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Perceived versus actual cricothyroid membrane landmarking accuracy by emergency medicine residents and staff physicians

  • Nicholas Schouela (a1), Michael Y. Woo (a1), Andy Pan (a1), Warren J. Cheung (a1) and Jeffery J. Perry (a1) (a2)...

Abstract

Objectives

Cricothyrotomy is an intervention performed to salvage “can't intubate, can't ventilate” situations. Studies have shown poor accuracy with landmarking the cricothyroid membrane, particularly in female patients by surgeons and anesthesiologists. This study examines the perceived versus actual success rate of landmarking the cricothyroid membrane by resident and staff emergency physicians using obese and non-obese models.

Methods

Five male and female volunteers were models. Each model was placed supine, and a point-of-care ultrasound expert landmarked the borders of each cricothyroid membrane; 20 residents and 15 staff emergency physicians were given one attempt to landmark five models. Overall accuracy and accuracy stratified by sex and obesity status were calculated.

Results

Overall landmarking accuracy amongst all participants was 58% (SD 18%). A difference in accuracy was found for obese males (88%) versus obese females (40%) (difference = 48%, 95% CI = 30–65%, p < 0.0001), and non-obese males (77%) versus non-obese females (46%) (difference = 31%, 95% CI = 12–51%, p = 0.004). There was no association between perceived difficulty and success (correlation = 0.07, 95% CI = −0.081–0.214, p = 0.37). Confidence levels overall were higher amongst staff physicians (3.0) than residents (2.7) (difference = 0.3, 95% CI = 0.1–0.6, p = 0.02), but there was no correlation between confidence in an attempt and its success (p = 0.33).

Conclusion

We found that physicians demonstrate significantly lower accuracy when landmarking cricothyroid membranes of females. Emergency physicians were unable to predict their own accuracy while landmarking, which can potentially lead to increased failed attempts and a longer time to secure the airway. Improved training techniques may reduce failed attempts and improve the time to secure the airway.

RésuméObjectif

La cricothyrotomie est une intervention de dernier recours qui se pratique dans les cas où il est impossible d'intuber ou de ventiler un patient. D'après des études, l'exactitude du repérage de la membrane cricothyroïde par les chirurgiens et les anesthésistes est peu élevée, surtout chez les femmes. L’étude visait donc à comparer le taux de réussite pressentie ou réelle du repérage de la membrane cricothyroïde par des résidents et des urgentologues, sur des modèles obèses et non obèses.

Méthode

Cinq hommes et femmes se sont prêtés au rôle de modèle; ceux-ci étaient en décubitus dorsal, et un spécialiste de l’échographie au chevet a repéré les bords de la membrane cricothyroïde sur chacun d'eux. Les résidents et les urgentologues participants, au nombre de 20 et de 15 respectivement, ne pouvaient tenter qu'une seule fois de repérer la membrane sur les 5 modèles. Les degrés d'exactitude globale et d'exactitude répartie selon le sexe et le degré d'obésité ont ensuite été calculés.

Résultats

Le taux global d'exactitude du repérage de la membrane a atteint 58% (écart type : 18%). Toutefois, un écart d'exactitude a été relevé entre les hommes obèses (88%) et les femmes obèses (40%) (écart : 48%; IC à 95% : 30-65%; p < 0,0001) ainsi qu'entre les hommes non obèses (77%) et les femmes non obèses (46%) (écart : 31%; IC à 95% : 12-51%; p : 0,004). Il n'y avait pas d'association entre le degré pressenti de difficulté et le degré de réussite (corrélation = 0,07; IC à 95% : -0,081-0,214; p : 0,37). Le degré de confiance, dans l'ensemble, était plus élevé chez les membres du personnel médical (3,0) que chez les résidents (2,7) (écart : 0,3; IC à 95% : 0,1-0,6; p : 0,02), mais il n'y avait pas de corrélation entre le degré de confiance dans la tentative de repérage et le degré de réussite (p : 0,33).

Conclusion

Le degré d'exactitude du repérage de la membrane cricothyroïde, par les médecins, était significativement plus faible chez les femmes. Les urgentologues n’étaient pas en mesure de prévoir leur propre degré d'exactitude pendant le repérage de la membrane, hésitation qui peut conduire à un nombre accru d’échecs et à une prolongation du temps nécessaire au rétablissement de la perméabilité des voies respiratoires. Aussi une amélioration des techniques de formation permettrait-elle de corriger ces deux lacunes.

Copyright

Corresponding author

Correspondence to: Nicholas Schouela, Department of Emergency Medicine, The Ottawa Hospital, 1053 Carling Ave, OttawaON, K1Y 4E9; Email: nschouela@toh.ca.

References

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3.Lamb, A, Zhang, J, Hung, O, et al. Accuracy of identifying the cricothyroid membrane by anesthesia trainees and staff in a Canadian institution. Can J Anaesth 2015;62(5):495503.
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7.Siddiqui, N, Yu, E, Boulis, S, et al. Ultrasound is superior to palpation in identifying the cricothyroid membrane in subjects with poorly defined neck landmarks: a randomized clinical trial. Anesthesiology 2018;129:1132–9.
8.CDC. Centers for Disease Control and Prevention. Overweight and obesity – defining adult overweight and obesity; April 11, 2017. Available at: https://www.cdc.gov/obesity/adult/defining.html (accessed July 16, 2019).
9.Fennessy, P, Drew, T, Husarova, V, Duggan, M, McCaul, CL.Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length. Br J Anaesth 2019;122(2):263–8.
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Perceived versus actual cricothyroid membrane landmarking accuracy by emergency medicine residents and staff physicians

  • Nicholas Schouela (a1), Michael Y. Woo (a1), Andy Pan (a1), Warren J. Cheung (a1) and Jeffery J. Perry (a1) (a2)...

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