Bystander cricothyroidotomy performed with an improvised airway

Military Medicine, Jan 2002 by Adams, Bruce D

Objective: We report a roadside cricothyroidotomy successfully performed with only a pocketknife and the drinking straw from a sports bottle. Our study compared the adequacy of standard medical airway devices with some readily available nonmedical items that might be used as temporary tracheostomy tubes (TT). Methods: We compared the airway resistances (R^sub aw^) of two standard cricothyroidotomy airway devices against the barrel from a ballpoint pen and two sports bottle straws. Results: There was no statistically significant difference in R^sub aw^, between the straws and standard airway devices. However, the pen barrel had much higher R^sub aw^. Conclusion: This is the first study to compare available nonmedical items that might be used as temporary TTs for bystander cricothyroidotomy. Two types of straws found on sports bottles had relatively low R^sub aw^ compared with standard TTs. However, the barrel from a ballpoint pen had a much higher R^sub aw^ and is an unacceptable choice.

Introduction

The first priority in prehospital trauma management is to establish an adequate airway.1 Airway obstruction can occur from blood, vomit, or foreign bodies in the airway, especially in the trauma patient with diminished level of consciousness from head injury or drugs.1 Simple techniques such as a jaw thrust or a chin lift may temporize an airway obstruction, but trauma patients often require the definitive airway techniques of endotracheal intubation and, if necessary, cricothyroidotomy.1 Emergency medical services (EMS) personnel commonly learn and perform both endotracheal intubation and cricothyroidotomy in the prehospital environment.2-4

Many trauma victims, however, die from airway obstruction before the arrival of EMS personnel because hypoxia from airway obstruction is so rapidly fatal. Up to half of potentially survivable trauma fatalities will be found on autopsy to have an obstructed airway.5 In an Australian series, 7% of traffic fatalities died from airway obstruction alone, without any other serious injuries on autopsy.6 This is especially true in rural areas, with extended EMS response times. Physicians who are serendipitous accident bystanders could potentially perform cricothyroidotomy before the arrival of EMS personnel and standard airway equipment. Many physicians are capable of such a lifesaving procedure, especially with the popularity of Advanced Trauma Life Support courses. Surprisingly, we could find no case reports of cricothyroidotomy performed under these circumstances in the literature. We include in this article the first case report of a cricothyroidotomy performed by a bystander using improvised airway supplies. This case inspired our subsequent study to determine what would be the best improvised device for a roadside cricothyroidotomy.

Once a physician bystander determines that a cricothyroidotomy is immediately required, gathering the appropriate equipment becomes the critical issue. Before EMS arrival, standard medical equipment such as a scalpel, tracheostomy tube (TT) or endotracheal tube (ETT), bag-valve-mask device, or stethoscope is unavailable. So the physician must improvise using common materials available at hand. The only essential requirements for a bystander cricothyroidotomy are a good knife and some type of hollow device to substitute for the ETT.1 Medical texts on this matter recommend the barrel of a ballpoint pen among other potential improvised airways.8,9 Anecdotes abound of such bystander resuscitations, usually performed with a pocketknife and a ballpoint pen. Indeed, even fictional television shows have depicted dramatic cricothyroidotomies also performed with a ballpoint pen. 10 The best candidate for TT surrogate should have these properties: ubiquitous so that at least one bystander at the accident scene would have it on hand; long enough to cannulate the cricothyroid membrane and still allow for mouth-totube ventilations; narrow enough to fit into the cricothyroid membrane; rigid enough to not collapse in the wound (like a soft drink straw would be expected to); and, most importantly, have a low airway resistance. But is the ballpoint pen barrel the best option for bystander cricothyroidotomy? In the case described below, the large plastic straw from a sports bottle (Fig. 1) was successfully improvised for the endotracheal tube. To further evaluate this choice, we conducted a comparative study to determine which improvised device had the lowest airway resistance: the ballpoint pen barrel or the sports bottle straw.

Case Report

On a rural interstate highway in the southwestern United States, a sport utility vehicle lost control and experienced a high-speed rollover. A middle-aged male unrestrained passenger was ejected from the back seat. A physician bystander (B.D.A.) evaluated the patient within 60 seconds of the accident. The patient's radial pulse was rapid and faint, and he had gurgling respirations at approximately 5 per minute. He had a Glasgow Coma Scale score of 3. The secondary survey revealed an open skull injury with a dilated left pupil, a flail mandibular fracture, and large contusions over his chest and left flank. Attempts at opening his airway with the jaw thrust technique were unsuccessful because of the mandibular fracture. Manually pulling his tongue forward improved his airway briefly, but blood and fluids subsequently filled his pharynx, and he became pulseless.