So we have discussed my preference for surgical over needle-based techniques for front-of-neck-access (FONA) many times on the podcast. You can see the needle vs. knife discussions in some of the earlier posts as well. Cut to air just works better in my opinion. If you'd like to see how I advocate you perform this procedure, come to the EMCrit Cric Page. This debate has heated up as the airway society of the UK has recently recommended scalpel-bougie cricothyrotomy as the first technique for FONA. Editorials explain why this decision was made. Currently, the Australians are still recommending needle-based techniques. So, to add gasoline to the debate, today I interview Laura Duggan, MD.
Laura completed residencies in both paediatrics and anesthesiology, as well as a cardiothoracic anesthesiology fellowship. She practiced for a time as a paediatric emergency physician in Canada. She now practices cardiac and general anesthesia at a level 1 trauma centre. In short, she is the perfect person to discuss these issues with. I got to chat with Laura at SmaccDUB about a paper she had just written on the high failure rate of transtracheal jet ventilation in can't intubate, can't oxygenate situations.
Laura's TTJV Failure Paper
Recent EM Paper regarding Needle Cricothyrotomy
The Airway App
Download it on the Airway Collaboration Site
The Ventrain Device
I tested this device on the bench (no COI) and the reason I think it is the best of the crop is its active exhalation and the ability to monitor ETCO2. They sell it in kits with a proper cannula as well.
- PMID 24980421
- PMID 21177698
- PMID 20100697
Other Jerry-Rigged Techniques (None are Recommended)
3-Way Stopcocks are Probably Inadequate
Catheter or cath with 3-way stopcock is prob. inadequate for exhalation unless 13 seconds between breaths (Anaesthesia 2009;64:1353 and Pediatric Anesth 2009;19:452)
Use a Ventilator
Br J Anaesth 2013;110(3):456
- PMID 22436319
Mann, C.M., Baker, P.A., Sainsbury, D.M., Taylor, R., 2021. A comparison of cannula insufflation device performance for emergency front of neck airway. Paediatr Anaesth 31, 482–490. https://doi.org/10.1111/pan.14128
Ventrain was the only device in this study that did not produce potentially injurious pressures, but ENK was pretty good and device below has not been tested
The original needle vs. knife for Andy Heard's Method
If you had to use one, here is the one Ric Solis and I Conceptualized
You can read more about it in EM News
Additional New Information
More on EMCrit
- Guest Post: More from Minh Le Cong on Needle Cricothyrotomy(Opens in a new browser tab)
- Podcast 053 – Needle vs. Knife: Part I(Opens in a new browser tab)
- EMCrit Wee – An Amazing (Wearable) Cric Trainer from Laura Duggan and the AirwayCollaboration Folks(Opens in a new browser tab)
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