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Role of ultrasonography in an impalpable tissue larynx model during a simulated front-of-neck access scenario: a randomized simulation study

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Abstract

Purpose

A large vertical incision is recommended when performing front-of-neck access in patients with impalpable neck landmarks during a cannot intubate–cannot oxygenate (CICO) scenario. We investigated the impact of ultrasonography on vertical incision size of a front-of-neck access on an ultrasound-compatible impalpable porcine larynx model.

Methods

Emergency medicine and anesthesia trainees were randomized to the Ultrasound (US, n = 21) and Non-Ultrasound (NUS, n = 21) groups. Within 1 week after a teaching session on airway ultrasound and Scalpel-Bougie-Tube (SBT) technique, participants were instructed to perform cricothyroidotomy on the model during a simulated cannot intubate–cannot oxygenate scenario. The primary outcome was a vertical size incision. Secondary outcomes were procedural completion time, horizontal size incision, tissue injury severity, and correct tube placement.

Results

The ultrasound group performed a significantly smaller vertical incision [median (IQR), 35.0 (15, 40) vs 65.0 (52, 100) mm (95% CI) − 30.0 (− 55.1, − 4.9), p = 0.02] and took longer total time to complete the procedure [median (IQR), 200.5 (126, 267) vs 93.5 (71.0, 167.5) secs (95% CI) 91.0 (3.73, 178.3), p = 0.04]. Tissue injury severity and correct tube placement were similar between groups.

Conclusions

Ultrasound-guided identification of the cricothyroid membrane significantly reduced the recommended vertical incision size with similar success rates. However, there was an increased time when performing a Scalpel-Bougie-Tube cricothyroidotomy on an impalpable porcine larynx model by physicians in training. Ultrasonography should not be used in an emergency scenario of airway rescue. Its potential use to pre-mark the cricothyroid membrane should be considered in difficult airway management of impalpable neck.

Résumé

Objectif

Il est recommandé de pratiquer une grande incision verticale lors de l'accès à l'avant du cou chez les patients dont les repères du cou sont impalpables, dans le cadre d'un scénario d'intubation impossible à oxygéner (CICO). Nous avons étudié l'impact de l'échographie sur la taille de l'incision verticale d'un accès à la face avant du cou sur un modèle de larynx porcin impalpable compatible avec l'échographie.

Méthodes

Des stagiaires en médecine d'urgence et en anesthésie ont été répartis de manière aléatoire entre les groupes "échographie" (US, n = 21) et "non-échographie" (NUS, n = 21). Une semaine après une session d'enseignement sur l'échographie des voies aériennes et la technique Scalpel-Bougie-Tube (SBT), les participants ont reçu l'instruction de réaliser une cricothyroïdotomie sur le modèle lors d'un scénario simulé d'impossibilité d'intubation et d'oxygénation. Le résultat primaire était une incision de taille verticale. Les résultats secondaires étaient le temps de réalisation de la procédure, la taille horizontale de l'incision, la gravité de la lésion tissulaire et le placement correct du tube.

Résultats

Le groupe échographie a réalisé une incision verticale significativement plus petite [médiane (IQR), 35,0 (15,40) vs 65,0 (52,100) mm (IC à 95 %) -30,0 (-55,1, -4,9), p = 0,02] et a pris un temps total plus long pour terminer la procédure [médiane (IQR), 200,5 (126, 267) vs 93,5 (71,0, 167,5) secondes (IC à 95 %) 91,0 (3,73, 178,3), p = 0,04]. La gravité des lésions tissulaires et le placement correct du tube étaient similaires entre les groupes.

Conclusions

L'identification échoguidée de la membrane cricothyroïdienne a réduit de manière significative la taille de l'incision verticale recommandée avec des taux de réussite similaires. Cependant, il y avait une augmentation du temps lors de la réalisation d'une cricothyroïdotomie Scalpel-Bougie-Tube sur un modèle de larynx porcin impalpable par des médecins en formation. L'échographie ne doit pas être utilisée dans un scénario d'urgence de sauvetage des voies respiratoires. Son utilisation potentielle pour pré-marquer la membrane cricothyroïdienne devrait être envisagée dans la gestion des voies aériennes difficiles du cou impalpable.

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Funding

Financial support and sponsorship: This study was funded by the Society of Airway Management Research Award. The funding source had no direct involvement in any stage of the study.

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Authors and Affiliations

  1. Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital-Sinai Health System, University of Toronto, 7-405, 600 University Avenue, Toronto, ON, M5G 1X5, Canada

    Fabricio Batistella Zasso, Dekel Lait, Naveed Siddiqui & Kong Eric You-Ten

  2. Department of Family Medicine-Emergency Medicine, Mount Sinai Hospital-Sinai Health System, University of Toronto, Toronto, ON, Canada

    Vsevolod S. Perelman

  3. MiCcare Research Centre, Mount Sinai Hospital-Sinai Health System, University of Toronto, Toronto, ON, Canada

    Xiang Y. Ye

Authors
  1. Fabricio Batistella Zasso
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  2. Dekel Lait
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  3. Naveed Siddiqui
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  4. Vsevolod S. Perelman
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  5. Xiang Y. Ye
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  6. Kong Eric You-Ten
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Contributions

FBZ, DL, NS, VSP, and KEYT: conceptualized and planned the study. KEYT: supervised all stages of the study. FBZ, DL, and KEYT: participated in data acquisition. FBZ, XYY, and KEYT: participated in the data analysis. FBZ and KEYT: participated in writing the manuscript draft. FBZ, DL, NS, VSP, XYY, and KEYT: reviewed, edited, and approved the final version of the manuscript.

Corresponding author

Correspondence to Kong Eric You-Ten.

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The authors have no conflicts of interest to declare.

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Zasso, F.B., Lait, D., Siddiqui, N. et al. Role of ultrasonography in an impalpable tissue larynx model during a simulated front-of-neck access scenario: a randomized simulation study. Can J Emerg Med 24, 862–866 (2022). https://doi.org/10.1007/s43678-022-00399-6

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  • DOI: https://doi.org/10.1007/s43678-022-00399-6

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