John Hinds, Critical Care and Irish Road Racing Doc, gave my absolute favorite lecture from SMACCgold. It was the con side of a debate on Cricoid Pressure for Emergency Airway Management. Well, it was actually a rep pitch for a new drug called Cricolol. You will enjoy it!
Here is the conference write-up version in ACEP Now
Note: This is a remixed version from the one up on Intensive Care Network (love those guys!), so watch it again…
Update
Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy. Acad Emerg Med. 2017 Sep 28. doi: 10.1111/acem.13326. [Epub ahead of print]
References
- Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. Lancet 1961;2:404-6.
- Koziol CA, Cuddeford JD, Moos DD. Assessing the force generated with application of cricoid pressure. AORN journal 2000;72:1018-28, 30.
- Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology 2003;99:60-4.
- Hartsilver EL, Vanner RG. Airway obstruction with cricoid pressure. Anaesthesia 2000;55:208-11.
- Allman KG. The effect of cricoid pressure application on airway patency. Journal of clinical anesthesia 1995;7:197-9.
- Levitan RM, Kinkle WC, Levin WJ, Everett WW. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Annals of emergency medicine 2006;47:548-55.
- Garrard A, Campbell AE, Turley A, Hall JE. The effect of mechanically-induced cricoid force on lower oesophageal sphincter pressure in anaesthetised patients. Anaesthesia 2004;59:435-9.
- Chassard D, Tournadre JP, Berrada KR, Bouletreau P. Cricoid pressure decreases lower oesophageal sphincter tone in anaesthetized pigs. Canadian journal of anaesthesia = Journal canadien d'anesthesie 1996;43:414-7.
- Heath KJ, Palmer M, Fletcher SJ. Fracture of the cricoid cartilage after Sellick's manoeuvre. British journal of anaesthesia 1996;76:877-8.
- Ralph SJ, Wareham CA. Rupture of the oesophagus during cricoid pressure. Anaesthesia 1991;46:40-1.
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Hahaha!- Greatest lecture ever!
O’Scott, The talk is entertaining at many points, but even stripped of the O’Godwin’s Law moment, it is far from convincing. Before getting to the critique: regurgitation is obviously infrequent (or there would be no debate) but it may still be of benefit in a subgroup of patients that are difficult to identify in advance. It is equally obvious that in many settings, expert judgment may dictate delegation of available resources for tasks other than CP. That is far from arriving at the conclusion that there is no evidence of benefit across all settings. The issue of evidence is particularly… Read more »
Greg, A reasoned and balanced set of points. I remain unconvinced of the net good of cricoid. My experience as the QA lead for every airway managed in the ED of Janus General over the past decade or so is that passive regurg is not a real event given the following: no provision of positive pressure breaths and all our patients are intubated in 20-30 degrees head-up. Aspiration events seem to occur when a patient needs BVM ventilation (an evil device that should be destroyed). Bad bvm=regurgitation. The study I’d like to see is every emergency intubation that requires BVM… Read more »
Scott, I understand reacting to a dictum by others that cricoid pressure (CP) be applied in all instances, but I would disagree that the best response is to develop a departmental policy concluding that CP has no value and will not be applied. Regurgitation is a rare event, but given the potentially severe consequences, the application of CP should not be framed as a yes/no question. Even those who advocate CP in virtually every high-risk patients make allowances for a cost/benefit decision. (Taken to it’s extreme, CP would be applied in every instance, since even well-fasted patients who are otherwise… Read more »
Hi Greg, Thanks for the comments! It’s the nature of the beast when you get 10 minutes to present one side of an argument – with the ultimate goal of “winning” – it’s tough to come up with something balanced, let alone comprehensive! Overall though I think that the spirit of my tactics were true. If it was a drug, none of us would be buying it and committing an assistant to give it during a airway intervention. We wouldn’t even be arguing the toss. We’d chase the drug rep out of the Unit. As a perceived “benign” and “free”… Read more »
John, You obviously had a good time with your side. I accept the sincerity of your position and recognize the challenges you face with unstable patients in an austere environment. I did use your talk as an opportunity to delve into some of the references and consider it a good investment of my time. Every package insert lists contraindications as well as indications for a drug. It’s especially easy to choose a drug where the effect can be observed directly; it can be a more challenging decision when the drug is preventative. Drugs also have directions for use. The debate… Read more »