Page 45 - Journal of Special Operations Medicine - Winter 2014

Prehospital and En Route Cricothyrotomy
Performed in the Combat Setting:

A Prospective, Multicenter, Observational Study

Ed B. G. Barnard, FCEM; Alicia T. Ervin, RN;
Robert L. Mabry, MD; Vikhyat S. Bebarta, MD

ABSTRACT
Introduction: Airway compromise is the third most com- discharge. The cricothyrotomy patients had more LSIs
mon cause of potentially preventable combat death. Sur- than noncricothyrotomy patients (four versus two LSIs
gical cricothyrotomy is an infrequently performed but per patient; p < .0011). Conclusion: In our prospective,
lifesaving airway intervention. There are limited pub- multicenter study evaluating cricothyrotomy in combat,
lished data on prehospital cricothyrotomy in civilian or procedural success was higher than previously reported.
military settings. Our aim was to prospectively describe In addition, the majority of cricothyrotomies were per-
the survival rate and complications associated with cri- formed by the evacuation helicopter medic rather than
cothyrotomy performed in the military prehospital and the prehospital combat medic. Prehospital military
en route setting. Methods: The Life-Saving Intervention medics should receive training in decision making and
(LSI) study is a prospective, institutional review board- be provided with adjuncts to facilitate this lifesaving
approved, multicenter trial examining LSIs performed in procedure.
the prehospital combat setting. We prospectively recorded
LSIs performed on patients in theater who were trans- Keywords: airway management, airway obstruction, mili-
ported to six combat hospitals. Trained site investigators tary medicine, war, emergency medical services, cricothy-
evaluated patients on arrival and recorded demograph- rotomy, airway
ics, vital signs, and LSIs performed. LSIs were predefined
and include cricothyrotomies, chest tubes, intubations,
tourniquets, and other procedures. From the large data-
set, we analyzed patients who had a cricothyrotomy per- Introduction
formed. Hospital outcomes were cross- referenced from Oral endotracheal intubation is the preferred method
the Department of Defense Trauma Registry. Descriptive of securing an airway in trauma. However, when the
1,2
statistics or Wilcoxon test (nonparametric) were used prehospital provider is not trained in this technique or
for data comparisons; statistical significance was set at when oral intubation is not possible (e.g., in a “can’t
p < .05. The primary outcome was success of prehospi- intubate, can’t ventilate” situation; when there is sig-
tal and en route cricothyrotomy. Results: Of the 1,927 nificant head, face, or neck trauma; or in the military,
patients enrolled, 34 patients had a cricothyrotomy per- when the tactical situation does not allow it), surgical
formed (1.8%). Median age was 24 years (interquartile cricothyrotomy can be lifesaving. Cricothyrotomy is
3,4
range [IQR]: 22.5–25 years), 97% were men. Mecha- the final common pathway of military and civilian air-
nisms of injury were blast (79%), penetrating (18%), and way algorithms. However, this emergency procedure
7,8
blunt force (3%), and 83% had major head, face, or neck can have significant complications, particularly in the
injuries. Median Glasgow Coma Scale score (GCS) was prehospital environment. 7,8
3 (IQR: 3–7.5) and four patients had GCS higher than
8. Cricothyrotomy was successful in 82% of cases. Rea- Airway compromise contributes to prehospital civil-
sons for failure included left main stem intubation (n = 1), ian trauma deaths and is the third most common cause
subcutaneous passage (n = 1), and unsuccessful attempt of death on the modern battlefield. 9,10 The prevalence of
(n = 4). Five patients had a prehospital basic airway inter- head, face, and neck injury, a common indication for crico-
vention. Unsuccessful endotracheal intubation preceded thyrotomy, has increased in recent conflicts, probably due
15% of cricothyrotomies. Of the 24 patients who had the to improvements in torso-protecting body armor. Data
11
provider type recorded, six had a cricothyrotomy by a from UK and US aeromedical advanced medical teams,
combat medic (pre-evacuation), and 18 by an evacuation typically including a military physician, demonstrate that
helicopter medic. Combat-hospital outcome data were 50% of patients with an injury severity score (ISS) of 16 or
available for 26 patients, 13 (50%) of whom survived to higher require an advanced airway intervention. 12

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