There is perhaps no greater emergency in anesthesiology than the “can’t intubate, can’t ventilate” (CICV) situation. This potential disaster is very rarely encountered (estimated at 1 in 12,500 to 1 in 50,000 cases), but threatens the patient’s life within seconds. The ultimate remedy to breathe for a patient who is anesthetized and often paralyzed, unable to breathe for himself, is to perform a cricothyrotomy or tracheotomy (place a small tube directly through the neck and into the windpipe, either through the cricothyroid membrane, or between the tracheal rings below). This can be accomplished with a scalpel, which anesthesiologists rarely wield in this fashion, or it can be performed using a needle and a subsequent series of steps called the “seldinger technique” with which anesthesiologists are quite experienced.
The ideal procedure for this rare but deadly emergency should be easy to master, rapid to perform with readily available equipment, and have a high success and low complication rate. Thus far, the literature is insufficient to demonstrate the superiority of any one technique; speed and success rates vary widely. It is therefore unknown which technique should be employed in an emergency, and moreover, which should be taught to physicians training in the specialty of anesthesiology. This uncertainty was recently reviewed in a case report by the Anesthesia Quality Institute.
A response was published shortly thereafter, by Dr. C. Phillip Larson of Stanford, who was a fellow faculty member and mentor to me when we were both at UCLA a few years ago. He says, “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.”
He goes on to say that, in his over 50 years of clinical practice, he has personally participated in seven emergency airway situations in which a knife based technique was performed, and all patients not only lived, but left the hospital with out any injury or complications from the airway procedure.
Dr. Larson also references a recent highly-publicized case in which an internal medicine physician specializing in infectious diseases saved a choking woman’s life in a restaurant, using a knife and ballpoint pen.
Dr. Larson’s technique, paraphrased: With a knife or scissors, cut quickly either vertically or horizontally below the thyroid cartilage to find the cricothyroid membrane or tracheal rings. Insert the knife into the trachea and turn it 90 degrees. At that point, a small tube of any type can be inserted next to the knife. The Daily Mail “infographic” above, perhaps funny, basically sums up the same.
There is often a preference in decision making to avoid that with which we are unfamiliar and “go with what we know”. For many anesthesiologists, this means going with a needle technique, which may be used for other procedures often, perhaps even daily. Omission bias is the tendency to avoid a certain action and prefer the status quo, typically out of fear of causing harm or being wrong. If Dr. Larson is correct, this fear is misplaced, since knife based cricothyrotomy or tracheotomy may be more successful in saving lives than needle based techniques. Apparently, this may be true even if the physician operating the knife has never before performed the emergency airway procedure.
As we wrote in the AQI article, perhaps the most important problem encountered in emergency airway situations is a delay in recognition or institution of emergency airway management. This human factors problem is illustrated in the video “Just a Routine Operation” in which two experienced anesthesiologists AND a head-and-neck surgeon specialist failed to act decisively, resulting in the patient’s death in an otherwise apparently routine and simple case. Retrospective studies and closed claims analyses tell us that patients are most often already in cardiac arrest before invasive airway attempts are performed.
While decisive and timely action is clearly needed, the decision to pursue a surgical airway is not an easy one; surgeons and the anesthesiologist are vulnerable to psychological phenomena that can lead to delay. A few examples include fixation (as with an inability to shift attention from traditional laryngoscopy attempts to an alternate technique); poor situation awareness (failure to recognize the amount of time passed), and omission bias described above. Ironically, delays due to fear may be also rooted in concern for litigation or damage to reputation. In fact, there is little legal risk from a surgical airway attempt – no matter how messy – if the patient survives, but enormous liability if the procedure is not attempted.
Read more on these kinds of decision factors here.
Have you ever performed an emergency invasive airway? What happened?