Pediatric neck rescue: randomized comparison of two emergency approaches to the trachea in an advanced simulated rabbit model

Background and Goal of Study: The rapid-sequence-tracheotomy (RST) and the scalpel-bougie-tracheotomy (SBT) are two recently introduced approaches that have explored establishing emergency front of neck access (eFONA) in an unanticipated difficult paediatric airway situation using a rabbit cadaver as a simulator. The objective of this study was to assess the two techniques in a simulated environment with enhanced realism including operative haemorrhage. Materials and Methods: 30 doctors were allocated to two groups for this randomized controlled cross-over equivalence trial. Af ter watching an illustrated training video and practicing one of the eFONA techniques four times, participants performed one final tracheotomy which was video recorded and rated. This sequence was then repeated for the other eFONA technique. Randomization determined whether the RST or SBT-technique was done first. Primary outcome was the comparison of the performance times between two surgical rescue techniques. Secondary outcomes included success rate, structural injuries, and subjective participant self-evaluation of their performance. Rabbit cadavers were acquired commercially and had been slaughtered exclusively for food purposes in accordance with the Swiss law in the presence of the cantonal veterinarian of the canton of Aargau. Based on previous data, we chose an equivalence margin of Δ= ±10 seconds with respect to the duration of the procedure. Results and Discussion: The two techniques were not equivalent with respect to the predefined margin of +/- 10 seconds. The median-time difference of 11.0 (95% CI: -4.9 – 29.0) seconds serves as weak evidence suggesting shorter performance time for the the SBT, yet there was no significant difference between the performance times of the two techniques (p = 0.07). The overall success rate was 93.3% (CI: 83.8% – 98.2%). Participants expressed a significant highly preference for the SBT-technique (p < 0.001). The median performance time difference exceeded our equivalence margin of 10 seconds and therefore we did not find equivalency between the two techniques. Nonetheless there was no significant difference between the performance times of the two techniques. Conclusion(s): Previously inexperienced clinicians can acquire the skillset needed to perform eFONA in small children in about a minute, by watching training videos. Fewer tracheal injuries and participants’ indicated preferences may favour the SBT.