Trauma

http://tra.sagepub.com Sellick's manoeuvre

A. Stannard and C. Ackroyd Trauma 2007; 9; 127 DOI: 10.1177/1460408607084837 The online version of this article can be found at: http://tra.sagepub.com

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Trauma 2007; 9: 127129

Sellicks manoeuvre
A Stannarda and C Ackroydb

The application of extrinsic pressure to the cricoid cartilage to prevent gastric contents leaking into the pharynx during tracheal intubation by extrinsic obstruction of the oesophagus.

Who was Sellick?

Brian Arthur Sellick MBBS, FRCA, FFARCS was born in Dorking on 13 June 1918 and died on 13 July 1996. He was an eminent anaesthetist who qualified in 1941 from the Middlesex Hospital, London. He served as a Surgeon Lieutenant in the Royal Naval Volunteer Reserve in both the Far East and Australian waters during the latter part of WWII. He later specialised in thoracic anaesthesia and was recognised as a European expert in hypothermic anaesthesia. Although he was involved in a number of important research projects including positive pressure ventilation, the value of pre-operative smoking cessation, hypothermic anaesthesia, postural drainage with percussive physiotherapy and the use of antibiotics, he is best known for the manoeuvre which bares his name (Pallister, 1996).

However, wider acceptance of this technique was not gained until Sellicks cadaveric experiments, during which the stomach was filled with water, cricoid pressure applied, then a steep head down Trendelenburg position assumed, with the observation that regurgitation of fluid into the pharynx did not occur. By inserting a soft latex tube into the oesophagus of anaesthetised and paralysed patients, extending the neck and applying pressure to the cricoid cartilage, the only complete ring of cartilage around the trachea, at the level of the 5th cervical vertebrate he was able to demonstrate by X-ray, occlusion of the lumen of the oesophagus. Sellick originally described his manoeuvre in his paper of 1961: Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia: preliminary communication (Sellick, 1961. All quotes from Sellick 1961 reproduced with kind permission from Elsevier). His description of the manoeuvre is as follows; Cricoid pressure must be exerted by an assistant. Before induction, the cricoid is palpated and lightly held between the thumb and second finger; as anaesthesia begins, pressure is exerted on the cricoid cartilage mainly by the index finger. Even a conscious patient can tolerate moderate pressure without discomfort but as soon as consciousness is lost, firm pressure can be applied without obstruction of the patients airway. Pressure is maintained until intubation and inflation of the cuff of the endotracheal tube is complete (Sellick, 1961). In his paper, Sellick recognises the potentially dis astrous consequences of gastric contents entering the airway, noting the risks to be particularly significant in obstetrics and emergency general surgery. This was an increasing problem following the introduction of short acting relaxant drugs to aid intubation.
10.1177/1460408607084837

Original citation
The application of cricoid pressure to reduce water in the lungs and prevent gastric distension was originally described by Dr Munro in 1774 (Salem).
a

Surg Lt Cdr RN, Academic Department of Military Surgery. Maj RAMC, SpR Anaesthetics.

Address for correspondence: Surg Lt Cdr Adam Stannard, Academic Department of Military Surgey and Trauma Royal Centre for Defence Medicine, Room 24 West Wing, Institute of Research and Development Birminhgam Research Park Vincent Drive, Birmingham. B15 2SQ, UK. E-mail: adamst@doctors.org.uk

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A Stannard and C Ackroyd

reason research on Sellicks manoeuvre has mainly focussed on improving training for those personnel who administer cricoid pressure. Early techniques included applying pressure to the bridge of the nose until pain is felt, although this has recently been discredited (Escott et al., 2003). The application of pressure to the trainees own cricoid has also proven unsatisfactory as retching occurs below the required pressure (Vanner et al., 1992). This has led to the development of several training models including simple systems which are composed of mock cricoid cartilage and simple scales to measure the amount of force applied through to more complex professionally built systems. Kopka showed that such biofeedback systems significantly improve the degree of optimal pressure application from 8% pre-training to 56% post-training (p 0.0005) in conscious patients (Kopka and Crawford, 2004). It is important that staff regularly update on these biofeedback systems in order to maintain the appropriate level of skill. Cricoid pressure is as effective in children as adults (Moynihan et al., 1993). Laryngeal mask airways (LMAs) can be used in conjunction with Sellicks manoeuvre (Brimacombe et al., 1993), however, some authors note impedance of ventilation (Ansermino and Blogg, 1992; Brimacombe and Berry, 1993) and difficulty in placing the LMA. It is suggested that if such difficulties are encountered that transient release of pressure allows correct LMA placement.

Indications and contraindications

Cricoid pressure should be used  when emergency induction of anaesthesia is required (full stomach).  when endotracheal intubation is delayed or not possible in patients with a compromised airway.  at induction of anaesthesia in elective surgical patients with an incompetent gastro-oesophageal sphincter (e.g. GORD or pregnancy).  in patients with delayed gastric emptying (e.g. autonomic neuropathy). Relative contraindications to cricoid pressure include:  unstable C-spine injuries;  patient actively vomiting (risk of oesophageal rupture);  when it makes intubation difficult (obscures laryngeal view);  trauma to the anterior neck (loss of landmarks);  a limited number of personnel (The International Liason Committee on Resuscitation (ILCOR) state that cricoid pressure should be applied as soon as a third rescuer arrives up to this point airway and breathing are the priorities.) (Hein and Owen, 2005).

The practicalities of applying cricoid pressure

Cricoid pressure is applied by locating the thyroid prominence, the most protuberant part of the anterior neck in the midline or the Adams apple, then sliding the finger inferiorly until it enters the cricothyroid notch; immediately below this is the cricoid cartilage. The thumb and index finger are applied either side of the cricoid cartilage, laterally, with a pressure of 34 kg (3040 Newtons) directly backwards until the instruction to remove the pressure is given by the anaesthetist, generally when the airway is fully secured. The main pitfall of applying cricoid pressure is the use of the correct amount of force. Studies have shown that in the majority of cases the force applied is less than optimal (Koziol et al., 2000). For this
Trauma 2007; 9: 127129

Complications of Sellicks manoeuvre

If too little force is applied then it is ineffective, however, the application of excessive pressure has recognised complications including the restriction of ventilation, poor laryngoscopic views, with discomfort and fatigue for the person performing the manoeuvre. Rarer complications such as oesophageal rupture have been reported in addition to exacerbation of unsuspected airway injuries (Landsman, 2004).

Discussion
Since its inception Sellicks manoeuvre has undoubtedly reduced mortality and morbidity in

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Sellicks manoeuvre
patients undergoing anaesthesia. This fact is almost universally recognised by those working in the field and was demonstrated when Sellick was awarded the Henry Hickman Medal by the Royal Society of Medicine on 21 March 1989. The citation stated It is impossible to over estimate the benefit that this discovery has made to the safe conduct of anaesthesia, as it has undoubtedly saved the lives of many patients who underwent surgery from serious post operative complications or death. Thirty years after its presentation, the technique is still in use world wide and has not been superseded by any other solution. (Pallistes, 1996, reproduced with kind permission from Blackwell publishing.) The importance of the skill of cricoid pressure application cannot be underestimated. This is a skill in which all those involved with resuscitation and anaesthesia should be accomplished and as such should be regularly practised using training models.

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References
Ansermino JM, Blogg CE. 1992. Cricoid pressure may prevent insertion of the laryngeal mask airway. Br J Anaesth 69: 4657. Brimacombe J, Berry A. 1993. Mechanical airway obstruction after cricoid pressure with the laryngeal mask airway. Anesth Analg 72: 4751.

Brimacombe J, White A, Berry A. 1993. Effect of cricoid pressure on ease of insertion of the laryngeal mask airway. Br J Anaesth 71: 8002. Escott MEA, Owen H, Strahan AD, Plummer JL. 2003. Cricoid pressure training: how useful are descriptions of force? Anaesth Intensive Care 31: 38891. Hein C, Owen H. 2005. The effective application of cricoid pressure. Journal of Emeregncy Primary Health Care 3: 12. Kopka A, Crawford J. 2004. Cricoid pressure: a simple yet effective biofeedback trainer. Eur J Anaesthesiol. 21(6): 4437. Koziol CA, Ceddeford JD, Moos DD. 2000. Assessing the force generated with application of cricoid pressure. AORN J B72(6): 101828. Landsman I. 2004. Cricoid pressure: indications and complications. Paediatr. Anaesth 14(1): 437. Moynihan RJ, Brock-Utne JG, Archer JH, Feld LH, Kreitzman TR. 1993. The effect of cricoid pressure on preventing gastric insufflation in infants and children. Anesthesiology 78(4): 6526. Pallister WK. 1996. Obituary - Brian Arthur Sellick. Anaesthesia 51: 119495. Sellick BA. 1961. Cricoid pressure to control regurgitation of stomach contents during induction of anaesthesia: preliminary communication. The Lancet 278 (7199): 4046. Vanner RG, ODwyer JP, Pryle BJ, Reynolds F. 1992. Upper oesophageal sphincter pressure and the effect of cricoid pressure. Anaesthesia 47: 95100.

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