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The neck is a critical region containing many essential structures. Before surgical intervention, it is crucial to assess the adequacy of the airway and circulation, as well as the presence of any skeletal or neurological damage. Here, we present a case of a 33-year-old male with a background of amphetamine abuse who presented to our emergency department with a penetrating neck injury just below the mandible at the hypopharynx level, resulting in an upper zone II neck injury with complete separation of the airway. The patient was taken immediately to the operating room for exploration. Airways were managed by direct intubation, hemostasis was maintained, and the open laryngeal injury was repaired. After the surgery, this patient was transferred to the intensive care unit for two days and discharged after a satisfactory full recovery. Penetrating neck injuries are rare but often fatal. Advanced trauma life support guidelines emphasize the importance of managing the airway as the first action. Providing multidisciplinary care before, during, and after trauma can help prevent and treat such incidents.

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BACKGROUND: With recent technological advances reducing the demand for emergent surgical airway placement, surgeons are less often performing this life-saving procedure. We sought to assess the characteristics and outcomes surrounding patients undergoing modern emergent cricothyrotomy. METHODS: A retrospective case series was performed between January 2010 and January 2020 at a single tertiary academic level 1 trauma center. Patients who underwent tracheostomy (CPT 31600, 31601) within 48 hours of admission or listed in the trauma registry were queried. Charts were individually reviewed to identify patients with cricothyrotomy. Demographic, operative and relevant hospital course data were collected. RESULTS: A total of 1642 patients were identified with 12 of those found to have met inclusion criteria. The population was mostly male (91.7%) with an average age of 43 years and average body mass index of 30. Survival rate of patients was 75%. A total of 7 patients (58%) had appropriate anatomical placement of cricothyrotomy. Of those patients, 75% were performed by Trauma Surgery. Of the 5 patients with misplaced cricothyrotomy, all were male, with an average age and body mass index of 36 years and 25, respectively. Procedures were performed by prehospital personnel (20%), referring hospital (20%), and Trauma Surgery (60%). DISCUSSION: Cricothyrotomy remains a vital tool in the successful management of emergent airway access. The most common complication observed was improper anatomical placement, which occurred in nearly half of patients. Trauma surgeons perform 75% of cricothyrotomies, with an anatomical accuracy rate of 66.7%.

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BACKGROUND: Airway guidelines recommend an emergency surgical airway as a potential life-saving treatment in a "Can't Intubate, Can't Oxygenate" (CICO) situation. Surgical airways can be achieved either through a cricothyroidotomy or tracheostomy. The current literature has limited data regarding complications of cricothyroidotomy and tracheostomy in an emergency situation. The objective of this systematic review is to analyze complications following cricothyroidotomy and tracheostomy in airway emergencies. METHODS: This synthesis of literature was exempt from ethics approval. Eight databases were searched from inception to October 2018, using a comprehensive search strategy. Studies were included if they were randomized controlled trials or observational studies reporting complications following emergency surgical airway. Complications were classified as minor (evolving to spontaneous remission or not requiring intervention or not persisting chronically), major (requiring intervention or persisting chronically), early (from the start of the procedure up to 7 days) and late (beyond 7 days of the procedure). RESULTS: We retrieved 2659 references from our search criteria. Following the removal of duplicates, title and abstract review, 33 articles were selected for full-text reading. Twenty-one articles were finally included in the systematic review. We found no differences in minor, major or early complications between the two techniques. However, late complications were significantly more frequent in the tracheostomy group [OR (95% CI) 0.21 (0.20-0.22), p < 0.0001]. CONCLUSIONS: Our results demonstrate that cricothyroidotomies performed in emergent situations resulted in fewer late complications than tracheostomies. This finding supports the recommendations from the latest Difficult Airway Society (DAS) guidelines regarding using cricothyroidotomy as the technique of choice for emergency surgical airway. However, emergency cricothyroidotomies should be converted to tracheostomies in a timely fashion as there is insufficient evidence to suggest that emergency cricothyrotomies are long term airways.

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Technical and psychological factors make performance of an emergency front-of-neck airway (eFONA) a challenging procedure for clinical teams involved in airway management. When 'cannot intubate, cannot oxygenate' (CICO) emergencies occur, eFONA is frequently performed too late or not at all. The concept of transition to eFONA comprises simultaneous efforts to prevent and prepare for eFONA before a declaration of CICO in an effort to facilitate its timely and effective implementation. Although such a transition represents an appealing idea, attention to many aspects of airway practice is required for it to become an effective intervention.

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A "cannot ventilate, cannot intubate" scenario is a rare, high-risk anesthesia event. Cricothyrotomy is the final step, but anesthesia training and maintenance of surgical airway skills is variable. The ability to "cut to air" when one performs a cricothyrotomy may be all that prevents a patient from experiencing anoxic brain injury or death. Forty-three Certified Registered Nurse Anesthetists (CRNAs) performed emergency cricothyrotomies on a simulation manikin. Three techniques were available: (1) cricothyrotomy kit, (2) scalpel and tracheostomy, and (3) scalpel/bougie/endotracheal tube. Technique selection and performance were recorded until successful confirmation of placement was achieved in less than 2 minutes. Confidence levels performing cricothyrotomy were also measured before and after simulation. Most CRNAs (53.5%) selected the cricothyrotomy kit, and all but 1 completed the cricothyrotomy in under 2 minutes. The scalpel/bougie/endotracheal tube combination was the fastest, with an average completion time of 86.6 seconds. The confidence of CRNAs in performing a successful cricothyrotomy in less than 2 minutes was significantly increased (P ≤ .001). Simulating airway skills improved performance, speed, and confidence. Because not all CRNAs have had extensive education in performing surgical airways and practicing these skills, simulation may have additional value in developing and maintaining skills and confidence.

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INTRODUCTION: An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments. METHODS: We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT). RESULTS: Of 207 DAMT activations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event. CONCLUSION: An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.

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BACKGROUND: Surfing is an increasingly popular activity and surfing-related injuries have increased accordingly. However, to the best of our knowledge, there are no reports of penetrating upper airway injuries in surfers. We present a "cannot ventilate, cannot intubate" situation following penetrating neck injury by a surfboard fin. CASE PRESENTATION: A previously healthy 29-year-old Japanese man was swept off his board by a large wave and his left mandible, tongue root, and right epipharynx were penetrated by the surfboard fin. He presented with severe hypovolemic shock because of copious bleeding from his mouth. Direct laryngoscopy failed, as did manual ventilation, because of the exacerbated upper airway bleeding and distorted upper airway anatomy. Open cricothyrotomy was immediately performed, followed by surgical exploration, which revealed extensive ablation of his tongue root and laceration of his lingual artery. After definitive hemostasis and intensive care, he returned home with no sequelae. CONCLUSIONS: The long, semi-sharp surfboard fin created both extensive crushing upper airway lesions and a sharp vascular injury, resulting in a difficult airway. This case illustrates that surfing injuries can prompt a life-threatening airway emergency and serves as a caution for both surfers and health care professionals.

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The aim of this study was to develop an audit tool to identify prospectively all peri-operative adverse events during airway management in a cost-effective and reproducible way. All patients at VU University Medical Center who required general anaesthesia for elective and emergency surgical procedures were included during a period of 8 weeks. Daily questionnaires and interviews were taken from anaesthesia trainees and anaesthetic department staff members. A total of 2803 patients underwent general anaesthesia, 1384 men and 1419 women, including 2232 elective patients and 571 emergency procedures, 697 paediatric and 2106 adult surgical procedures. A total of 168 airway-related events were reported. The incidence of severe airway management-related events was 24/2803 (0.86%). There were 12 (0.42%) unanticipated ICU admissions, two patients (0.07%) required a surgical airway. There was one (0.04%) death, one cannot intubate cannot oxygenate (0.04%), one aspiration (0.04%) and eight (0.29%) severe desaturations < Sp O2 50%. We suggest that our method to determine and investigate airway management-related adverse events could be adopted by other hospitals.

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BACKGROUND: Airway management is essential in critically ill or injured patients. In a "can't intubate, can't oxygenate" scenario, an emergency surgical airway (ESA), similar to a cricothyroidotomy, is the final step in airway management. This procedure is infrequently performed in the prehospital or clinical setting. The incidence of ESA may differ between physician- and non-physician-staffed emergency medical services (EMS). We examined the indications and results of ESA procedures among our physician-staffed EMS compared with non-physician-staffed services. METHODS: Data for all forms of airway management were obtained from our EMS providers and analyzed and compared with data from non-physician-staffed EMS found in the literature. RESULTS: Among 1871 patients requiring a secured airway, the incidence of a surgical airway was 1.6% (n=30). Fourteen patients received a primary ESA. In 16 patients, a secondary ESA was required after failed endotracheal intubation. The total prehospital ESA tracheal access success rate was 96.7%. CONCLUSION: The incidence of ESA in our patient population was low compared with those reported in the literature from non-physician-staffed EMS. Advanced intubation skills might be a contributing factor, thus reducing the number of ESAs required.

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