Skip to content

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

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s


Implementing Effective Safety Solutions

Emergency Medicine Literature of Note

In memory of Dr John Hinds


Medical education in the tropics

Rural General Practice

Thoughts and experiences on the journey to enlightenment



EM in Focus

time to get focused on your patients.


The ACEM Fellowship Exam Resource

Dr. Smith's ECG Blog

In memory of Dr John Hinds


"Live as if you will die tomorrow; Learn as if you will live forever"

Songs or Stories

Sharing the Science and Art of Paediatric Anaesthesia


In memory of Dr John Hinds

Liz Crowe

Wellbeing Counsellor and Educator


In memory of Dr John Hinds

EM Basic

Your Boot Camp Guide to Emergency Medicine

Medical Admission Note

In memory of Dr John Hinds


Ramblings from a gasdoc with interests in #anaesthesia, #intensivecare, #echo, #PHEM and #FOAM

pulmcrit – EMCrit

In memory of Dr John Hinds

Miss Chardy

Laughter in the Outback

The Collective

A Hive Mind for Prehospital and Retrieval Med

Bits & Bumps

Obstetrics and Gynaecology Podcast


A Free Open Access Medical Education Emergency Medicine Core Content Mash Up

Adventure Medic

Just another site


Or "How I'm Learning to Stop Worrying and Love Emergency Medicine"


A great site

Genevieve's anthology

Writings to amuse, teach, inspire and entertain.

JR Paramedic

In memory of Dr John Hinds

Monash Anaesthesia

In memory of Dr John Hinds


A topnotch site


Bringing the boring to emergency medicine


Navigating resuscitation

Doctor's bag

by Dr Edwin Kruys

EM nerd

In memory of Dr John Hinds

The Chart Review

In memory of Dr John Hinds

ETM Course

Emergency Trauma Management Course

The Doctor's Dilemma

Modern Medical Musings from Dr Marlene Pearce

Sim and Choppers

A blog combining medical education, simulation and helicopter retrieval medicine


Reflections of a Rural GP

Auckland HEMS

Unofficial site for prehospital care providers of the Auckland HEMS service

Rural Doctors Net

useful resources for rural clinicians

expensive care

end of life, ethics and communication in critical care

Nomadic GP

Adventures of a Rural Locum


Free Open Access Medical Education for Paramedics

Not just a GP

Why GP is the greatest job in the world

the short coat

In memory of Dr John Hinds


Bringing the Boring to EM

%d bloggers like this: