Page 20 - Journal of Special Operations Medicine - Fall 2017

Prehospital Cricothyrotomy Kits Used in Combat

A Case Series

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Steven G. Schauer, DO, MS, RDMS *; Michael D. April, MD, PhD ;
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Cord W. Cunningham, MD ; Adrianna N. Long, MD ; Robert Carter III, PhD, MPH 5
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ABSTRACT
Background: Surgical cricothyrotomy remains the only de- trauma patients required prehospital SC versus 0.15% among
finitive airway management modality for the tactical setting civilian trauma patients. 6
recommended by Tactical Combat Casualty Care guidelines.
Some units have fielded commercial cricothyrotomy kits to This procedure has a significant complication rate even under
assist Combat Medics with surgical cricothyrotomy. To our the best of circumstances. In one study of 38 patients undergo-
knowledge, no previous publications report data on the use ing SC by trained emergency medicine and surgery physicians,
of these kits in combat settings. This series reports the the use 12 patients (31.6%) had complications, including incorrect
of two kits in four patients in the prehospital combat setting. tube placement and intubation time longer than 3 minutes.
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Methods: Using the Department of Defense Trauma Registry Airway decompensation and compromise requiring SC often
and the Prehospital Trauma Registry, we identified four cases occur in the prehospital setting, where healthcare providers
of patients who underwent prehospital cricothyrotomy with with relatively little experience in airway management are of-
the use of commercial kits. In the first two cases, a Medic suc- ten required to perform SCs. Complication rates are higher
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cessfully used a North American Rescue CricKit (NARCK) still under these circumstances when nonphysicians carry out
to obtain a surgical airway in a Servicemember with multiple the procedure outside of the hospital setting. Civilian prehos-
amputations from an improvised explosive device explosion. pital data suggest emergency medical technicians correctly
In case 3, the Medic unsuccessfully used an H&H Medical kit place SC after failed orotracheal intubation 64% of the time.
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to attempt placement of a surgical airway in a Servicemember Battlefield data similarly report that many SCs performed by
shot in the head by small arms fire. A second attempt to place Medics in the prehospital setting result in significant complica-
a surgical airway using a NARCK was successful. In case 4, tions and preventable deaths. 8,10–12
a Soldier sustained a gunshot wound to the chest. A Medic
described fluid in the airway precluding bag-valve-mask ven- Surgical airway assist devices offer one mechanism alongside
tilation; the Medic attempted to place a surgical airway with improved training to potentially decrease the occurrence of
the H&H kit without success. Conclusion: Four cases of pre- complications associated with SCs performed by Medics in
hospital surgical airway cannulation on the battlefield dem- the prehospital combat setting. 8,10,13,14 This report describes
onstrated three successful uses of prehospital cricothyrotomy the use of commercially prepared cricothyrotomy kits in the
kits. Further research should focus on determining which kits prehospital combat setting. The objective of this case series is
may be most useful in the combat setting. to highlight the feasibility and potential clinical utility of these
devices for optimizing airway management and, hence, patient
Keywords: airway, surgical; cricothyrotomy; cricothyroidot- survival on the battlefield (Table 1).
omy; combat; prehospital; Medic, Afghanistan
Cases
Case Acquisition
Introduction
We identified subjects using the Prehospital Trauma Regis-
Background try (PHTR) and the Department of Defense Trauma Registry
On the battlefield, successful prehospital airway management (DODTR). The PHTR was in existence from January 2013
is a significant challenge facing emergency military personnel. through September 2014 in Afghanistan. We acquired these
Despite significant advances in airway management devices, cases as part of a study seeking to evaluate prehospital care
complications related to airway management remain the third within the Prehospital Trauma Registry (PHTR). We obtained
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most common preventable cause of combat death. Poor out- only deidentified data. This study met U.S. Army Institute of
comes are likely attributable, in part, to the unique technical Surgical Research regulatory requirements.
challenges of managing airway compromise due to battlefield
trauma, which frequently necessitates surgical cricothyrotomy The Joint Trauma System PHTR is a data collection and ana-
(SC). Indeed, one study reported 0.24% of admitted battlefield lytic system designed to provide near real-time feedback

*Correspondence to steven.g.schauer.mil@mail.mil
1 MAJ Schauer is the Combat Casualty Care task area medical director at the U.S. Army Institute of Surgical Research (USAISR) and core faculty
for the emergency medicine program at the San Antonio Military Medical Center (SAMMC) in San Antonio, TX. MAJ April is an emergency
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medicine physician and the director of research for the emergency medicine residency program at the SAMMC in San Antonio, TX. LTC Cun-
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ningham is an emergency medicine and emergency medical services physician at the USAISR in San Antonio, TX. CPT Long is with the Winn
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Army Community Hospital, Fort Stewart, GA. LTC Carter is with the U.S. Army Institute for Surgical Research, JBSA Fort Sam Houston, TX.
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