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Cricoid Pressure – You Decide

Attributed to some joker on Twitter

Attributed to some joker on Twitter

[View the story “Cricoid Pressure – You decide” on Storify]

Whilst this twitter debate is mainly in light hearted humour, there is some controversy that is relevant to clinical practice.

My concern is that a lot of EM trainees go to anaesthesia rotations to learn basic safe airway techniques and RSI , and in the main as standard of care, cricoid pressure is taught there . Now there is a growing near majority of EM /CC providers who do not teach , use or advocate cricoid pressure at all as part of standard RSI. This causes confusion and silos of practice.

I have seen nurses become quite confused over this, with some wanting to apply cricoid pressure as that is traditional and then getting rebuked for doing so. I think it is important to have a general idea of what expert bodies, guidelines and our peers think on this. the recent PHARM survey on cricoid pressure revealed a narrow majority of respondents still advocated for application of cricoid pressure, with removal of it if any airway difficulty encountered. The main reason to do this cited was for medicolegal reasons as it is considered the standard of care. The Difficult Airway Society of UK recommends application of cricoid pressure in RSI. A recent personal communication from an Australian state commision on anaesthetic related morbidity/mortality reiterated the importance of cricoid pressure as part of RSI to reduce risk of fatal aspiration.

Here are useful resources to further explore the issue for readers.

Cricoid pressure for emergency department rapid sequence tracheal intubations : A risk/benefit analysis

Cricoid pressure : indications and complications

Cricoid pressure : are we doing it right?

The last reference on a clinical trial on training cricoid pressure technique is important in that it points to the issue in why past studies have found little good evidence of proven benefit of CP in reducing aspiration risk. The technique has been poorly taught and standardised in RSI training. You cannot say that one person’s application of cricoid pressure is the same across 100 providers. The force applied varies and so the issues arise with obstruction and poor airway views.

The best practice compromise for now is to train CP appropriately using recommended guidelines and technique, apply it for RSI as standard and remove it as needed. Alternatively ( and this is my own approach currently) is to select its use for high risk aspiration cases e.g trauma cases, UGIB, bowel obstruction, acute abdomens, late pregnancy

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