Note to readers: The following piece is a tongue-in-cheek condemnation of the evidentiary base for the use of cricoid pressure for emergency airway management. Cricolol is an imaginary medication, but all of the references quoted below actually refer to cricoid pressure rather than Cricolol. Dr. Hinds uses the artifice of this fabricated drug to demonstrate how poor the evidentiary support is for the use of cricoid pressure for airway management.—SDW
Explore This IssueACEP Now: Vol 33 – No 07 – July 2014
If an assistant’s hand is placed on the patient’s neck, it should be for the sole purpose of assisting with external laryngeal manipulation to allow better glottic exposure.
Recently, I was at the Social Media and Critical Care (SMACC) conference in the Gold Coast of Australia. I looked forward to attending a debate on cricoid pressure for rapid sequence intubation (RSI) in the emergency department and ICU. The speaker was an Irish anaesthetist, intensivist, and prehospital doctor named John Hinds. I looked forward to this lecture because I have always believed the evidence does not support the use of cricoid pressure and that it should not be used for emergency airway management.1
In an inexplicable turn of events, this lecturer got up and, instead of discussing cricoid pressure, used his allotted time to push a brand-new medication called Cricolol. I still remember Dr. Hinds’ pitch for the drug. It was apparently invented as an herbal remedy by an Irish chap called O’Monroe in 1774, then refined and rebranded by O’Sellick in 1961. O’Sellick performed a nonrandomized trial of just 26 patients in a single hospital.2 Even more worrisome for this new medication, there was no standardizing of dose—they just pushed what looked like a good amount. Somehow, based on this, the drug not only got approved, but it was incorporated into national guidelines throughout Ireland. Dr. Hinds indicated that we should be administering it for all of our emergent intubations.
The way Cricolol is administered requires a dedicated and trained assistant to start pushing the medication at the beginning of airway management and continue administration throughout the entire process of securing the airway. The problem is that even though dosing guidelines are included on the package insert, the ampule itself is unmarked and contains variable amounts of drug. When they did postmarketing surveillance, it turns out that the correct dose of the drug was given only 5 percent of the time.3
Aside from that initial small trial, Dr. Hinds tried to convince his audience of the merits of the drug with additional support from BSE data. I’d have to watch the video of the lecture (see below) to remember what that stands for, but I remember the evidentiary level was not very impressive—something about corpses and magnetic resonance imaging (MRI) scanners.