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Ultrasonic Assessment of the Cricothyroid Membrane

Ultrasonic Assessment of the Cricothyroid Membrane. Better than Landmarking?. Dr ZHANG Jinbin MMED (Anaes) Consultant Department of Anaesthesiology, Intensive Care and Pain Medicine Tan Tock Seng Hospital, Singapore. Outline. Anatomy

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Ultrasonic Assessment of the Cricothyroid Membrane

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  1. Ultrasonic Assessment of the Cricothyroid Membrane Better than Landmarking? Dr ZHANG Jinbin MMED (Anaes) Consultant Department of Anaesthesiology, Intensive Care and Pain Medicine Tan Tock Seng Hospital, Singapore

  2. Outline • Anatomy • Locating the cricothyroid membrane (CTM) using ultrasound • Limitations of landmark palpation • Is ultrasound useful?

  3. Why is the Cricothyroid Membrane (CTM) important? • Surgical airway access • Transtracheal injection of LA

  4. Anatomy of the CTM

  5. Superior Thyroid artery Superior Laryngeal artery Cricothyroid artery Conventionally… • Landmark Technique • Between the thyroid and cricoid cartilages

  6. Limitations of Palpation • Poorly discernible landmarks • Thick neck • Thick subcutaneous tissue • Obese patients • Females • Distorted anatomy • Previous radiotherapy to neck • Tracheal deviation due to head & neck tumours • Infection

  7. Landmark palpation is inaccurate • 6 volunteers • BMI from 24-53kg/m2 • 18 participants • 30% within defined area • 10% on target • 51% missed above • 35% missed below Elliot et al. Anaesthesia 2010; 65

  8. Landmark palpation is inaccurate • 56 females, child-bearing age • 15 obese (mean BMI 40.5 + 9.9 kg/m2) • 24 participants • 17 anesthesiologists • 7 OB/GYN trainees • Neutral: • 25% in non-obese • 0% in obese group • Hyperextended: • 29% vs 6% Aslani et al. Anesth Analg 2012:114

  9. Range of values extensive • Ease of ultrasonic assessment did not differ with BMI

  10. Landmark palpation is inaccurate • NAP 4 study • 15/29 (52%) of the cricothyroidotomies performed by anaesthetists failed • 100% success in those done by surgeons

  11. How can Ultrasound help us?

  12. Ultrasound – Tissue air interface M.S Kristensen, W.H.L Teoh. Airway Management 1st Edition, Springer 2014

  13. Advantages Safe Quick Reproducible Non-invasive Portable Available by bedside Gives dynamic images

  14. Localize Cricothyroid membrane

  15. Ultrasound Helps • Ease of image acquisition not affected by BMI • Quick image acquisition • 24.32s + 20.18s (95% CI 18.59 – 30.05) • Poorly discernible landmarks • Easier to locate CTM, retention of training Nicholls et al. Am J Emerg Med 2008;26 Barbe et al. Ann Fr Anesth Reanim 2014; 33

  16. Limitations of Ultrasound • Expertise • Subcutaneous air – image interference • Preparation and boot-up time? • Role for Emergency CICO? • Minimum training required?

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