Page 24 - Journal of Special Operations Medicine - Fall 2015

training and capability of the medics, equipment avail- the skin, a horizontal incision through the cricothyroid
ability, and the tactical environment. The optimal tech- membrane (CTM), a dilator or tool to enlarge or main-
nique should minimize the chance of error and failure. tain the opening through the CTM (commonly a finger,
It should be fast, simple, involve few steps or pieces of tracheal hook, curved forceps, or scalpel handle), fol-
equipment, and be easy to train and sustain for a large lowed by insertion of an endotracheal or tracheostomy
number of Combat medics who do not have ongoing tube. 1,22–27
exposure to trauma patients in peacetime (Table 1).
There are several difficulties inherent to the standard
Table 1 Military Tactical Environment open SC technique. First, surgeons are much more fa-

• Prehospital providers (medics) likely not experienced miliar with surgical anatomy of the neck and often pre-
with orotracheal intubation fer a horizontal to a vertical skin incision. This is similar
• Often a single provider has responsibility for multiple to the familiar tracheostomy incision with which most
11
casualties surgeons are very comfortable. The horizontal skin in-
• Limited equipment cision is the technique taught in the American College of
25
• Supraglottic airways (King Systems, Surgeons Advanced Trauma Life Support Course and,
http://www.kingsystems.com; esophageal tracheal thus, is the technique often preferred and subsequently
Combitube; laryngeal mask airway) are of questionable taught by surgeons to other providers attending Ad-
utility in semiconscious trauma patients or those with vanced Trauma Life Support classes. Nonsurgeons, such
facial trauma as emergency physicians, anesthesia providers, critical
• Suction not available or of poor quality care physicians, and prehospital providers, who may be
• Oxygen not available required to perform SC will not have performed dozens
or even hundreds of tracheotomies as a regular part of
• Paralysis (neuromuscular blockade) not possible their training and practice; therefore, they will not be
or impractical
as familiar with the anatomy of the neck as a surgeon
• High incidence of face and neck trauma (bleeding, would be.
disrupted anatomy, aspiration of blood)
• High incidence of traumatic brain injury and risk of For the nonsurgeon and less experienced operators such
secondary brain injury from hypoxia
as prehospital providers, we advocate a vertical skin
• Noisy, dark, extremes of temperature, vibration incision. A vertical incision maximizes exposure of the
appropriate anatomy for providers not as familiar with
the surgical anatomy of the neck. This incision can then
Discussion
be extended at either end if further exposure is needed.
Our previous autopsy study showed that four of five
Techniques failed SC cases had horizontal incisions—in some cases,
The medical literature describes many different SC tech- multiple horizontal incisions—yet the airway was not
niques. Several studies offer a comparison of one tech- successfully cannulated. 28
nique over another. This literature is often difficult to
interpret because studies compare different types of pro- A vertical midline incision also potentially minimizes
viders and different types of models. Studies have been bleeding. Goumas et al. studied 107 autopsy specimens,
done using anesthesia providers, 5,14,15 critical care physi- specifically examining the vascular structures (arter-
cians, emergency physicians, 10,17,18 and prehospital pro- ies and veins) located in the cricothyroid space that lie
16
viders. Some compare results of only a few experienced within 1cm of the midline. Veins with a diameter of
19
29
providers performing multiple repetitions of the same greater than 2mm were considered a significant source
procedure, 20,21 while others include medical students, of bleeding during the performance of an SC. Goumas
residents, and experienced physicians.
and his colleagues found that 10.2% of 107 cadavers
had veins greater than 2mm in diameter located in the
Many different techniques and variations of SC have midline, whereas 30.8% of specimens had these vascu-
been described. We discuss several of these in this article lar structures within 1cm of the midline. 29
and attempt to identify potential sources of procedural
difficulty, error, and complications.
The “rapid four-step technique” (RFST) is a simplified
version of the open surgical technique and is designed
Open Techniques to increase speed by using a single horizontal puncture
that simultaneously extends through the skin and CTM,
Open Surgical Technique
followed by insertion of a tracheostomy tube through
The “standard” open SC technique and its variations the opening. By combining the incisions into one single
typically involve a horizontal or vertical incision through incision, and by not using a dilator, this technique was

12 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2015