Pediatric Emergency Front of the Neck Access (eFONA): Assessing a Novel Experiential Learning Approach

Current difficult airway algorithms end with the need for tracheal airway access to be obtained via Front Of Neck Access (FONA) to achieve oxygenation. In children < 8 years existing recommendations and the literature do not offer guidance on how to perform emergent FONA. Emergent tracheotomy is the potentially life-saving procedure - which needs to be performed without delay. When emergent tracheotomy is attempted in children < 8 years of age, there is a substantial risk for complications. As a result, health care providers who do not have routine at performing this procedure are often reluctant to perform FONA, Diameters, vertical/horizontal dimensions, vocal cord distance, larynx position, and cricothyroid membrane size of the rabbit airway suggest considerable similarities with infant airways, making it a good model to learn this technique. The FONA rapid sequence technique (RST) is a simple technique suitable for emergent pediatric tracheotomy. RST outlines 4 clearly defined steps, that enable airway establishment.

Step 1: Vertical midline skin incision and separate the strap muscles Step 2: Expose trachea and cricoid through palpation, lift and immobilize trachea with a clamp Step 3: Vertical trachea incision with the sharp tip scissors (2 cm) Step 4: Open the trachea and insert the tube The steps are easy to perform, if sufficiently practiced. Anesthesiologist, pediatric intensivists, surgeons, and emergency physicians who are most likely to need to perform FONA in small children, shall learn to perform RST emergent pediatric tracheotomy in less than 60 seconds. The investigators seek to measure and study learning curves of participants for establishing an artificial airway using the RST.

Hypothesis: After having practiced the procedure 10 times, 80% of study participants will not be able to successfully demonstrate FONA within 60 seconds. Alternative hypothesis: study participants will be able to successfully demonstrate FONA within 60 seconds.

Single-center interventional trial. The only inclusion criterion is informed consent. A high quality instructional video demonstrating the RST on a rabbit cadaver will teach the participants. Performance time will be defined (from touching the skin until ventilation of the trachea with a standard self-inflating bag connected to the tube). The investigators seek to assess the learning curves of participants.

Sample size. In order to obtain a lower limit of the 95% Confidence interval of 80% success in FONA the investigators would need 40 study participants assuming 2 failures by the 10th attempt. Statistical methods: Descriptive statistics for demographics. To establish the learning curve the increase over the 3 attempts will be analyzed by repeated ANOVA or Friedman.