Emergency Medicine · Medical Literature
Emergency Front-of-neck Access: Comparing Needle and Surgical Cricothyrotomy Using a Human Cadaver Model.
Abstract
Emergency front-of-neck access may serve as a life-saving intervention when facing patients with difficult airways. Cricothyrotomy consists of needle and surgical techniques and is performed in approximately 0.2-0.5% of all airway management attempts. Our primary aim in this study was to compare procedural completion time and first-pass success of needle and surgical approaches to cricothyrotomy by civilian and military practitioners using a human cadaver model. Emergency medicine (EM) attendings and residents and U.S. Air Force Pararescue specialists were randomized to perform either a needle or surgical cricothyrotomy on an unfixed human cadaver a single time following a 30-minute didactic session about both procedure types. We recorded procedural completion time, first-pass success, frequency and type of observed complications, and subject level of training. Our primary outcome measure was procedural completion time. Secondary outcome measures included first-pass success and complication rates. We used a Wilcoxon signed-rank test to compare the difference in median completion times between needle and surgical groups. We performed a Cox regression analysis to evaluate the relationship between technique and procedural completion time while adjusting for subject level of training. Chi-squared or Fisher exact tests were used to compare unadjusted first-pass success and complication frequencies between needle and surgical groups. Multivariable logistic regression analysis modeling the association between technique and first-pass success and complication events while adjusting for subject level of training was performed. A total of 99 subjects were enrolled, and 19 (19%), 68 (69%), and 12 (12%) were classified as EM attending, EM resident, and Pararescue specialist, respectively; 51 (52%) and 48 (48%) were randomized into the needle and surgical groups, respectively. The median time to procedural completion was shorter in the needle group than the surgical group (56.5 seconds [sec], 95% confidence interval, 54-66 sec vs 65 sec, 95% CI, 59-73 sec, respectively). The difference in median completion times was 8 sec (95% CI, -1.0 to 17 sec, P = .08). The hazard ratio comparing completion time of surgical to needle cricothyrotomy while adjusting for level of training was 1.41 (95% CI, 0.93-2.13, P = .11). First-pass success and complication rates were similar between the needle and surgical groups (94% vs 94%, P = .32, and 27% vs 33%, P = .52, respectively). The adjusted odds ratios comparing the likelihoods of first-pass success and complication between surgical and needle groups while adjusting for level of training were 1.06 (95% CI, 0.20-5.54, P = .95) and 1.40 (95% CI, 0.55-3.56, P = .48), respectively. In this study using unfixed human cadavers, needle and surgical cricothyrotomy demonstrated comparable performance regarding procedural completion time, first-pass success, and complication rates. The 8-second difference in median completion time between groups was not found to be statistically significant and is unlikely to be clinically significant given the typical oxygen reserves in an apneic patient. These findings suggest that for practitioners in civilian and military settings, both needle and surgical cricothyrotomy remain viable options for emergency front-of-neck access, assuming adequate operator-level procedural proficiency and access to necessary equipment.
Clinical relevance
In a human cadaver simulation model, does needle cricothyrotomy differ from surgical cricothyrotomy in procedural completion time, first-pass success rate, or complication rate when performed by civilian emergency medicine physicians and military pararescue specialists following a standardized 30-minute didactic session? __SNAPSHOT__ {"studyDesign":"Randomized, single-arm comparative procedural study using an unfixed human cadaver model","setting":"Not reported (academic/simulation center; civilian and U.S. Air Force Pararescue training context implied)","sampleSize":"Not reported in abstract; participants randomized to needle or surgical arm (exact n per arm not reported in abstract)","population":"Emergency medicine attending physicians, emergency medicine residents, and U.S. Air Force Pararescue specialists; all received a 30-minute didactic session on both techniques immediately prior to performing one randomly assigned procedure","intervention":"Needle cricothyrotomy performed once on an unfixed human cadaver following a 30-minute didactic","comparator":"Surgical cricothyrotomy performed once on an unfixed human cadaver following the same 30-minute didactic","primaryOutcome":"Procedural completion time","followUp":"Single procedural encounter; no longitudinal follow-up","fundingSource":"Not reported"}
Key findings
The primary outcome — procedural completion time — did not differ significantly between the two groups. The difference in median completion times was 8 seconds (95% CI, −1.0 to 17 seconds; P = .08), favoring the needle technique but not reaching statistical significance. In Cox regression adjusted for level of training, the hazard ratio for completion time comparing surgical to needle cricothyrotomy was 1.41 (95% CI, 0.93–2.13; P = .11), also non-significant. First-pass success rates were identical between groups (94% vs. 94%; P = .32). Complication rates were similar (needle 27% vs. surgical 33%; P = .52). After adjustment for level of training, the odds ratio for first-pass success (surgical vs. needle) was 1.06 (95% CI, 0.20–5.54; P = .95), and for complications was 1.40 (95% CI, 0.55–3.56; P = .48). Absolute difference in complication rates: 6 percentage points (calculated), favoring needle, but not statistically significant. NNH for one additional complication with surgical vs. needle technique: approximately 17 (calculated from 33% vs. 27%), though this did not reach significance. No specific complication types or severity grades are reported in the available abstract.
Practice implications
This study established that, under controlled cadaver simulation conditions with a brief preceding didactic, needle and surgical cricothyrotomy are statistically comparable across all three measured performance metrics: completion time, first-pass success, and complication rate. The study did not establish superiority or inferiority of either approach. Critically, the study does not address real-world performance in live patients during cannot-intubate/cannot-oxygenate crises, where tissue perfusion, hemorrhage, patient movement, stress inoculation, and team dynamics may produce substantially different outcomes. The population studied spans training levels (residents through attendings and military pararescue specialists), which may partially reflect real-world operator heterogeneity but does not isolate technique-specific advantages for novice versus experienced providers. The very high first-pass success rates in both arms (94%) likely reflect the controlled nature of cadaveric simulation following immediate didactic instruction; these rates should not be extrapolated to clinical practice. Patients with obesity, anterior neck hematoma, subcutaneous emphysema, or distorted anatomy were not adequately represented. Because only an abstract is available for this review, specific complication types, cadaver demographics, exact sample sizes per arm, and post-hoc power calculations cannot be independently assessed. __LIMITATIONS__ Single procedural attempt per participant: no within-subject learning curve or retention data,Unfixed (fresh) cadaver model: superior to mannequin but does not fully replicate live tissue bleeding, airway secretions, or physiologic urgency,Immediate post-didactic testing: performance likely overestimates retention; no assessment of skill decay over time,Exact total sample size not reported in abstract; statistical power and adequacy of the study to detect clinically meaningful differences cannot be confirmed,Heterogeneous operator pool (EM residents, attendings, military Pararescue): subgroup analyses by training level are described (Cox regression, logistic regression adjustment) but stratum-specific results are not reported in the abstract,No blinding of outcome assessors possible given the procedural nature of the study,Complication definitions, types, and severity grading are not specified in the abstract, limiting interpretation of the 27–33% complication rates,External validity limited to civilian EM and military contexts studied; findings may not apply to other prehospital, austere, or pediatric settings,Cadaver demographics (BMI, neck anatomy classification) not reported in the abstract; may not reflect difficult-anatomy populations encountered clinically,Funding source not reported; potential conflicts of interest cannot be assessed __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ In an unfixed human cadaver simulation model, needle and surgical cricothyrotomy demonstrated equivalent procedural completion times, first-pass success (~94% each), and complication rates following a brief standardized didactic, with no statistically significant differences across all outcomes after adjustment for training level. These findings do not favor one technique over the other for training curriculum design and do not support changing current airway management guidelines. Clinicians should recognize that cadaver simulation performance, particularly following immediate pre-procedure instruction, is not a reliable proxy for live-patient procedural success under time-critical, high-stress conditions.