Document Detail

Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation?
MedLine Citation:
PMID:  20398995     Owner:  NLM     Status:  MEDLINE    
OBJECTIVES: This is the first study to look at the effects of cricoid pressure/laryngeal manipulation on the laryngeal view and intubation success in the emergency or pre-hospital environment. Cricoid pressure is applied in the hope of reducing the incidence of aspiration. However the technique has never been evaluated in a randomized trial and may adversely affect laryngeal view. In order to improve intubating conditions cricoid pressure may be released and the larynx manipulated into a more favourable position.
METHODS: We carried out a prospective observational study to evaluate the effects of cricoid pressure and laryngeal manipulation on laryngeal view in our physician led pre-hospital trauma service.
RESULTS: 402 patients were included over a 16-month period. We intubated 98.8% patients on the first or second attempt. In 61 intubations (in 55 patients, 13.6%) the larynx required manipulation to facilitate intubation. In 22 intubations cricoid pressure was removed with the laryngeal view improving in 50%. Bimanual laryngeal manipulation was used in 25 intubations and the larynx better visualised in 60% of these. Backwards upwards rightwards pressure was applied to the larynx in 14 intubations and the laryngeal view improved in 64%. Two patients regurgitated when cricoid pressure was released. Both had prolonged periods of bag valve mask ventilation and difficult intubations.
DISCUSSION: The results suggest that cricoid pressure should be removed if the laryngeal view obtained is not sufficient to allow immediate intubation. Further manipulation of the larynx is likely to improve the chances of successful tracheal tube placement.
Tim Harris; Daniel Y Ellis; Liz Foster; David Lockey
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Publication Detail:
Type:  Journal Article     Date:  2010-04-15
Journal Detail:
Title:  Resuscitation     Volume:  81     ISSN:  1873-1570     ISO Abbreviation:  Resuscitation     Publication Date:  2010 Jul 
Date Detail:
Created Date:  2010-06-28     Completed Date:  2010-10-14     Revised Date:  2011-02-14    
Medline Journal Info:
Nlm Unique ID:  0332173     Medline TA:  Resuscitation     Country:  Ireland    
Other Details:
Languages:  eng     Pagination:  810-6     Citation Subset:  IM    
Dept of Emergency Medicine and Pre-hospital Care, Royal London Hospital, Whitechapel, London, UK.
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MeSH Terms
Air Ambulances
Anesthetics / administration & dosage
Chi-Square Distribution
Cohort Studies
Confidence Intervals
Cricoid Cartilage / physiology*
Critical Care / methods
Critical Illness / mortality,  therapy
Emergency Medical Services / methods*
Great Britain
Intubation, Intratracheal / adverse effects,  methods*
Laryngoscopy / methods
Larynx / physiology*
Odds Ratio
Prospective Studies
Respiration, Artificial / methods*
Risk Assessment
Safety Management
Survival Rate
Treatment Outcome
Reg. No./Substance:
Comment In:
Resuscitation. 2011 Feb;82(2):233; author reply 234   [PMID:  21036450 ]

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