TECHNICAL STRATEGY
Manikin Model With Breathing Tube for Wire-Guided Percutaneous Cricothyrotomy in Patients Applying an Intermaxillary Fixation Kun Hwang, MD, PhD,* Han Joon Kim, MD,* Yoo Chan Kim,* Yong Soon Choi,* and Se Won HwangÞ
Abstract: Jaw fracture surgery or orthognathic surgery usually involves the application of an intermaxillary fixation (IMF). Obstructions that cannot be relieved by suction require an immediate release of IMF wires, but releasing the IMF may damage the surgical alignment of the facial bones. The mean time taken to release the jaws was an average of 2 minutes 9 seconds by hospital staff involved in caring for these patients. The aims of this study were to introduce a training model for wire-guided percutaneous cricothyrotomy in the patients applying an IMF and to perform the procedure for medical students. Our model consisted of a facial mannequin, a plastic breathing tube, 2 rolls of tapes, and a reservoir bag. The inner parts of the 2 used rolls of tape represent tracheal/cricoid rings (1-inch width for thyroid and half-inch width for cricoid), and the space between them represents the cricothyroid membrane, which is wrapped with PehaHaft. A surgeon demonstrated the technique on the model, and then, 60 medical students who had never attended airway-training courses applied the Melker cricothyrotomy kit on the model. All 60 students completed the procedure successfully. The mean (SD) time needed to insert a cricothyrotomy catheter of the medical students was 175 (50) seconds (range, 76Y297 s). Most of the students (54; 90%) performed it within 4 minutes; more than half (33; 55%), within 3 minutes. With our manikin model and Melker cricothyrotomy kit, 60 medical students completed the procedure successfully. This model can be useful to cricothyrotomy training for medical personnel. Key Words: Airway management, tracheostomy, jaw fixation techniques, students, medical (J Craniofac Surg 2014;25: 1846Y1848)
From the *Department of Plastic Surgery, Inha University School of Medicine, Incheon, South Korea; and †Peninsula Medical School, Exeter, United Kingdom. Received September 11, 2013. Accepted for publication November 14, 2013. Address correspondence and reprint requests to Dr. Kun Hwang, Department of Plastic Surgery, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 400-711, South Korea; E-mail: [email protected] Supported by a grant from Inha University (Inha research grant). The authors report no conflicts of interest. Authors Yoo Chan Kim and Yong Soon Choi are students at Inha University School of Medicine. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000576
1846
J
aw fracture surgery or orthognathic surgery usually involves the application of an intermaxillary fixation (IMF). The risk for an acute airway obstruction, particularly the one encountered immediately after the postoperative period, is well recognized.1 In our previous report, among 17 cases of mortality and 3 cases of patients in a vegetative state after cosmetic jaw surgery, we found that 75% (15 cases) were caused by an airway obstruction.2 Respiratory insufficiency after jaw surgery is caused by airway obstruction that results from an edema of the respiratory tract. Because the upper jaw and lower jaw are fixed by an IMF after jaw surgery, the patients cannot expectorate sputum easily.3 Obstructions that cannot be relieved by suction require immediate release of the IMF wires, but releasing the IMF may damage the surgical alignment of the facial bones.4 Wire cutters are a necessary safety precaution and a standard part of practice. Nurses and patients should know the proper technique for clearing the mouth and airway of a patient with an IMF. Hemorrhage evaluation and secretion control also require skilled observation and assistance by the nurse. Therefore, the practice of releasing an IMF is required for the nurses and house staff.4 In addition, the mean time taken to release the jaws was an average of 35.3 seconds by experienced surgeons and an average of 2 minutes 9 seconds by hospital staff involved in caring for the patients.5 In case of airway obstruction due to laryngeal edema after jaw surgery, the airway maintenance through the oral route is very difficult and sometimes impossible. Thereafter, it would rather be better to perform a cricothyrotomy than trying mask or oral or nasal intubation. According to the Metterlein experiment using sheeps and the wire-guided technique (Melker Set), successful placement was possible in all attempts, whereas the catheter-over-needle method (QuickTrach Set) was successful in 63% and had a higher complication rate (75% versus 13%).6 Thereafter, we thought that the wire-guided percutaneous cricothyrotomy might be used to train medical personnel and medical students who care for the patients applying an IMF. The aims of this study were to introduce a training model for wire-guided percutaneous cricothyrotomy in the patients applying an IMF and to perform the procedure for medical students.
MATERIALS AND METHODS Manikin Model With Breathing Tube Our model consisted of a facial manikin, a plastic breathing tube, 2 rolls of tapes, and a reservoir bag. The inner parts of the 2 used rolls of tape (3M Co, St Paul, MN) represent the tracheal/cricoid rings (1-inch width for thyroid and half-inch width for cricoid), and the space between them represents the cricothyroid membrane, which is wrapped with Peha-Haft (Paul Hartmann Pty Ltd). The ‘‘trachea’’ may be rotated or moved longitudinally between uses to
The Journal of Craniofacial Surgery
& Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 5, September 2014
Manikin Model for Cricothyrotomy
present a fresh surface for a puncture. The reservoir bag from an anesthetic breathing system may be placed at the end of the tube to demonstrate insufflations (Fig. 1). The incision site of the neck was covered with brown-colored 3M tape to shield it after each procedure.
Wire-Guided Percutaneous Cricothyrotomy Equipment and Procedure A Melker cricothyrotomy kit (Cook, Inc, Bloomington, IN) was used.7 Procedures are as follows (Fig. 2)8: 1. Identify the cricothyroid membrane (B) between the thyroid (A) and cricoid (C) cartilages (Fig. 2A). 2. Carefully palpate the cricothyroid membrane and, while stabilizing the cartilage, make a vertical incision in the midline. 3. Attach the supplied syringe to either the introducer needle or the catheter introducer needle and advance the needle through the incision into the airway at a 45-degree angle to the frontal plane in a caudal direction, in the midline (Fig. 2B). 4. If using the catheter introducer needle, remove the syringe and needle, leaving the catheter in place. If using the introducer needle, remove only the syringe, leaving the needle in place. 5. Advance the soft, flexible end of the wire guide through the catheter or needle and into the airway several centimeters. 6. Remove the catheter or needle, leaving the wire guide in place. (Fig. 2C). 7. Advance the handled dilator, tapered end first, into the connector end of the airway catheter until the handle stops against the connector.
FIGURE 2. Procedure of Melker cricothyrotomy: A, Make limited skin incision to the cricothyroid membrane (b) between the thyroid (a) and cricoid (c) cartilages. B, Advancement of an 18-gauge needle through the incision and the cricothyroid membrane until free air return is encountered on suction. Placement of a guidewire through the 18-gauge needle. C, Removal of the 18-gauge needle, leaving the guidewire in place. D, Advancement of a dilator-airway catheter assembly over the guidewire. E, Inflation of a catheter cuff after the removal of the guidewire and dilator (Adopted from Cook Inc.8 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.).
8. Advance the airway catheter/dilator assembly over the wire guide until the proximal stiff end of the wire guide is completely through and visible at the handle end of the dilator. It is important to continually visualize the proximal end of the wire guide during the airway insertion procedure to prevent its inadvertent loss into the trachea. 9. Maintaining wire guide position, continue to advance the airway catheter/dilator assembly over the wire guide with a reciprocating motion completely into the trachea. (Fig. 2D) 10. Remove the wire guide and dilator simultaneously. 11. Inflate the cuff with air using a syringe (Fig. 2E). 12. Fix the airway catheter in place with tracheostomy tape strip in standard fashion. 13. Connect the airway catheter, using its standard 15-mm connector, to an appropriate ventilator device.
Participants and Education Participants included 60 medical students in the 4 classes (years 1, 2, 3, and 4 of a 4-year course of medical school) in the year 2013. Among the 60 participants, there were 40 men and 20 women (age range, 24Y36 y; mean age, 28.9 y), with 12 to 18 students in each year group. All the students had never attended airwaytraining courses. A surgeon demonstrated the technique on the model; then, the students applied a Melker cricothyrotomy kit on the model (Fig. 3). FIGURE 1. Manikin model with breathing tube. Top, The inner parts. Two used rolls of tape represent tracheal/cricoid rings (1 inch for thyroid and half an inch for cricoid). The space between them represents the cricothyroid membrane, which is wrapped with Peha-Haft. Middle, Posterior view of the assembled facial manikin, plastic breathing tube, 2 rolls of tapes, and reservoir bag. Bottom, Anterior view ready for cricothyrotomy.
Measured Times Time needed to insert the cricothyrotomy catheter (CTC) for the medical students was measured.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1847
The Journal of Craniofacial Surgery
Hwang et al
RESULTS All 60 students completed the procedure successfully. The mean (SD) time needed to insert the CTC of the medical students was 175 (50) seconds (range, 76Y297 s). Most of the students (54; 90%) performed it within 4 minutes; and more than half (33; 55%), within 3 minutes. There were no significant differences in each group (161.6 [45.9] s in year 1, 182.4 [45.4] s in year 2, 193.2 [49.1] s in year 3, and 151.3 [49.9] s in year 4; P = 0.094 [analysis of variance]) (Table 1).
DISCUSSION This model is an upgraded version of the ‘‘homemade model’’ of Varaday et al.9 Their model consisted of a plastic tray as a base, plastic breathing tube, sticky tape, and gauze. In our model, we used a manikin for the facial cosmetics (Yedang Co, Seoul, South Korea) instead of a plastic tray and wrapped the cricothyroid membranes with Peha-Haft (Paul Hartmann Pty Ltd). With this model, the mean (SD) time needed to insert CTC of the medical students was 175 (50) seconds. Compared with the previous article of Vadodaria et al10 (Melker Set 53 [52Y56] s), our results reveal longer times needed. In their study, 10 experienced anesthetists (consultants or specialist registrars in their fifth year of training) performed cricothyroidotomies on the human patient stimulator (MET1 Simulator; Medical Education Technologies, Inc,
& Volume 25, Number 5, September 2014
TABLE 1. Time Needed to Insert the CTC No. of Students (%) Year 1 Year 2 Year 3 Year 4 Sum
14 16 18 12 60
(23.3) (26.7) (30.0) (20.0) (100.0)
Mean (s)
Standard Deviation
161.6 182.4 193.2 151.3 175.0
45.9 45.4 49.1 49.9 50.0
Sarasota, FL).10 In the current study, all the students had never attended airway-training courses. Considering the mean (SD) time of 2 minutes 9 seconds (129 s) taken to release the jaws by hospital staff involved in caring for these patients,5 the time needed to insert CTC will be shorter than the time needed to release the jaw and perform the intubation. Considering that a relatively short time was needed for the inexperienced students (90% performed within 4 min and 55% performed within 3 min), paramedics or nurses can learn to perform this procedure easily and can do it in emergency situations. With our manikin model and Melker cricothyrotomy kit, the 60 medical students who had never attended airway-training courses completed the procedure successfully. This model can be useful for cricothyrotomy training for medical personnel.
REFERENCES
FIGURE 3. A student applying a Melker cricothyrotomy kit on the model.
1848
1. Fisher SE. Respiratory/cardiac arrest complicating intermaxillary fixation. Br J Oral Surg 1982;20:192Y195 2. Hwang K, Choi YB. Post-operative monitoring is essential following jaw surgeries. Arch Plast Surg 2013;40:66Y67 3. Hwang K, Kim HJ, Lee HS. Airway obstruction after orthognatic surgery. J Craniofac Surg 2013;24:1857Y1858 4. Frost CM, Frost DE. Nursing care of patients in intermaxillary fixation. Heart Lung 1983;12:524Y528 5. Goss AN, Chau KK, Mayne LH. Intermaxillary fixation: how practicable is emergency jaw release? Anaesth Intensive Care 1979;7:253Y257 6. Metterlein T, Frommer M, Ginzkey C, et al. A randomized trial comparing two cuffed emergency cricothyrotomy devices using a wire-guided and a catheter-over-needle technique. J Emerg Med 2011;41:326Y332 7. Melker JS, Gabrielli A. Melker cricothyrotomy kit: an alternative to the surgical technique. Ann Otol Rhinol Laryngol 2005;114:525Y528 8. Cook Inc. Melker emergency cuffed and uncuffed cricothyrotomy catheter sets; instruction for use. Cook Inc: Bloomington, 2009:1Y5 9. Varaday SS, Yentis SM, Clarke S. A homemade model for training in cricothyrotomy. Anaesthesia 2004;59:1012Y1015 10. Vadodaria BS, Gandhi SD, McIndoe AK. Comparison of four different emergency airway access equipment sets on a human patient simulator. Anaesthesia 2004;59:73Y79
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Manikin Model With Breathing Tube for Wire-Guided Percutaneous Cricothyrotomy in Patients Applying an Intermaxillary Fixation Kun Hwang, MD, PhD,* Han Joon Kim, MD,* Yoo Chan Kim,* Yong Soon Choi,* and Se Won HwangÞ
Abstract: Jaw fracture surgery or orthognathic surgery usually involves the application of an intermaxillary fixation (IMF). Obstructions that cannot be relieved by suction require an immediate release of IMF wires, but releasing the IMF may damage the surgical alignment of the facial bones. The mean time taken to release the jaws was an average of 2 minutes 9 seconds by hospital staff involved in caring for these patients. The aims of this study were to introduce a training model for wire-guided percutaneous cricothyrotomy in the patients applying an IMF and to perform the procedure for medical students. Our model consisted of a facial mannequin, a plastic breathing tube, 2 rolls of tapes, and a reservoir bag. The inner parts of the 2 used rolls of tape represent tracheal/cricoid rings (1-inch width for thyroid and half-inch width for cricoid), and the space between them represents the cricothyroid membrane, which is wrapped with PehaHaft. A surgeon demonstrated the technique on the model, and then, 60 medical students who had never attended airway-training courses applied the Melker cricothyrotomy kit on the model. All 60 students completed the procedure successfully. The mean (SD) time needed to insert a cricothyrotomy catheter of the medical students was 175 (50) seconds (range, 76Y297 s). Most of the students (54; 90%) performed it within 4 minutes; more than half (33; 55%), within 3 minutes. With our manikin model and Melker cricothyrotomy kit, 60 medical students completed the procedure successfully. This model can be useful to cricothyrotomy training for medical personnel. Key Words: Airway management, tracheostomy, jaw fixation techniques, students, medical (J Craniofac Surg 2014;25: 1846Y1848)
From the *Department of Plastic Surgery, Inha University School of Medicine, Incheon, South Korea; and †Peninsula Medical School, Exeter, United Kingdom. Received September 11, 2013. Accepted for publication November 14, 2013. Address correspondence and reprint requests to Dr. Kun Hwang, Department of Plastic Surgery, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 400-711, South Korea; E-mail: [email protected] Supported by a grant from Inha University (Inha research grant). The authors report no conflicts of interest. Authors Yoo Chan Kim and Yong Soon Choi are students at Inha University School of Medicine. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000576
1846
J
aw fracture surgery or orthognathic surgery usually involves the application of an intermaxillary fixation (IMF). The risk for an acute airway obstruction, particularly the one encountered immediately after the postoperative period, is well recognized.1 In our previous report, among 17 cases of mortality and 3 cases of patients in a vegetative state after cosmetic jaw surgery, we found that 75% (15 cases) were caused by an airway obstruction.2 Respiratory insufficiency after jaw surgery is caused by airway obstruction that results from an edema of the respiratory tract. Because the upper jaw and lower jaw are fixed by an IMF after jaw surgery, the patients cannot expectorate sputum easily.3 Obstructions that cannot be relieved by suction require immediate release of the IMF wires, but releasing the IMF may damage the surgical alignment of the facial bones.4 Wire cutters are a necessary safety precaution and a standard part of practice. Nurses and patients should know the proper technique for clearing the mouth and airway of a patient with an IMF. Hemorrhage evaluation and secretion control also require skilled observation and assistance by the nurse. Therefore, the practice of releasing an IMF is required for the nurses and house staff.4 In addition, the mean time taken to release the jaws was an average of 35.3 seconds by experienced surgeons and an average of 2 minutes 9 seconds by hospital staff involved in caring for the patients.5 In case of airway obstruction due to laryngeal edema after jaw surgery, the airway maintenance through the oral route is very difficult and sometimes impossible. Thereafter, it would rather be better to perform a cricothyrotomy than trying mask or oral or nasal intubation. According to the Metterlein experiment using sheeps and the wire-guided technique (Melker Set), successful placement was possible in all attempts, whereas the catheter-over-needle method (QuickTrach Set) was successful in 63% and had a higher complication rate (75% versus 13%).6 Thereafter, we thought that the wire-guided percutaneous cricothyrotomy might be used to train medical personnel and medical students who care for the patients applying an IMF. The aims of this study were to introduce a training model for wire-guided percutaneous cricothyrotomy in the patients applying an IMF and to perform the procedure for medical students.
MATERIALS AND METHODS Manikin Model With Breathing Tube Our model consisted of a facial manikin, a plastic breathing tube, 2 rolls of tapes, and a reservoir bag. The inner parts of the 2 used rolls of tape (3M Co, St Paul, MN) represent the tracheal/cricoid rings (1-inch width for thyroid and half-inch width for cricoid), and the space between them represents the cricothyroid membrane, which is wrapped with Peha-Haft (Paul Hartmann Pty Ltd). The ‘‘trachea’’ may be rotated or moved longitudinally between uses to
The Journal of Craniofacial Surgery
& Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 5, September 2014
Manikin Model for Cricothyrotomy
present a fresh surface for a puncture. The reservoir bag from an anesthetic breathing system may be placed at the end of the tube to demonstrate insufflations (Fig. 1). The incision site of the neck was covered with brown-colored 3M tape to shield it after each procedure.
Wire-Guided Percutaneous Cricothyrotomy Equipment and Procedure A Melker cricothyrotomy kit (Cook, Inc, Bloomington, IN) was used.7 Procedures are as follows (Fig. 2)8: 1. Identify the cricothyroid membrane (B) between the thyroid (A) and cricoid (C) cartilages (Fig. 2A). 2. Carefully palpate the cricothyroid membrane and, while stabilizing the cartilage, make a vertical incision in the midline. 3. Attach the supplied syringe to either the introducer needle or the catheter introducer needle and advance the needle through the incision into the airway at a 45-degree angle to the frontal plane in a caudal direction, in the midline (Fig. 2B). 4. If using the catheter introducer needle, remove the syringe and needle, leaving the catheter in place. If using the introducer needle, remove only the syringe, leaving the needle in place. 5. Advance the soft, flexible end of the wire guide through the catheter or needle and into the airway several centimeters. 6. Remove the catheter or needle, leaving the wire guide in place. (Fig. 2C). 7. Advance the handled dilator, tapered end first, into the connector end of the airway catheter until the handle stops against the connector.
FIGURE 2. Procedure of Melker cricothyrotomy: A, Make limited skin incision to the cricothyroid membrane (b) between the thyroid (a) and cricoid (c) cartilages. B, Advancement of an 18-gauge needle through the incision and the cricothyroid membrane until free air return is encountered on suction. Placement of a guidewire through the 18-gauge needle. C, Removal of the 18-gauge needle, leaving the guidewire in place. D, Advancement of a dilator-airway catheter assembly over the guidewire. E, Inflation of a catheter cuff after the removal of the guidewire and dilator (Adopted from Cook Inc.8 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.).
8. Advance the airway catheter/dilator assembly over the wire guide until the proximal stiff end of the wire guide is completely through and visible at the handle end of the dilator. It is important to continually visualize the proximal end of the wire guide during the airway insertion procedure to prevent its inadvertent loss into the trachea. 9. Maintaining wire guide position, continue to advance the airway catheter/dilator assembly over the wire guide with a reciprocating motion completely into the trachea. (Fig. 2D) 10. Remove the wire guide and dilator simultaneously. 11. Inflate the cuff with air using a syringe (Fig. 2E). 12. Fix the airway catheter in place with tracheostomy tape strip in standard fashion. 13. Connect the airway catheter, using its standard 15-mm connector, to an appropriate ventilator device.
Participants and Education Participants included 60 medical students in the 4 classes (years 1, 2, 3, and 4 of a 4-year course of medical school) in the year 2013. Among the 60 participants, there were 40 men and 20 women (age range, 24Y36 y; mean age, 28.9 y), with 12 to 18 students in each year group. All the students had never attended airwaytraining courses. A surgeon demonstrated the technique on the model; then, the students applied a Melker cricothyrotomy kit on the model (Fig. 3). FIGURE 1. Manikin model with breathing tube. Top, The inner parts. Two used rolls of tape represent tracheal/cricoid rings (1 inch for thyroid and half an inch for cricoid). The space between them represents the cricothyroid membrane, which is wrapped with Peha-Haft. Middle, Posterior view of the assembled facial manikin, plastic breathing tube, 2 rolls of tapes, and reservoir bag. Bottom, Anterior view ready for cricothyrotomy.
Measured Times Time needed to insert the cricothyrotomy catheter (CTC) for the medical students was measured.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1847
The Journal of Craniofacial Surgery
Hwang et al
RESULTS All 60 students completed the procedure successfully. The mean (SD) time needed to insert the CTC of the medical students was 175 (50) seconds (range, 76Y297 s). Most of the students (54; 90%) performed it within 4 minutes; and more than half (33; 55%), within 3 minutes. There were no significant differences in each group (161.6 [45.9] s in year 1, 182.4 [45.4] s in year 2, 193.2 [49.1] s in year 3, and 151.3 [49.9] s in year 4; P = 0.094 [analysis of variance]) (Table 1).
DISCUSSION This model is an upgraded version of the ‘‘homemade model’’ of Varaday et al.9 Their model consisted of a plastic tray as a base, plastic breathing tube, sticky tape, and gauze. In our model, we used a manikin for the facial cosmetics (Yedang Co, Seoul, South Korea) instead of a plastic tray and wrapped the cricothyroid membranes with Peha-Haft (Paul Hartmann Pty Ltd). With this model, the mean (SD) time needed to insert CTC of the medical students was 175 (50) seconds. Compared with the previous article of Vadodaria et al10 (Melker Set 53 [52Y56] s), our results reveal longer times needed. In their study, 10 experienced anesthetists (consultants or specialist registrars in their fifth year of training) performed cricothyroidotomies on the human patient stimulator (MET1 Simulator; Medical Education Technologies, Inc,
& Volume 25, Number 5, September 2014
TABLE 1. Time Needed to Insert the CTC No. of Students (%) Year 1 Year 2 Year 3 Year 4 Sum
14 16 18 12 60
(23.3) (26.7) (30.0) (20.0) (100.0)
Mean (s)
Standard Deviation
161.6 182.4 193.2 151.3 175.0
45.9 45.4 49.1 49.9 50.0
Sarasota, FL).10 In the current study, all the students had never attended airway-training courses. Considering the mean (SD) time of 2 minutes 9 seconds (129 s) taken to release the jaws by hospital staff involved in caring for these patients,5 the time needed to insert CTC will be shorter than the time needed to release the jaw and perform the intubation. Considering that a relatively short time was needed for the inexperienced students (90% performed within 4 min and 55% performed within 3 min), paramedics or nurses can learn to perform this procedure easily and can do it in emergency situations. With our manikin model and Melker cricothyrotomy kit, the 60 medical students who had never attended airway-training courses completed the procedure successfully. This model can be useful for cricothyrotomy training for medical personnel.
REFERENCES
FIGURE 3. A student applying a Melker cricothyrotomy kit on the model.
1848
1. Fisher SE. Respiratory/cardiac arrest complicating intermaxillary fixation. Br J Oral Surg 1982;20:192Y195 2. Hwang K, Choi YB. Post-operative monitoring is essential following jaw surgeries. Arch Plast Surg 2013;40:66Y67 3. Hwang K, Kim HJ, Lee HS. Airway obstruction after orthognatic surgery. J Craniofac Surg 2013;24:1857Y1858 4. Frost CM, Frost DE. Nursing care of patients in intermaxillary fixation. Heart Lung 1983;12:524Y528 5. Goss AN, Chau KK, Mayne LH. Intermaxillary fixation: how practicable is emergency jaw release? Anaesth Intensive Care 1979;7:253Y257 6. Metterlein T, Frommer M, Ginzkey C, et al. A randomized trial comparing two cuffed emergency cricothyrotomy devices using a wire-guided and a catheter-over-needle technique. J Emerg Med 2011;41:326Y332 7. Melker JS, Gabrielli A. Melker cricothyrotomy kit: an alternative to the surgical technique. Ann Otol Rhinol Laryngol 2005;114:525Y528 8. Cook Inc. Melker emergency cuffed and uncuffed cricothyrotomy catheter sets; instruction for use. Cook Inc: Bloomington, 2009:1Y5 9. Varaday SS, Yentis SM, Clarke S. A homemade model for training in cricothyrotomy. Anaesthesia 2004;59:1012Y1015 10. Vadodaria BS, Gandhi SD, McIndoe AK. Comparison of four different emergency airway access equipment sets on a human patient simulator. Anaesthesia 2004;59:73Y79
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
