Cut to Air.

A "cannot ventilate, cannot intubate" scenario is a rare, high-risk anesthesia event. Cricothyrotomy is the final step, but anesthesia training and maintenance of surgical airway skills is variable. The ability to "cut to air" when one performs a cricothyrotomy may be all that prevents a patient from experiencing anoxic brain injury or death. Forty-three Certified Registered Nurse Anesthetists (CRNAs) performed emergency cricothyrotomies on a simulation manikin. Three techniques were available: (1) cricothyrotomy kit, (2) scalpel and tracheostomy, and (3) scalpel/bougie/endotracheal tube. Technique selection and performance were recorded until successful confirmation of placement was achieved in less than 2 minutes. Confidence levels performing cricothyrotomy were also measured before and after simulation. Most CRNAs (53.5%) selected the cricothyrotomy kit, and all but 1 completed the cricothyrotomy in under 2 minutes. The scalpel/bougie/endotracheal tube combination was the fastest, with an average completion time of 86.6 seconds. The confidence of CRNAs in performing a successful cricothyrotomy in less than 2 minutes was significantly increased (P ≤ .001). Simulating airway skills improved performance, speed, and confidence. Because not all CRNAs have had extensive education in performing surgical airways and practicing these skills, simulation may have additional value in developing and maintaining skills and confidence.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an Option for Uncontrolled Hemorrhagic Shock: Current Best Practices and Anesthetic Implications.

Noncompressible torso hemorrhage is reported to be a leading cause of potentially preventable mortality in both civilian trauma victims and military combat casualties. This hemorrhage may come from venous, arterial, or additional combined sources in the chest, abdomen, pelvis, axilla, or groin regions. Aortic occlusion as an adjunct to strategies for trauma damage control can decrease the amount of bleeding distal to the occluded site and provide a time-sensitive opportunity for resuscitation and definitive hemorrhage control. Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a temporary hemorrhage control and resuscitation technique that has the advantage of being minimally invasive and may offer improved patient morbidity and mortality compared with the traditional emergency department thoracotomy. An overview of the history of REBOA and indications and contraindications for its use is provided. A placement strategy for this technology, which includes basic suggested insertion techniques and anatomical placement sites, is also provided. Additionally, device-related morbidity and mortality are addressed. Anesthetic implications in the perioperative period are reviewed in light of current best practices. Recommendations are given for future research aimed at refining and improving the care of seriously injured patients who may require this type of lifesaving treatment.