International Journal of Healthcare Simulation

Background:

The difficult airway society states that emergency front of neck access skills should be recapped every 6 months amongst those practitioners expected to perform the skill. Furthermore, the national audit states that, of the 25 emergency cricothyroidotomy cases, 9 failed. These were largely due to incorrect identification of the midline and tube misplacement. There is a convincing argument for training practitioners in ultrasound identification of the cricothyroid membrane, mitigating the risks of incorrect midline identification and blood vessel damage ^[1].

Aim:

Our aim was two-fold: introduce and embed the skill of ultrasound identification of the cricothyroid membrane for use in emergency front of neck access and encourage regular recap of these skills through a training package of blended learning, consisting of videos, ‘tea trolley’ style theatre training and a more formal simulation-based course that focuses on the ultrasound and front of neck access skill and human factors as we know this is a key factor in the success or failure of this scenario.

Methods:

A pilot course was rolled out amongst anaesthetic trainees to assess relative comfort with performing emergency front of neck access. The course consisted of a short lecture on the background and anatomy, teaching of the ultrasound skill using live subjects, practising of ultrasound-guided front of neck access on animal necks and finally a simulation with debrief surrounding implementation of the skill itself and human factors. This course is now being rolled out regionally and aims to teach all trainees in the region. We encourage trainees to generate their own informal logbook of ultrasound cases, whereby they consent patients to undergo a short ultrasound scan in the anaesthetic room prior to intubation, have their neck marked and then are rescanned after intubation to confirm correct identification. This should be done with ‘normal’ airways, not just those expected to be difficult, as this practice embeds the skill. Our ‘tea trolley’ style teaching is yet to be commenced but will involve ad hoc teaching within the theatre suite including the multi-disciplinary team who would be involved in such an event – the anaesthetist, operating department practitioner and theatre team. Finally, we are generating a video bank, which can be accessed in users’ own time to recap and review the process and troubleshooting of ultrasound identification of the cricothyroid membrane and ensuing cricothyroidotomy.

Results:

An improvement was reported in trainees’ comfort levels to perform ultrasound-guided cricothyroidotomy and all trainees felt that this was a worthwhile skill to embed into their practice. These improvements were tested via a pre- and post-course questionnaire. The same we hope will be true for the tea trolley training and we aim to address the human factors involved during these sessions too.

Implications in practice:

The aspiration is that ultimately ultrasound identification of the cricothyroid membrane for emergency front of neck access will at the very least become a skill that all trainees are formally taught and encouraged to practice and at the most will become the new standard for plan D airway access in the difficult airway society guidelines.