Accuracy of pediatric cricothyroid membrane identification by digital palpation and implications for emergency front of neck access

Background: Emergency front of neck access in a “can't intubate can't oxygenate” scenario in pediatrics is rare. Ideally airway rescue would involve the presence of an ear, nose, and throat surgeon. If unavailable however, responsibility lies with the anesthesiologist and accurate identification of anterior neck structures is essential for success. Aim: We assessed anesthesiologists’ accuracy in identification of the pediatric cricothyroid membrane by digital palpation in three predefined age groups (37 weeks to <1 year old, 1-8 years old, and 9-16 years old) and whether accuracy improved with repetition. We also investigated a novel hypothetical vertical skin incision strategy to successfully expose the cricothyroid membrane. Methods: We asked anesthesiologists to identify the location of the cricothyroid membrane of anesthetized children in the extended neck position. Accuracy was defined as a mark made within the margins of the cricothyroid membrane using ultrasound as a reference standard. The position of the cricothyroid membrane relative to the neck midpoint, between the suprasternal notch and mentum, was defined for each child. Using this neck midpoint, we determined the hypothetical vertical skin incision lengths required to successfully expose the cricothyroid membrane (“midpoint incision”). Results: Ninety-seven patients were included in this study. There were 14, 58, and 25 patients recruited across the three predefined groups. Accurate anesthesiologist identification of the location of the cricothyroid membrane occurred in 29.4%, 28.6%, and 38.2% of attempts, respectively. The majority of inaccurate assessments (64.1%) were below the cricothyroid membrane. There was no improvement in accuracy with repetition. Hypothetical “midpoint incision” lengths of 20, 30, and 35 mm were required. Conclusion: Significant anesthesiologist inaccuracy exists in locating the cricothyroid membrane in children of all ages. This has implications for the technical approach to emergency front of neck access and how we teach the management of “can't intubate can't oxygenate” in pediatric practice.