Brief Report
Locating the cricothyroid membrane in males: Influence of the morphological characteristics of the neck
Localización de la membrana cricotiroidea en varones: influencia de las características morfológicas del cuello
V. Ruiz-Alcalá
, X. Onrubia, C. García-Vitoria, J. Baldó, E. Martínez, J.M. Seller
Corresponding author
Servicio Anestesiología-Reanimación, Hospital Universitari Dr. Peset, València, Spain
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Se objetiva de superficial a profundo el tejido cutáneo, el tejido subcutáneo y glándula tiroidea, y seguidamente la MCT, la cual se localizó a 5<span class="elsevierStyleHsp" style=""></span>mm desde el tejido cutáneo.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Imagen B.1: Fotografía del cuello en posición neutra del modelo 2.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Imagen B.2: Imagen ecográfica de la MCT (señalizada) del modelo 2. Se objetiva de superficial a profundo el tejido cutáneo, el tejido subcutáneo y glándula tiroidea, y seguidamente la MCT, la cual se localizó a 15<span class="elsevierStyleHsp" style=""></span>mm desde el tejido cutáneo.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V. Ruiz-Alcalá, X. Onrubia, C. García-Vitoria, J. Baldó, E. Martínez, J.M. Seller" "autores" => array:6 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Ruiz-Alcalá" ] 1 => array:2 [ "nombre" => "X." 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Ruiz-Alcalá, X. Onrubia, C. García-Vitoria, J. Baldó, E. Martínez, J.M. Seller" "autores" => array:6 [ 0 => array:4 [ "nombre" => "V." "apellidos" => "Ruiz-Alcalá" "email" => array:1 [ 0 => "veruizal5@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "X." "apellidos" => "Onrubia" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "García-Vitoria" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Baldó" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Martínez" ] 5 => array:2 [ "nombre" => "J.M." "apellidos" => "Seller" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio Anestesiología-Reanimación, Hospital Universitari Dr. Peset, València, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Localización de la membrana cricotiroidea en varones: influencia de las características morfológicas del cuello" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1954 "Ancho" => 2500 "Tamanyo" => 280636 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Photographic and ultrasound images from both models:</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Image A.1: Photograph of the neck of model 1 in the neutral position.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Image A.2: Ultrasound image of the CTM (arrow) with posterior reverberations in model 1. Shown from superficial to deep: skin tissue, subcutaneous tissue and thyroid gland, then the CTM, which was located 5<span class="elsevierStyleHsp" style=""></span>mm from skin tissue.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Image B.1: Photograph of the neck of model 2 in the neutral position.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Image B.2: Ultrasound image of the CTM (arrow) in model 2. Shown from superficial to deep: skin tissue, subcutaneous tissue and thyroid gland, then the CTM, which was located 15<span class="elsevierStyleHsp" style=""></span>mm from skin tissue.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In a cannot intubate, cannot oxygenate (CICO) situation, scientific societies recommend front-of-neck (FON) access,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1,2</span></a> mainly cricothyrotomy, because it can be performed rapidly in an attempt to minimize the adverse effects of prolonged hypoxaemia.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However, because cricothyrotomy is rarely performed in clinical practice, training in the technique can be perfunctory, and anaesthesiologists do not maintain their skills. As a results, many have difficulty in correctly identifying the cricothyroid membrane (CTM) which is the first step in cricothyrotomy.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Several studies have reported a low success rate in locating the CTM by palpation.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4–7</span></a> This can cause serious errors and complications in FON.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7–12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this study, we used a simulated CICO scenario to determine whether the morphological characteristics of the patient's neck can affect correct palpation of the CTM, the time required to locate the membrane, and whether a refresher course in FON improves location of the CTM.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This is an observational study, approved by the ethics committee of our hospital, to evaluate localization of the CTM by palpation on 2 male models with the following anthropometric characteristics:</p><p id="par0025" class="elsevierStylePara elsevierViewall">Model 1: weight 59<span class="elsevierStyleHsp" style=""></span>kg, height 172<span class="elsevierStyleHsp" style=""></span>cm, BMI 20<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, thyromental distance 9<span class="elsevierStyleHsp" style=""></span>cm, neck circumference at the thyroid cartilage 33<span class="elsevierStyleHsp" style=""></span>cm, and no beard.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Model 2: weight 59<span class="elsevierStyleHsp" style=""></span>kg, height 184<span class="elsevierStyleHsp" style=""></span>cm, BMI 37<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>, thyromental distance 6<span class="elsevierStyleHsp" style=""></span>cm, neck circumference at the thyroid cartilage 4<span class="elsevierStyleHsp" style=""></span>cm, and beard.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Doctors (subjects) from the Anaesthesia and Critical Care service and the Intensive Care service were invited to participate in the study. They were explained that this was a simulated CICO scenario in which they would have to locate the CTM access point in the shortest possible time to perform an emergency cricothyrotomy.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In an open room, the 2 models were placed on beds, in the supine position, separated by a screen. The neck was placed in a neutral position, without a pillow, and a transparent sticker was placed on the front of the neck. Each doctor was given a marker with erasable ink and asked to locate and mark the CTM access point. The time taken from the first palpation until the CTM was marked with the pen was recorded. Immediately after this, the same doctor was asked to repeat the same procedure on the second model. The procedure was timed in the same way.</p><p id="par0045" class="elsevierStylePara elsevierViewall">After the test, we used ultrasound (SonoSite<span class="elsevierStyleSup">®</span> M-Turbo™, Fujifilm Inc., Tokyo, Japan) to check the accuracy of the mark (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The attempt was considered successful if the mark was located anywhere on the CTM, and failed if the point was outside the membrane. After the test, the mark on each sticker was removed with alcohol before allowing the next subject to start their test.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Each subject completed a questionnaire specifying their years of professional practice and whether they had received training in FON in the preceding 12 months</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Data management and analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">To determine the sample size, we calculated that, accepting an alpha risk of 0.05 and a beta risk of 0.2 for a two-tailed test, 30 tests on each model would be needed to detect a significant difference of more than 30% in the success rate between models (we expected a success rate ratio of 0.8 in the standard model).</p><p id="par0060" class="elsevierStylePara elsevierViewall">Continuous variables are presented as median and interquartile range, and categorical variables as absolute numbers and percentages.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">U</span> Mann–Whitney non parametric test was used analyse continuous variables. Categorical variables were analysed using the Chi-square test.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using Stata.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Participants</span><p id="par0075" class="elsevierStylePara elsevierViewall">A total of 30 doctors (22 anaesthesiologists and 8 intensivists) participated in the study; 13 (43.3%) had between 1 and 10 years of experience, and 17 (56.7%) had more than 10 years.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Of the 30 subjects, only 8 (26.67%) had undergone a refresher course in FON in the preceding 12 months, while 22 (73.3%) had not. Each subject performed the test on each model, giving a total of 60 tests.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Successful location of the CTM</span><p id="par0085" class="elsevierStylePara elsevierViewall">Twenty three subjects (76.67%) successfully located the CTM on model 1, compared to 9 subjects (30%) who did so on model 2. The difference between the success rates on both models is statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.000291).</p><p id="par0090" class="elsevierStylePara elsevierViewall">Among subjects who had undergone a refresher course in the preceding 12 months (8 of the 30 subjects), there 11 were successes (68.7%) and 5 failures (31.3%) out of a total of 16 tests. In the 22 subjects without recent training there were 21 successes (47.7%) and 23 failures (52.3%) out of a total of 44 tests. The differences between both groups are not statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.1489).</p><p id="par0095" class="elsevierStylePara elsevierViewall">Of the 17 subjects with more than 10 years of experience, 13 (76.5%) correctly located the CTM in model 1, and the remaining 4 (23.5%) did not; on model 2, 5 (29.4%) were successful and 12 (70.6%) were not. Of the 13 subjects with up to 10 years of experience, 9 (69.2%) correctly located the CTM in model 1, and 4 (30.8%) did not, while in model 2, 4 (30.8%). %) correctly located the CTM and 9 (69.2%) did not. The differences between both groups in this case are not statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.977).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Time taken to locate the CTM</span><p id="par0100" class="elsevierStylePara elsevierViewall">Overall, subjects took 9 (6.5 to 15.5)<span class="elsevierStyleHsp" style=""></span>s to locate the CTM in model 1, compared to 14 (11–17.5)<span class="elsevierStyleHsp" style=""></span>s in model 2, with a statistically significant difference (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.00398)</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The purpose of our study was to determine whether the morphological characteristics of the neck of the models used affected correct location of the CTM and the time needed to locate the membrane, and whether additional training in FON affects the CTM location success rate.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The results obtained support the findings described in previous studies,<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6,11</span></a> in which a direct correlation was observed between the morphological characteristics of the neck and the level of success in locating the CTM by palpation (the greater the BMI and the circumference of the neck, the higher the failure rate).</p><p id="par0115" class="elsevierStylePara elsevierViewall">The standard of CTM location by palpation continues to be low, irrespective of the patient's morphology, and many authors have highlighted this as the main reason for the failed attempts and complications that occur during cricothyrotomy.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6,10</span></a> The results of our study (23% failed CTM locations in model 1 and 70% in model 2) support these findings.</p><p id="par0120" class="elsevierStylePara elsevierViewall">For this reason, many authors recommend performing the first step in FON, namely CTM location, using ultrasound prior to anaesthesia induction in patients with predictors of difficult airway, thereby increasing the probabilities of success and reducing complications.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,6,10–12</span></a> In our study, we used ultrasound to confirm the correct/incorrect location of the CTM.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The use of ultrasound to evaluate pretracheal soft tissue as a predictor of difficult airway, instead neck circumference measurement, has also been suggested.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> For this purpose, several authors recommend training anaesthesiologists in ultrasound skills to facilitate difficult airway management.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3,7–9,11,12</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In most studies analysing standard CTM location success/failure rates, the neck was placed in a neutral position. This, however, is not the best position for FON. The CTM should be palpated with the neck in extension, provided this is not contraindicated, as this increases the distance between the suprasternal recess and the CTM and facilitates correct location of the different structures.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2,6</span></a> In contrast, Aslani et al. considered a possible anatomical distortion with cervical hyperextension.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> Due to the controversy in the literature, in this study we did not analyse the impact of changing the position of the neck during the test.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In terms of the time needed to locate the CTM, we observed statistically significant differences between both models (9<span class="elsevierStyleHsp" style=""></span>s [6.5–15.5] in model 1, compared to 14<span class="elsevierStyleHsp" style=""></span>s [11–17.5] in model 2 [<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.00398]). These findings cannot be compared with the literature due to the differing patient characteristics and measurements used in other studies, which results in considerable differences in the time needed to locate the CTM (10 vs. 22<span class="elsevierStyleHsp" style=""></span>s).<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4,6,7,9</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Since CICO situations are rare, most professionals will have had little practise in performing FON. Hence the importance of continuing training in surgical airway management, which is only way to acquire skills that are difficult to obtain in routine clinical practice. Early studies showed that the technical skills acquired in practical workshop were lost after 6 months, and recommeded holding refresher courses every 6 months.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">11,14</span></a> However, Boet et al. later showed that technical skills are maintained up to 1 year after high-fidelity simulated learning, due to the realism of the learning scenario.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Although we were unable to demonstrate statistically the importance of refresher courses in emergency airway management, we did observe that 100% and 37.5% of participants who had undergone such training successfully located the CTM in model 1 and 2, respectively, versus 68% and 27.27%, respectively, of subjects receiving no such training.</p><p id="par0150" class="elsevierStylePara elsevierViewall">In conclusion, locating the CTM by palpation is associated with a high failure rate, which increases in direct relation with increased BMI and neck circumference. In addition, subjects needed more time to located the CTM in the model with difficult airway predictors.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Limitations</span><p id="par0155" class="elsevierStylePara elsevierViewall">In this study, we only used male models in order to avoid confusion in the results, since the anatomical differences between the female and male larynx (particularly greater angulation of the posterior aspect of the thyroid cartilage and less prominence of the thyroid cartilage in women) are associated with greater difficulty in palpating the CTM.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5,6,9</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0160" class="elsevierStylePara elsevierViewall">This study was not funded by grants from the public sector, trade sector or non-profit entities.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1160506" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Materials and method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results and conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1086804" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1160507" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0730" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 3 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados y conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1086803" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Data management and analysis" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Participants" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Successful location of the CTM" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Time taken to locate the CTM" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Limitations" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-20" "fechaAceptado" => "2018-10-31" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1086804" "palabras" => array:4 [ 0 => "Cricothyroid membrane" 1 => "Neck morphology" 2 => "Location" 3 => "Cricothyrotomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1086803" "palabras" => array:4 [ 0 => "Membrana cricotiroidea" 1 => "Características morfológicas" 2 => "Localización" 3 => "Cricotirotomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cricothyrotomy is a recommended technique to restore oxygenation in most of guidelines for difficult airway management. A correct location of the cricothyroid membrane (CTM) is fundamental for a proper performance of the technique. Several studies have shown poor accuracy with the identification the CTM by palpation, resulting in a high failure rate of the technique.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to determine the impact of the patient's neck morphology on the accurate location of the CTM and on the time employed.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Materials and method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Observational study in which anaesthesiologists and intensivists voluntarily participated in a simulation that consisted of a “cannot intubate, cannot oxygenate” scenario, where they had to locate the CTM, as soon as possible, in 2 selected male patients with different morphological characteristics of the neck. The time was measured from the beginning of CTM palpation to locating it with a marker.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results and conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A higher body mass index and a higher neck circumference correlated with a 70% location failure rate and with a longer time as compared with a standard model.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Materials and method" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results and conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La cricotirotomía es una técnica que forma parte de los algoritmos de manejo de vía aérea difícil. Para su adecuada realización se precisa una correcta localización de la membrana cricotiroidea (MCT). Diversos estudios han encontrado una alta tasa de error en la localización por palpación, lo que condiciona un fracaso en el resultado de la técnica.</p></span> <span id="abst0730" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0840">Objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El propósito del estudio fue determinar si las características morfológicas del cuello del paciente influyen en la correcta localización de la MCT y en el tiempo empleado.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional donde participaron voluntariamente anestesiólogos e intensivistas en una simulación consistente en un escenario de «cannot intubate, cannot oxygenate» donde tenían que localizar en el menor tiempo posible la MCT en 2 varones seleccionados con diferentes características morfológicas de cuello. Se cronometró el tiempo empleado desde que el sujeto comenzaba a localizar la MCT hasta que la marcaba con un rotulador.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados y conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se encontró que el modelo con mayor índice de masa corporal y mayor perímetro cervical tenía una tasa de fracaso en la localización de un 70%, empleando, además, mayor tiempo, comparado con el modelo de características estándares.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0730" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 3 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados y conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruiz-Alcalá V, Onrubia X, García-Vitoria C, Baldó J, Martínez E, Seller JM. Localización de la membrana cricotiroidea en varones: influencia de las características morfológicas del cuello. Rev Esp Anestesiol Reanim. 2019;66:144–148.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1954 "Ancho" => 2500 "Tamanyo" => 280636 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Photographic and ultrasound images from both models:</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Image A.1: Photograph of the neck of model 1 in the neutral position.</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Image A.2: Ultrasound image of the CTM (arrow) with posterior reverberations in model 1. Shown from superficial to deep: skin tissue, subcutaneous tissue and thyroid gland, then the CTM, which was located 5<span class="elsevierStyleHsp" style=""></span>mm from skin tissue.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Image B.1: Photograph of the neck of model 2 in the neutral position.</p> <p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Image B.2: Ultrasound image of the CTM (arrow) in model 2. Shown from superficial to deep: skin tissue, subcutaneous tissue and thyroid gland, then the CTM, which was located 15<span class="elsevierStyleHsp" style=""></span>mm from skin tissue.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "American Society of Anesthesiologists Task Force on Management of the Difficult Airway" "etal" => true "autores" => array:6 [ 0 => "J.L. Apfelbaum" 1 => "C.A. Hagberg" 2 => "R.A. Caplan" 3 => "C.D. Blitt" 4 => "R.T. Connis" 5 => "D.G. 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