ASTANDING-ORDER PROTOCOL FOR CRICOTHYROTOMY IN PREHOSPITAL EMERGENCY P ATIENTS Evadne G. Marcolini, MD, John H. Burton, MD, Jay R. Bradshaw, EMT-P, Michael R. Baumann, MD ABSTRACT Objective. To study utilization, indications, and outcomes associated with the use of a statewide, emergency medical services (EMS) standing-order protocol for cricothyrotomy. Methods. A statewide EMS database was queried for patients who received cricothyrotomy under a standardized, standing-order protocol. Patient EMS and hospital records were reviewed in a defined sequence with information recorded on a standardized collection form. Results. EMS records included eight years of practice with 1.5 million patient encounters. For each year studied, approximately 540 emergency medical technicians (EMTs) were certified to perform cricothyrotomy. State EMS providers performed a collective mean of eight cricothyrotomy procedures per year (range, 1–17), for a total of 68 cricothyrotomies performed within the eight-year period. Hospital records were available for review in 61 patients. Fifty-six patients received cricothyrotomy by open surgical incision, six by needle with jet ventilation, and one by both methods. Categorization of cricothyrotomy patients as trauma or medical was 61% trauma and 39% medical. Thirty-six patients (59%) were in cardiac arrest on EMS arrival and 12 patients (20%) died during transport. Thirteen trauma patients (21%) were admitted with eight patients surviving to discharge (13%). The neurologic impairment at time of hospital discharge was severe in four, moderate in two, and minimal or none in two patients (3%). Conclusion. A considerable percentage of cricothyrotomy procedures were performed on patients with non-trauma-related diagnoses in this investigation describing a standing-order EMS protocol for cricothyrotomy. The majority of patients undergoing cricothyrotomy with this protocol were in cardiac arrest at the time of cricothyrotomy, with a small minority of patients surviving to hospital discharge and fewer surviving neuro- logically intact. Key words: cricothyrotomy; emergency medical services; endotracheal intubation. PREHOSPITAL EMERGENCY CARE 2004;8:23–28 For more than 20 years, emergency medical services (EMS) practice protocols have included cricothyrotomy as an invasive procedure of last resort to secure the airway of the most critical of prehospital patients when intubation attempts have been unsuccessful. 1–3 In some EMS systems, other airway procedures such as multi- lumen airway or laryngeal mask airway are available and may provide a less invasive method of securing an airway after failed intubation attempts. 4–7 Previous studies have investigated surgical cri- cothyrotomy utilization by prehospital personnel with online medical control in trauma patients as well as cricothyrotomy utilized by flight nurses and physicians. 8–12 We are unaware of any previous in- vestigation that has described a standing-order EMS cricothyrotomy protocol for patients with trauma and medical diagnoses. The objective of this study was to describe the utilization, indications, and outcomes associated with the use of a statewide, EMS standing- order protocol for cricothyrotomy. METHODS Study Design The study was a retrospective health records survey of EMS records from January 1, 1993, through December 31, 2000. The Maine Medical Center Research Institute Institutional Review Board (IRB) for Research on Human Subjects approved the study. Population and Setting The Maine state EMS system is primarily a rural EMS system with advanced life support (ALS) and basic life support (BLS) personnel. Approximately 200,000 an- nual patient encounters occur in this system. The state of Maine has a population of 1.3 million with census of 41.3 persons per square mile. Pre- hospital resources include an air ambulance service in the state in addition to ground-based EMS services. Typical ground-based transport times vary greatly throughout the state and include prehospital ground transport times up to two hours given the number of Maine hospitals relative to the geographic state size. Additionally, the mountainous topography of Maine frequently presents communication challenges for EMS providers contacting hospital-based medical control via radio and cell phone. This challenging environment Received May 23, 2003, from the University of Vermont School of Medicine (EGM), Burlington, Vermont; the Department of Emergency Medicine (JHB, MRB), Maine Medical Center, Portland, Maine; and Maine Emergency Medical Services (JRB), Augusta, Maine. Revision received August 19, 2003; accepted for publication August 22, 2003. Supported by grants from the Maine Medical Center Research Institute and the University of Vermont School of Medicine. Address correspondence and reprint requests to: John H. Burton, MD, Department of Emergency Medicine, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102. e-mail: <burtoj@mmc.org>. doi:10.1197/S1090-3127(03)00277-6 23