 46 30

0±2 correct 25 18 19 34 4

a SpR Ð specialist registrar.b On at least one resuscitation course.

P. Davies / Injury, Int. J. Care Injured 30 (1999) 659±662660

likely to initiate or supervise use of these skills in anemergency situation. They were encouraged to describetheir normal practice rather than what they perceivedas ideal management.

Whilst a surgical airway will only be needed in aminority of patients attending an A&E department,the provision of such an airway needs to be immediateto be lifesaving. The three main methods of obtaininga surgical airway are needle cricothyroidotomy, surgi-cal cricothyroidotomy or blind stab techniques usingcommercial equipment [2]. Of these needle cricothyroi-dotomy allows the fastest, most simple access [12].

Anaesthetists have already recognised the import-ance of needle cricothyroidotomy in the setting of theanaesthetic room [13±15]. Three important trainingpoints have been identi®ed for its use to be im-plemented successfully [16]. These are:

. prior knowledge of needle cricothyroidotomy;

. availability of equipment;

. familiarity of use in the emergency situation.

Our survey shows that while needle cricothyroidot-omy would be the preferred choice for a surgical air-way in nearly 50% of the departments in GreatBritain, few if any of these departments' present prac-tice would meet the above points in their currentdepartmental training programmes. It is well knownthat resuscitation skills need to be practised regularlyto ensure adequate retention of knowledge [17]. This

appears to be con®rmed in our study, as instructors onresuscitation courses (who are likely to have regularexposure to surgical airway skills through their teach-ing) demonstrated a far better knowledge of the skillsused for needle cricothyroidotomy.

Sta� grades as a group were less likely to demon-strate adequate knowledge. Proportionately fewer wereinstructors on resuscitation courses and nearly 10%had not attended any courses at all (Table 3). Duringquestioning a number of sta� grades commented thatthey are also unable to attend departmental teaching,due to clinical commitments. Ideally, all sta� likely tobe involved in emergency airway management shouldhave the opportunity to update skills on a regularbasis.

The range of adapted equipment at present used forneedle cricothyroidotomy is diverse. Although basedon descriptions in the previously mentioned texts [4±9],the equipment is generally `Heath Robinson' in its de-

Fig. 1. Various `Heath Robinson' equipment for needle cricothyroidotomy.

Table 3

Comparison of instructor/provider status across grades of A&E

department doctors (%)

Instructor Provider Neither

Consultant 66 30 3

Sta� grade 11 80 9

SpR 30 62 2

P. Davies / Injury, Int. J. Care Injured 30 (1999) 659±662 661

sign; its simplicity of assembly, bulkiness and ease ofuse varies greatly. Recent research on similar equip-ment used in anaesthetic settings shows that design sig-ni®cantly a�ects oxygen delivery [18]. This is alsolikely to apply to the varying equipment describedduring our survey, and we are currently assessingwhether this is the case.

Our survey made no attempt to ascertain whetherother doctors would be called to the A&E departmentto help with the management of patients as describedin our scenario. Patients requiring a surgical airwayare seriously ill and are likely to be resuscitated by amulti-speciality team. Liaison with anaesthetic and sur-gical colleagues would ensure a standardisation ofequipment in all high dependency areas and a highlevel of doctors trained in its use.

To expand on the advice of Petty [16], whateverequipment is chosen for needle cricothyroidotomy itshould be similar, easily identi®ed equipment availablein the same location in every high dependency area.All personnel expected to use such equipment shouldknow its location and be trained its use on a regularbasis.

5. Conclusion

Whilst rarely performed, needle cricothyroidotomyis a potentially life saving procedure. Its e�ective usein A&E departments requires both immediate avail-ability of adequate equipment and regular training ofall sta� involved in its use.

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