# Why was cricoid pressure stopped?



## Lamiae (Oct 24, 2012)

I'm an AEMT/EMT-I student now and I am currently learning about delivering oxygen. Yesterday, we covered the usage of a bag-mask device with a reservoir. In background research, I read about the three-person bag-mask technique where one provider is performing the Sellick maniver/applying cricoid pressure. I brought it up during class, and the teacher said that it was no longer used and moved on with the lesson.

I was wondering if anyone would be able to tell me why it is no longer practiced to prevent gastric distension during artificial ventilation.


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## Handsome Robb (Oct 24, 2012)

It's still used. Good BVM techniques can limit gastric insufflation and crich pressure can help limit it further although it's generally low on the list of priorities if I'm bagging someone. 

With that said, every tube I've ever dropped has involved crich pressure/BURP to help facilitate visualization during intubation as well as keeping them from throwing up in my face.


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## Veneficus (Oct 24, 2012)

Rob is right, 

Cricoid pressure is no longer emphasized or taught in ACLS guidelines.

It sounds like your teacher misinterpreted the intent.


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## Handsome Robb (Oct 24, 2012)

Veneficus said:


> Rob is right



Not gonna lie, very tempted to make this my signature  Probably the only time I'll ever hear it coming from Vene :lol:


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## WTEngel (Oct 24, 2012)

Ultimately, the decision to de-emphasize cricoid pressure as a topic was made due to the high incidence of providers performing this technique incorrectly, leading to increased incidence of failed intubation, or decreased ability to ventilate via BVM device. Essentially, the majority of providers do not use this technique enough to be proficient at it, so they (AHA) de emphasized it. It was counterproductive.

In fact if you listen closely to the video (or, GASP! read the guidelines!) you will notice that they specifically say "the ROUTINE use of cricoid pressure" is no longer recommended. The operative word is routine. It hasn't been removed all together.

We still use it regularly in the critical care environment and most anesthesiologists I rotate with still keep it in their tool box. 

So now you need to go educate your educator!


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## ffemt8978 (Oct 24, 2012)

Not to mention, how many three man ambulance crews are there out there?


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## mycrofft (Oct 24, 2012)

WTEngel said:


> Ultimately, the decision to de-emphasize cricoid pressure as a topic was made due to the high incidence of providers performing this technique incorrectly, leading to increased incidence of failed intubation, or decreased ability to ventilate via BVM device. Essentially, the majority of providers do not use this technique enough to be proficient at it, so they (AHA) de emphasized it. It was counterproductive.
> 
> In fact if you listen closely to the video (or, GASP! read the guidelines!) you will notice that they specifically say "the ROUTINE use of cricoid pressure" is no longer recommended. The operative word is routine. It hasn't been removed all together.



E.G., basically the same reason tourniquets and field cricothyrotomies were deemphasized after years of TK's done with lamp cords and field crics sliding off into thyroids etc. If enough people at level X fail at doing it, then their level loses it until/unless suporting education (anatomy mostly) is improved, or some other reason unknown to us groundlings.


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## Lamiae (Oct 24, 2012)

Thanks everyone. I asked one instructor why it was no longer used, and he stated that it was because (1)too much pressure was applied and (2)patients could vomit, tearing esophageal tissue. 

I was slightly confused by his second reason, because the Sellick maneuver is to not only prevent gastric insufflation but also prevent vomiting during ventilations but also PREVENT vomiting. Despite confusion, I didn't challenge his response but he shall receive an e-mail from me challenging being told that is is no longer used in ventilations and in ET tube placement.


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## mycrofft (Oct 24, 2012)

Lamiae said:


> Thanks everyone. I asked one instructor why it was no longer used, and he stated that it was because (1)too much pressure was applied and (2)patients could vomit, tearing esophageal tissue.
> 
> I was slightly confused by his second reason, because the Sellick maneuver is to not only prevent gastric insufflation but also prevent vomiting during ventilations but also PREVENT vomiting. Despite confusion, I didn't challenge his response but he shall receive an e-mail from me challenging being told that is is no longer used in ventilations and in ET tube placement.



"Be cool"!


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## socalmedic (Oct 24, 2012)

your instructors response #1 was correct in that it is deemphasized due to incorrect usage. many providers applying the sellick where applying too much force causing an actual flattening of the larynx increasing difficulty in intubation. instead laryngeal manipulation (bURP, note the lower case B) should be used instead. by applying only slight posterior pressure then manipulating in the direction of the patients right ear your view should be enhanced allowing a greater view of the trachea. 

with all this said, there is research that supports both sides of the fence so only time will tell what holds true. the above seams to work well for me.


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## BLS Systems Limited (Oct 25, 2012)

Lamiae said:


> I was slightly confused by his second reason, because the Sellick maneuver is to not only prevent gastric insufflation but also prevent vomiting during ventilations but also PREVENT vomiting.



I believe the concern there is that the patient could still attempt to vomit through gastric contractions but blocking the esophagus could lead to a rupture of the esophagus itself due to the high pressures being generated.  So yes, you can prevent gastric contents from entering the airway but you can also create a whole lot of larger problems.  I have no idea what the incidence of that is, but it has been voiced to me before by several anasethesiologists.


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## Melclin (Oct 25, 2012)

We have Rich Levitan's book at work and I seem to remember him being against it although I forget the details.


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## Pavehawk (Oct 25, 2012)

Melclin said:


> We have Rich Levitan's book at work and I seem to remember him being against it although I forget the details.



Levitan showed some MRI's at a presentation that showed that in most cases the esophogas does not compress posteriorly, but rather slides sideways displacing the entire tube laterally while not decreasing the diameter to actually occulde any passage of vomit. 

Also keep in mind that the AHA suggestions are for routine use of cricoid pressure with CPR/BVM use, not during intubation. Some Doc's around here still use it for RSI some don't.


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## KellyBracket (Oct 25, 2012)

I just want to highlight a point about cricoid pressure (i.e Sellick's) that is misunderstood by many people, including some physicians. It boils down to this:

Cricoid pressure ≠ BURP ≠ External laryngeal manipulation

I go in a bit more detail in my review  *Intubation and Mis-en-place*, but let me summarize the key distinctions:


> Cricoid pressure, in which the *cricoid cartilage* is displayed posteriorly, is not meant to aid visualization, but to prevent passive _regurgitation_ during RSI.
> The Backwards-Upwards-Rightwards-Pressure (BURP) maneuver employs manipulation of the *laryngeal cartilage*. It is performed by an unguided _assistant_, and is intended to improve _visualization_.
> External laryngeal manipulation (of the laryngeal cartilage) is performed by the _laryngoscopist_ with their free right hand, also to improve the view.



Cricoid is *not* used to improve the view of the cords - it's been shown to worsen the view, actually. (See the review for citations)

With that in mind, release of cricoid pressure is the first thing I ask for when the view of the cords isn't great.


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## Brandon O (Oct 25, 2012)

Short answer is that it often doesn't work, at least not well. As Engel said, "routine" use is not recommended anymore. (I have a bunch of those studies, let me known if you're interested and I can provide once I'm on my computer.) As a tool especially in the sparse BLS toolbox I think it should be retained, but way toward the bottom -- start with lighter and slower bagging, positioning, pharyngeal airways, etc. When performed think light and directly backwards (don't let it roll or deviate).


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## Brandon O (Oct 25, 2012)

Oh, and almost certainly the prevention of active regurgitation is a long shot -- think more decreasing gastric insufflation in the first place by limiting the esophageal diameter.


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## Christopher (Oct 25, 2012)

NVRob said:


> With that said, every tube I've ever dropped has involved crich pressure/BURP to help facilitate visualization during intubation as well as keeping them from throwing up in my face.



Proper positioning and bimanual external laryngeal manipulation (ELM) is far superior to BURP. Ever since I switched to face-neutral/ear-to-sternal notch positioning I've not once required BURP (n=8ish) and used ELM only twice.


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## mycrofft (Oct 25, 2012)

"I believe the concern there is that the patient could still attempt to vomit through gastric contractions but blocking the esophagus could lead to a rupture of the esophagus itself due to the high pressures being generated."

If esophageal preure=esophageal pressure, then why wouldn't an esophagus occluded by a mechanical airway (EOA) also create such pressures?



"Oh, and almost certainly the prevention of active regurgitation is a long shot -- think more decreasing gastric insufflation in the first place by limiting the esophageal diameter. "

Air compresses mightily. You'd need to REALLY, really, really reduce the esophageal diameter to avoid pushing air down there with a BVM or oral inflation short of closing it.


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## Brandon O (Oct 26, 2012)

mycrofft said:


> "Oh, and almost certainly the prevention of active regurgitation is a long shot -- think more decreasing gastric insufflation in the first place by limiting the esophageal diameter. "
> 
> Air compresses mightily. You'd need to REALLY, really, really reduce the esophageal diameter to avoid pushing air down there with a BVM or oral inflation short of closing it.



Well, you're not going to seal it, but you can make it a little harder to get in, and we need every advantage we can get. See:

http://www.ncbi.nlm.nih.gov/pubmed/3293480

http://journals.lww.com/anesthesiol...=1993&issue=04000&article=00007&type=abstract


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## mycrofft (Oct 26, 2012)

Brandon Oto said:


> Well, you're not going to seal it, but you can make it a little harder to get in, and we need every advantage we can get. See:
> 
> http://www.ncbi.nlm.nih.gov/pubmed/3293480
> 
> http://journals.lww.com/anesthesiol...=1993&issue=04000&article=00007&type=abstract



Thanks for the references!


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## Handsome Robb (Oct 26, 2012)

KellyBracket said:


> I just want to highlight a point about cricoid pressure (i.e Sellick's) that is misunderstood by many people, including some physicians. It boils down to this:
> 
> Cricoid pressure ≠ BURP ≠ External laryngeal manipulation
> 
> ...





Christopher said:


> Proper positioning and bimanual external laryngeal manipulation (ELM) is far superior to BURP. Ever since I switched to face-neutral/ear-to-sternal notch positioning I've not once required BURP (n=8ish) and used ELM only twice.



Much appreciated, thank you!


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## AnthonyM83 (Oct 26, 2012)

ROUTINE use of cricoid pressure when ventilating with a BVM is no longer recommended. One can STILL use it when needed or as part of RSI procedure prior to intubation or to help visualize the cords during intubation.

KellyBracket's distinctions are also important.


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