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Cricoid Pressure: Just a Pain in the Neck?


Cricoid pressure, also known as the Sellick maneuver, refers to the application of external pressure against the cricoid cartilage to compress the esophagus between the cricoid ring and the cervical vertebrae. The maneuver is performed by placing the thumb and forefinger at either side of the cricoid cartilage and directing force in an upward and downward direction.

Cricoid pressure is performed during rapid sequence intubation (RSI) with intent to prevent regurgitation of gastric and esophageal contents and aspiration. However, there is currently no data available from randomized controlled trials to evaluate the efficacy of cricoid pressure in this setting. Several observational studies have failed to confirm the benefit of cricoid pressure in preventing regurgitation or aspiration and have pointed out associated risks of the maneuver in the emergency setting.

Important Risks of Cricoid Pressure

  • Prone to operator error when performed by an untrained assistant - common mistakes include: application of pressure to the thyroid cartilage leading to airway compression, using insufficient force to occlude esophagus, and premature release of pressure

  • May increase risk of aspiration - can induce retching and vomiting if applied before the patient is fully sedated, has been found to decrease tone of the lower esophageal sphincter and often provides incomplete occlusion of the esophagus, making regurgitation more likely

  • Associated with trauma to airway - studies have proven an increased incidence of injury to the airway and surrounding structures in patients receiving cricoid pressure, including fracture of the cricoid cartilage, esophageal rupture, cervical spine injury

  • Can interfere with airway management - has been found to prolong intubation duration due to obscuring glottic visualization or obstructing passage of the endotracheal tube

As we await findings from randomized controlled trials, cricoid pressure remains a technique with unproven clinical benefit but with potential to interfere with airway management. Gastric emptying prior to RSI may be a more effective and safer method of reducing aspiration risk in these patients.

Bottom Line: Cricoid pressure should no longer be part of routine rapid sequence intubation as there has been no proven benefit in its ability to reduce the incidence of gastric aspiration in the emergency setting.

References:

  1. Sellick, BA. (1961). Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia. The Lancet, 278(7199), 404-406.

  2. Algie CM, Mahar RK, Tan HB, et al. (2015). Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database of Systematic Reviews, 11.

  3. Stewart JC, Bhananker S, Ramaiah, R. (2014). Rapid-sequence intubation and cricoid pressure. International journal of critical illness and injury science, 4(1), 42.

  4. Caruana E, Chevret S, Pirracchio R. (2017). Effect of cricoid pressure on laryngeal view during prehospital tracheal intubation: a propensity-based analysis. Emerg Med J, 34, 132-137.

  5. Boet S, Duttchen K, Chan J, et al. (2012). Cricoid pressure provides incomplete esophageal occlusion associated with lateral deviation: a magnetic resonance imaging study. Journal Emerg Med, 42(5), 606-611.

Image credit: https://calsprogram.org/manual/volume2/Section5_AirwaySkills/AirSkGraphics/6_as_5.jpg

 

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