Prehospital Cricothyrotomy: A Narrative Review of Technical, Educational, and Operational Considerations for Procedure Optimization

Background: Definitive airway management is a requisite skill in the prehospital setting, most often accomplished with either an endotracheal tube or supraglottic airway. When clinicians encounter a cannot oxygenate and cannot ventilate scenario, a patient's airway still must be secured. Prehospital cricothyrotomy is a high acuity, low frequency procedure used to secure the airway through the anterior neck. Patients who require cricothyrotomy often have significant comorbid conditions and mortality, and there can be a high rate of procedural complications. The ability to perform a cricothyrotomy is within the scope of practice for many prehospital clinicians and mastery of the procedure is crucial for patient outcomes. Despite this, initial training on the procedure is minimal, and paramedics report discomfort in their ability to perform the procedure. Objective: Review and summarize the best available evidence relating to the performance of cricothyrotomies and propose technical, educational, and operational considerations to minimize complications and optimize success of prehospital cricothyrotomies. Discussion: Technical considerations when performing cricothyrotomy in the prehospital setting can be used to mitigate airway misplacement, mainstem intubation, and hemorrhage. Educational consideration should include focus on a singular technique, use of established curriculum, spaced repetition with either simulation or mental practice, and a focus on intention training of when to perform the procedure. The preferred technique from the National Association of Emergency Medical Service (EMS) Physician guidelines is the surgical technique. Operational considerations to optimize a successful procedure should include checklists, preassembled kits, and robust quality improvement and insurance after a cricothyrotomy is performed. Conclusions: By focusing on technical, educational, and operation considerations relating to prehospital cricothyrotomy, prehospital clinicians can optimize the chance for procedural success.