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Comparison of surgical cricothyroidotomy training: a randomized controlled trial of a swine model versus an animated robotic manikin model
  1. Vinciya Pandian1,
  2. William Robert Leeper2,
  3. Christian Jones3,
  4. Kristy Pugh4,
  5. Gayane Yenokyan5,
  6. Mark Bowyer4,
  7. Elliott R Haut3
  1. 1Department of Nursing Faculty, Johns Hopkins School of Nursing, Baltimore, Maryland, United States
  2. 2Department of Surgery, London Health Sciences Centre, Victorial Hospital, London, Ontario, Canada
  3. 3Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
  4. 4Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
  5. 5Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland, United States
  1. Correspondence to Dr Elliott R Haut, Department of Surgery, Johns Hopkins University, Baltimore, MD 21218, USA; ehaut1{at}


Background Airway obstruction remains a preventable cause of death on the battlefield. Surgical cricothyroidotomy is an essential skill for immediate airway management in trauma. Training for surgical cricothyroidotomy has been undertaken using simulators, cadavers or animal models. The ideal approach to training for this low volume and high-risk procedure is unknown. We hypothesized that current simulation technology provides an equal or better education for surgical cricothyroidotomy when compared with animal tissue training.

Methods We performed a prospective randomized controlled study comparing training for surgical cricothyroidotomy using hands-on training on swine versus inanimate manikin. We enrolled medical students who had never performed or had formal instruction on surgical cricothyroidotomy. We randomized their instruction to use either a swine model or the inanimate version of the Operative Experience Inc. advanced surgical manikin. Participants’ skills were then evaluated on human cadavers and on an advanced robotic manikin. Tests were scored using checklists modified from Objective Structured Assessment of Technical Skills and Tactical Combat Casualty Care. We compared scores between the groups using Wilcoxon rank sum tests and generalized linear models.

Results Forty-eight participants were enrolled and trained; 30 participants completed the first testing session; 25 completed the second testing session. The mean time to establish an airway from the incision until the cuff was blown up was 95±52 s. There were no significant differences in any of the outcome measures between the two training groups.

Discussion Measured performance was not different between subjects trained to perform surgical cricothyroidotomy on an animal model or a high fidelity manikin. The use of an advanced simulator has the potential to replace live tissue for this procedure mitigating concerns over animal rights.

Levels of evidence I

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  • VP and WRL are joint first authors.

  • Contributors VP, WL, MB and ERH provided substantial contributions to the conception or design of the work; VP, KP and WL were involved or the acquisition of the data; VP, WL, CJ and GY were involved in the analysis and interpretation of data for the work; VP drafted the work; and WL, CJ, KP, GY, MB and ERH revised it critically for important intellectual content. All authors provided final approval of the version to be published and are in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This work was funded by the Henry M. Jackson Foundation, Uniformed Services University of the Health Sciences (HU0001-14-0038, Subward 2884).

  • Competing interests VP has received two research grants from National Institutes of Health. The first grant is through the Nursing Institute of Nursing Research to assess symptoms and screen for laryngeal injury postextubation in intensive care unit settings (R01NR017433-01A1). The second grant is funded through the National Institute of Aging to evaluate the effectiveness of a novel arm restraint for intubated patients with cognitive impairment to reduce agitation, sedation and immobility (R42AG059451). ERH is/was primary investigator of contracts from PCORI entitled 'Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology' (CE-12-11-4489) and 'Preventing Venous Thromboembolism (VTE): Engaging Patients to Reduce Preventable Harm from Missed/Refused Doses of VTE Prophylaxis' (DI-1603-34596). ERH is primary investigator of a grant from the Agency for Healthcare Research and Quality (1R01HS024547) entitled 'Individualized Performance Feedback on Venous Thromboembolism Prevention Practice' and is a coinvestigator on a grant from the National Institute of Health/National Heart, Lung, and Blood Institute (R21HL129028) entitled 'Analysis of the Impact of Missed Doses of Venous Thromboembolism Prophylaxis'. ERH is supported by a contract from The Patient-Centered Outcomes Research Institute (PCORI), 'A Randomized Pragmatic Trial Comparing the Complications and Safety of Blood Clot Prevention Medicines Used in Orthopedic Trauma Patients' (PCS-1511-32745). ERH receives royalties from Lippincott, Williams, Wilkins for a book 'Avoiding Common ICU Errors'. ERH was the paid author of a paper commissioned by the National Academies of Medicine titled 'Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making', which was used to support the report titled 'A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury'.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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