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Emergency scalpel cricothyroidotomy use in a prehospital trauma service: a 20-year review
  1. Shadman Aziz1,2,
  2. Elizabeth Foster1,2,
  3. David J Lockey1,3,
  4. Michael D Christian1,2
  1. 1 London's Air Ambulance, London, UK
  2. 2 Barts Health NHS Trust, London, UK
  3. 3 Blizard Institute, Barts and the London School of Medicine and Dentistry, London, UK
  1. Correspondence to Dr Shadman Aziz, London's Air Ambulance, London E1 1FR, UK; shadman.aziz{at}


Background This study aimed to determine the rate of scalpel cricothyroidotomy conducted by a physician–paramedic prehospital trauma service over 20 years and to identify indications for, and factors associated with the intervention.

Methods A retrospective observational study was conducted from 1 January 2000 to 31 December 2019 using clinical database records. This study was conducted in a physician–paramedic prehospital trauma service, serving a predominantly urban population of approximately 10 million in an area of approximately 2500 km2.

Results Over 20 years, 37 725 patients were attended by the service, and 72 patients received a scalpel cricothyroidotomy. An immediate ‘primary’ cricothyroidotomy was performed in 17 patients (23.6%), and ‘rescue’ cricothyroidotomies were performed in 55 patients (76.4%). Forty-one patients (56.9%) were already in traumatic cardiac arrest during cricothyroidotomy. Thirty-two patients (44.4%) died on scene, and 32 (44.4%) subsequently died in hospital. Five patients (6.9%) survived to hospital discharge, and three patients (4.2%) were lost to follow-up. The most common indication for primary cricothyroidotomy was mechanical entrapment of patients (n=5, 29.4%). Difficult laryngoscopy, predominantly due to airway soiling with blood (n=15, 27.3%) was the most common indication for rescue cricothyroidotomy. The procedure was successful in 97% of cases. During the study period, 6570 prehospital emergency anaesthetics were conducted, of which 30 underwent rescue cricothyroidotomy after failed tracheal intubation (0.46%, 95% CI 0.31% to 0.65%).

Conclusions This study identifies a number of indications leading to scalpel cricothyroidotomy both as a primary procedure or after failed intubation. The main indication for scalpel cricothyroidotomy in our service was as a rescue airway for failed laryngoscopy due to a large volume of blood in the airway. Despite high levels of procedural success, 56.9% of patients were already in traumatic cardiac arrest during cricothyroidotomy, and overall mortality in patients with trauma receiving this procedure was 88.9% in our service.

  • airway
  • rsi
  • pre-hospital
  • anaesthesia
  • helicopter retrieval

Data availability statement

Data are available on reasonable request.

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Data availability statement

Data are available on reasonable request.

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  • Handling editor Caroline Leech

  • Twitter @ShadmanAziz2, @DrMikeChristian

  • Contributors MDC, DJL and SA devised the study. EF provided database management and data entry. SA conducted data abstraction and cleaning; 10% of cases were abstracted a second time by MDC for quality assurance purposes. All authors conducted data analysis and interpretation. SA and MDC wrote the first and subsequent drafts of the manuscript. All authors critically revised and approved submission of the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.