Page 47 - Journal of Special Operations Medicine - Winter 2014

Table 2 Glasgow Coma Scale Scores on Arrival to the Patients who received cricothyrotomies had significantly
Combat Hospital and Their Survival to Combat Hospital more additional LSIs than did patients who did not have
Discharge a cricothyrotomy (median of four LSIs per patient versus
GCS No. % Survival,%* two LSIs, respectively; p < .0011). The most frequently
undertaken LSIs in cricothyrotomy patients were vas-
15 3 9 100
cular access, application of a hypothermia- mitigating
8 1 3 100 blanket, and all types of wound pressure packing (he-
3–7 6 18 67 mostatic and nonhemostatic) (Table 4).
3 22 ‡ 65 23
Table 4 The Frequency of Additional Lifesaving
Not recorded 2 6 0 Interventions (LSIs) Performed in Conjunction With
Notes: GCS = Glasgow Coma Scale score. a Prehospital or En Route Cricothyrotomy
*Survival percentage is only described for patients with a known
outcome. LSI No. %
‡ Four of the patients with GCS of 3 were sedated. Intravenous access 23 68
Hypothermia blanket 19 56
medication (midazolam or ketamine) prehospital or en
route; all of these had a GCS score of 3 on arrival to the Intravenous fluid 17 53
combat hospital. Wound pressure packing 14 41
Intraosseous access 14 41
Hospital outcomes were available for 26 patients; 13 Combat tourniquet 10 29
(50%) survived to discharge from a combat hospital. The
survival of patients who had a GCS score of 3 was 23%,
compared with 67% for a GCS score of 3–7 and 100% Discussion
for those with a GCS score of 8 of higher (Table 2).
In our prospective, multicenter, combat study of prehos-
The indication for cricothyrotomy was available for 32 pital and en route care cricothyrotomies, we found a
patients (94%). The leading indication was head injury rate of survival to discharge from a combat hospital of
(n = 16; 50%) (Table 3). 50%. Cricothyrotomy was successful in 82% of cases
and helicopter-borne medics (all nonphysicians) per-
Table 3 Indication for Prehospital or En Route Cricothyrotomy formed three-quarters of the procedures. Patients who
received a cricothyrotomy had significantly more other
Predominant Injury/Indication No. % LSIs performed during their prehospital care.
Head injury, GCS 3 11 34
Head injury, GCS >3 5 16 The survival rate of 50% reported in this study appears
higher than that described in retrospective studies of
Facial injury, GCS 3 5 16
combat setting data (34%). However, survival data
16
Facial injury, GCS >3 6 19 were only available on three-quarters of the patients,
Airway obstruction/injury 3 9 making the possible range of survival from 38% to 62%
Traumatic evisceration 1 3 and is, therefore, only comparable. The patients lost to
follow-up were those who were not identifiable from
GSW, neck and shoulder 1 3
DoDTR (i.e., non-US Servicemembers). Owing to the
Notes: GCS = Glasgow Coma Scale score; GSW = gunshot wound. similar levels of care afforded to all emergency patients,
regardless of affiliation, this is unlikely to have signifi-
Cricothyrotomy was successfully performed in 28 cases cantly affected the outcome.
(82%). Reasons for failure included left main-stem intu-
bation (n = 1), subcutaneous passage (n = 1), and “un- The success of prehospital cricothyrotomy in our series
successful attempt” (n = 4). Five patients were recorded (82%) is higher than that previously described in com-
9
as having received prehospital basic airway maneuvers bat (68%). It is unclear from the data available whether
prior to cricothyrotomy. An unsuccessful attempt at oral this is due to a higher level of skill demonstrated or
endotracheal intubation preceded five cricothyrotomies whether the difficulty of the procedure was significantly
(15%). different. This study does have a higher prevalence of
blast injury (79% versus 42% ) and this may have had
16
Twenty-four patients (71%) had the type of prehospital an effect. This success rate, however, is still considerably
provider recorded. Significantly more cricothyrotomies lower than that observed in pooled, civilian, prehospital
3
were inserted by evacuation helicopter medics than by data (92.2%). This higher success rate may be due to
ground medics (pre-evacuation) (18 versus 6; p < .02). better training or experience but also could be due to the

Prehospital and En Route Cricothyrotomy in Combat 37