The Problem

idea series teaching residents quality improvement

Cricothyroidotomy is an emergency life-saving procedure that involves surgical placement of a tube through the cricothyroid membrane in order to establish a patent airway for oxygenation and ventilation. The indications for this procedure are when traditional means, such as orotracheal or nasotracheal intubation, are contraindicated or have failed during attempts to establish an emergency airway.1,2 It is a critical skill for emergency physicians but the declining rate of this procedure has resulted in decreased exposure during training.3,4

It is well known that training improves the rate of success of cricothyroidotomy but this can be limited by simulator accessibility and cost of purchasing training equipment.1,5 Simulation using animal trachea is costly and local institutions may have restrictions on the type of animal models that are allowed.

Previous studies examining the impact of model fidelity on cricothyroidotomy skills acquisition demonstrated equal effectiveness between those trained on low-fidelity versus high-fidelity simulators.4 It is therefore important to use available simulations to provide residents and medical students with adequate training on this low-frequency procedure that can be life saving.

The Innovation

The purpose of this simulation workshop is to provide an easily-assembled, simple, inexpensive, and reusable low-fidelity simulation model for teaching emergency medicine (EM) residents and EM-bound medical students how to perform cricothyroidotomy.

Target Learners

This simulation workshop is designed for EM learners.

Group Size

The ideal group size is 10-50 learners. Ideally, this workshop runs parallel with other airway skills acquisition stations. Ideally, each learner has their own model. We used 4 models per station and rotated every 20-25 minutes.

Materials Needed

Materials Image Cost Quality
1-1/4 in. x 6 in. Polypropylene Tailpiece Extension Tube $2.96 1 per station
6 in. Folding Jab Saw $14.97 1 (optional)
1-1/4 in. Polypropylene Wall Tube $1.30 1 per station
1 in. x 6 ft. Rubber Self-Stick Pipe Insulation $7.61 1 per station. This is the recurring cost for future simulations. To simulate more difficult anatomy, use more layers.
1-1/4 in. I.D. x 1 ft. Polyethylene Pool and Spa Hose $4.62 1/2 per station
Scotch 3/4 in. x 66 ft. x 0.007 in. #35 Vinyl Electrical Tape, Red $3.98 1
11 in. UV Cable Tie – Black (10-Pack) $1.98 1

Description of the Innovation

The construction materials were purchased at a local hardware store and assembled by 1 person in 1 hour.

The low-fidelity cricothyroidotomy models were used during a simulation workshop to train and improve the confidence and performance of cricothyroidotomy for EM residents and medical students. The workshop occurred in a classroom setting during the weekly scheduled resident conference time period.

The cricothyroidotomy procedure was first demonstrated by an EM faculty member using the low-fidelity model and explained in a step-wise fashion. The learners performed the procedure, ideally each on their own cricothyroidotomy model, while the faculty observed each attempt. Real-time feedback was provided during each attempt.

As the learners honed their skill with the model, following attempts increased in difficulty by providing additional layers of “tissue” (pipe insulation) to resemble difficult neck anatomy. Chicken skin can also be added on the surface to simulate organic skin.

After each individual attempt, the cricothyroid membrane should be replaced with tape and the biosimulation models reassembled.

Base Model: Connecting the wall tube to the extension tube

  • Connect the wall tube to the extension tube.
  • The pool and spa hose was cut in the back to allow for easy insertion into the extension tube.
  • A 1 cm x 2 cm slit was cut on the wall tube using the Jab Saw.
  • This slit will then be covered with the electrical tape to simulate the cricothyroid membrane.
  • The base model has been reused several times for future simulations.
Figure 1. Base model. This model can be been reused several times for future simulations.
Figure 2. Base model + additional simulated texture

The Actual Model: Adding realism

  • Pipe insulation was used to cover the length of the contraption to simulate adipose
  • Chicken skin may be placed over the pipe insulation to further simulate the neck texture. On the second iteration, simulation without the chicken creates a similar  experience without the mess.
  • We used old pillows to set the model on the table.
  • Learners are able to learn and practice traditional cricothyroidotomy, scalpel-bougie-ETT approach, and reverse intubation using Seldinger approach.
Figure 3. The Actual Model

Lessons Learned

Cricothyroidotomy training is fundamental to the development of the proper skill and confidence needed to effectively perform this life saving procedure under suboptimal circumstances. Low-fidelity simulators have been proven to achieve equal effectiveness in skill acquisition as their more expensive high-fidelity counterparts.

The low-fidelity model we present provides a cost effective means of training on this procedure that can result in higher success rates, lower cricothyroidotomy procedure times, and increased EM learner confidence.

Theory Behind the Innovation

Cricothyroidotomy is an essential life-saving emergency procedure used to establish a patent airway in a difficult situation and potentially save a patient’s life. Due to the declining rate of this procedure, simulation has become an essential component to ensure the adequate exposure needed to become competent and confident under the most difficult circumstances. Although a number of high-fidelity simulators are available, the cost can be a limiting factor for many institutions. Through a low-fidelity, inexpensive, reusable simulator, all learners may obtain the exposure and training on this procedure to develop the competency and confidence needed to perform a cricothyroidotomy under emergency situations.

Read more about the IDEA Series.

References

  1. 1.
    Jayaraman V, Feeney J, Brautigam R, Burns K, Jacobs L. The use of simulation procedural training to improve self-efficacy, knowledge, and skill to perform cricothyroidotomy. Am Surg. 2014;80(4):377-381.
  2. 2.
    Schroeder AA. Cricothyroidotomy: When, why, and why not? American Journal of Otolaryngology. 2000;21(3):195-201. doi:10.1016/s0196-0709(00)85024-3
  3. 3.
    Chang RS, Hamilton RJ, Carter WA. Declining Rate of Cricothyrotomy in Trauma Patients with an Emergency Medicine Residency: Implications for Skills Training. Academic Emergency Medicine. 1998;5(3):247-251. doi:10.1111/j.1553-2712.1998.tb02621.x
  4. 4.
    Friedman Z, You-Ten KE, Bould MD, Naik V. Teaching Lifesaving Procedures: The Impact of Model Fidelity on Acquisition and Transfer of Cricothyrotomy Skills to Performance on Cadavers. Anesthesia & Analgesia. 2008;107(5):1663-1669. doi:10.1213/ane.0b013e3181841efe
  5. 5.
    Varaday SS, Yentis SM, Clarke S. A homemade model for training in cricothyrotomy. Anaesthesia. 2004;59(10):1012-1015. doi:10.1111/j.1365-2044.2004.03810.x
Samuel Garcia

Samuel Garcia

Medical Student
Texas Tech University Health Sciences Center
Paul L. Foster School of Medicine
El Paso, TX
Al'ai Alvarez

Al'ai Alvarez

Assistant Residency Program Director
Clinical Assistant Professor
Department of Emergency Medicine
Stanford University School of Medicine
Palo Alto, CA