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Emergency front of neck access in children: a new learning approach in a rabbit model
Francis Ulmer1, Julian Lennertz2, Robert Greif2
1Department of Paediatrics, Section of Paediatric Critical Care, Bern University Hospital, University of Bern, Bern, Switzerland.
Insights
Pediatric clinicians master emergency front of the neck access (eFONA) within four attempts, significantly reducing procedure time and injury risk. This vital airway management skill is crucial for pediatric emergencies.
Area of Science:
- Pediatric Emergency Medicine
- Surgical Skills Training
- Airway Management
Background:
- Cannot intubate-cannot ventilate scenarios in children are rare but dangerous.
- Limited guidance exists for emergency front of the neck access (eFONA) in children under 8 years old.
- This study investigates the learning curve for simulated pediatric eFONA.
Purpose of the Study:
- To evaluate the learning curve of clinicians performing simulated pediatric eFONA.
- To determine the number of attempts required to achieve proficiency.
- To assess factors influencing performance and injury rates.
Main Methods:
- 50 physicians from diverse specialties underwent training via an instructional video.
- Participants performed 10 simulated emergency tracheotomies on rabbit cadavers.
- Performance was analyzed based on time to completion and associated injuries.
Main Results:
- Overall success rate was 94%, with performance time decreasing from 107s to 55s over 10 attempts.
- The most significant improvement occurred within the first four attempts.
- Risk of severe injury dropped from 58% on the first attempt to 14% by the second attempt.
Conclusions:
- Pediatric clinicians achieve proficiency in eFONA within four attempts.
- Average airway establishment time was under one minute using a pediatric airway simulator.
- Factors like age and experience influenced the learning curve, but not medical specialty.
Background:
Cannot intubate-cannot ventilate situations in healthy children are uncommon but are often associated with poor outcome. Several airway management algorithms suggest emergency tracheal access. Little agreement exists on how to perform emergency front of the neck access (eFONA) in children <8 yr. We studied the learning curves of clinicians performing simulated paediatric eFONA.
Methods:
After watching an instructional video, 50 physicians, from five medical specialties, performed 10 emergency tracheotomies on rabbit cadavers. We analysed their learning curves relative to performance time and concurring injuries.
Results:
With an overall success rate of 94%, performance time decreased from 107 s (standard deviation [sd], 45) to 55 s (sd 17) over 10 attempts. The learning curve was steep between the first and the fourth attempts with an 11% decrease in performance time (95% confidence interval [CI], 9-13%; P<0.001) per attempt and then flattened to a 4% (95% CI, 3-5%; P<0.001) decrease per attempt between the fourth and the tenth attempt. Age, years of clinical experience, and sex showed a significant effect on the learning curve, whereas medical specialty and adult eFONA experience did not. The 58% (95% CI, 44-72%) probability for severe injury during the first attempt decreased to 14% (95% CI, 8-20%) at the second attempt. Men were more likely to cause minor injuries than women (P<0.001).
Conclusions:
Irrespective of medical specialty, paediatric clinicians acquired the eFONA technique within four attempts and were on average able to establish an airway in <1 min when performing emergency tracheotomy on a paediatric airway simulator.
Clinical Trial Registration:
NCT03576352.
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