Methods Introduction Cricothyroidotomy occurs between 0-2% of all intubations and is lifesaving. Familiarity and experience for emergency physicians is essential. Because it is infrequent and there is limited cadaver availability secondary to cost presents, achieving and maintaining adequate exposure to cricothyroidotomy is difficult. If trainees outnumber cadavers, not all participants have the opportunity to perform the initial skin incision. We present cadaveric autografting as a novel way to simulate cricothyroidotomy from start to finish in order to increase the number of trainees with first pass experience. Enhancement of Cricothyroidotomy Procedural Competency using Cadaver Autograft Study design: prospective crossover study Participants: volunteers currently in residency training or participating in an emergency medicine sub- internship and had not performed a cricothyroidotomy on the study day twenty-seven residents and nine students Procedure: volunteers randomized to perform cricothyroidotomy initially on previously incised native neck tissue or on grafted tissue, then vice-versa A board-certified emergency physician instructed all participants in cricothyroidotomy. Materials: autograft of cadaveric iliotibial band covered with lateral thigh skin to simulate cricothyroid membrane and native anterior neck anatomy Outcomes: evaluated via Likert scale Chandler I, Coughlin RF, Binford J, Bonz J, Hile D Yale-New Haven Hospital Department of Emergency Medicine

Figures Enhancement of Cricothyroidotomy Procedural Competency using Cadaver Autograft Chandler I, Coughlin RF, Binford J, Bonz J, Hile D Yale-New Haven Hospital Department of Emergency Medicine Figure 1. IT band graft on cadaver neck. Figure 2. Lateral thigh skin on cadaver neck.

Results Conclusions Enhancement of Cricothyroidotomy Procedural Competency using Cadaver Autograft 30 of 36 (83%) of participants agreed or strongly agreed that they preferred cadaver grafting over previously incised native tissue. 32 of 36 (89%) agreed or strongly agreed that performing cricothyroidotomy with a cadaver graft was useful. 23 of 36 (64%) agreed or strongly agreed that performing cricothyroidotomy on previously incised native tissue (p =.001) was useful. 26 of 36 (72%) felt more comfortable with cricothyroidotomy in the emergency department after using cadaveric grafting versus 19/36 (53%) who felt more comfortable after using the native tissue (p =.003). Grafted cadaveric tissue is perceived as useful by the majority of participating emergency medicine trainees. Autografting maximizes the educational potential of each cadaver by allowing multiple participants to perform cricothyroidotomy from start to finish. Cadaveric grafting may function as a useful training adjunct for multiple emergency procedures, particularly in rare procedures that are invasive and difficult to perform more than once starting from initial incision, including tube thoracostomy, peripheral venous cut down, initial incisions for canthotomy, thoracotomy, or perimortem cesarean section. Chandler I, Coughlin RF, Binford J, Bonz J, Hile D Yale-New Haven Hospital Department of Emergency Medicine

References Enhancement of Cricothyroidotomy Procedural Competency using Cadaver Autograft 1. Bair AE, Panacek EA, Wisner DH, Bales R, Sakles JC: Cricothyrotomy: a 5-year experience at one institution. J Emerg Med. 2003;24(2): Erlandson MJ, Clinton JE, Ruiz E, Cohen J: Cricothyrotomy in the emergency department revisited. J Emerg Med. 1989;7(2): Fortune JB, Judkins DG, Scanzaroli D, McLeod KB, Johnson SB: Efficacy of prehospital surgical cricothyrotomy in trauma patients. J Trauma. 1997;42(5): Harwood, Nuss: Clinical Practice of Emergency Medicine, 5 th edition. Philadelphia, Lippincott Williams & Wilkins, 2010, pp 6-11, Vanderbilt AA, Mayglothling J, Pastis N, Franzen D: A review of the literature: direct and video laryngoscopy with simulation as educational intervention. Adv Med EducPract ;5:15-23 Chandler I, Coughlin RF, Binford J, Bonz J, Hile D Yale-New Haven Hospital Department of Emergency Medicine