To his credit, Dr. Hinds did admit to some problems with the medication. Cricolol may make airway management more difficult.^4-6 It can prevent endotracheal tube placement once you visualize the cords.⁷ It lowers the esophageal sphincter tone and increases the potential for regurgitation.^8,9 If the medication is dosed too high (a significant risk given the lack of ampule standardization), side effects can include airway fracture and esophageal rupture.^10,11

Dr. Hinds stressed again that the medication must be administered by your trained airway assistant throughout the whole procedure. He wanted to make sure we understood that the assistant’s full attention must be devoted to medication administration at the exclusion of any other assistance during RSI. He did mention that Cricolol will soon be available in suppository form, which may aid administration.

Anticipating audience questions, Dr. Hinds addressed whether it would be reasonable to start administering Cricolol at the beginning of an intubation and, if it made the airway more difficult, we could simply stop administering it. He strongly warned against this plan, explaining that the drug’s creator had the highest incidence of regurgitation ever reported when he used that strategy.

I don’t think I will be pushing for my hospital to add Cricolol to the formulary.

Message Behind the Joke

All kidding aside, Dr. Hinds’ lecture is a must-watch. You can see it at http://emcrit.org/wee/cricolol.

In summary, cricoid pressure, considered an essential aspect of rapid sequence tracheal intubation when it was first conceived, has come under increasing scrutiny within critical care and emergency medicine.¹ Computed tomography and MRI scanning have shown that cricoid pressure causes tracheal compression in 80 percent of patients. Numerous studies have found that cricoid pressure hinders bag-valve-mask device ventilation, increases peak inspiratory pressure, and reduces tidal volumes.1 For the same reasons that the airway obstruction induced by cricoid pressure may preclude effective manual ventilation, it may limit the effectiveness of apneic oxygenation as well. 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.^7,12

I do not believe in the use of cricoid pressure for RSI for all of the reasons mentioned above. However, I don’t think you should make this call as an individual doc but instead make a departmental guideline stating that, after a review of the evidence, cricoid pressure seems not helpful and possibly harmful. This will protect all members of your department while allowing excellent patient care.