I read with interest the case report number 2013-10 in the October NEWSLETTER by Dr. Dutton, regarding use of a knife or needle in emergency airway management. The only reason there is any debate about this matter is that most anesthesia personal have no real-life experience with either technique, and hence have no way to judge which is better. However, in a life-threatening airway obstruction, there is no question which is better. An emergency cricothyrotomy is much quicker, easier, safer and more effective than any needle-based technique. I can state with confidence that there is no place in emergency airway management for needle-based attempts to establish ventilation. It should be deleted from the ASA Difficult Airway Algorithm. I have participated in seven cricothyrotomies in emergency airway situations, and all of the patients left the hospital without any neurological injury or complications from the cricothyrotomy. The risk-benefit ratio is markedly in favor of the knife technique.
First, cricothyrotomy is quicker and easier, since one can find the cricothyroid membrane or tracheal rings and trachea much faster with a knife or scissors than with a needle.I have been teaching routine transtracheal injections to residents for more than 50 years, and even after multiple attempts by experienced residents, they still struggle to find the trachea. In an emergency, that delay is unacceptable. With a knife, or scissors, one cuts quickly either vertically or horizontally below the thyroid cartilage and there is the cricothyroid membrane or tracheal rings. The knife is inserted into the trachea and turned 90 degrees, and an airway is established. At that point, a small tube of any type can be inserted next to the knife. The knife technique is much safer because there is virtually nothing that one can harm by making an incision within two inches or less in the midline of the neck, and it can be performed in less than 30 seconds. In contrast, the needle is fraught with complications, including identifying the trachea, making certain that the needle is entirely in the trachea and does not move (to avoid subcutaneous emphysema when an oxygen source is established), establishing a pressurized oxygen delivery system (which will take more than five minutes even in the most experienced circumstances), and avoiding causing a tension pneumothorax with ventilation against an obstructed glottis. Finally, the knife technique is much more effective. I know of multiple cases of acute airway obstruction where the needle technique was attempted, and in all cases the patients died. I know of no such cases when a cricothyrotomy was used as the primary treatment of acute airway obstruction.
In a recent nationally publicized case, an internist successfully performed a cricothyrotomy in a restaurant following a failed Mueller maneuver in an overweight woman who developed acute airway obstruction from a piece of meat. If an internist can do this in a restaurant, anesthesia providers should be able to do it in the more controlled setting of an operating room or hospital. DITCH THE NEEDLE AND TEACH THE KNIFE!
C. Phillip Larson, Jr., M.D.
Professor Emeritus, Anesthesia and Neurosurgery
Professor of Clinical AnesthesiaDavid Geffen School of Medicine, UCLA
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