Page 21 - Journal of Special Operations Medicine - Fall 2017

Table 1 Characteristiscs of the Injured Servicemembers cricothyrotomy kit (H&H Medical Corp, https://buyhandh.
Primary com) but was unsuccessful. The records do not document the
Case Age, y MOI ISS Injury Final Status reason for the initially failed airway attempt. The Medic then
Multiple placed the surgical airway using the NARCK and pressure
1 39 IED 75 amputations Dead bandage while on the back of a vehicle and receiving small
Bilateral leg arms fire. The patient’s initial vital signs included HR of 96/
2 28 IED Unavailable Unavailable
amputation min, RR of 80/min, and blood pressure (BP) estimated at
3 29 GSW 30 GSW to head Alive 80mmHg systolic by palpation. Repeated vital signs after the
4 20 GSW Unavailable GSW to chest Dead procedure were HR of 120/min, RR of 30/min, and systolic BP
GSW, gunshot wound; IED, improvised explosive device; ISS, Injury of 80mmHg by palpation. The patient underwent air evacua-
Severity Score; MOI, mechanism of injury. tion to the hospital. On arrival, his BP was 151/100mmHg,
99% oxygen saturation, an HR of 67/min, and a composite
to commanders. Central Command and their Joint Theater ISS of 30. He went to the operating room for surgical repair of
Trauma System capture data on prehospital trauma care pro- his traumatic wound. He survived to final hospital discharge.
vided on the ground by all services in the Afghanistan theater.
Data sources include TCCC cards (before becoming the DD Case 4
1380), DD 1380 forms, and TCCC After Action Reports. The
DODTR provides data regarding medical care after arrival the A conventional forces Soldier was engaged in a small arms
Role 3 hospital. gunfight while on dismounted patrol and sustained a GSW to
the chest. A Medic placed a chest seal and then attempted to
use a bag-valve-mask but noted significant fluid in the airway.
Case 1
Subsequently, the Medic tried to place a surgical airway us-
A U.S. Special Operations Command (SOCOM) Servicemem- ing an H&H cricothyrotomy kit but was unsuccessful. The
ber sustained injuries from an improvised explosive device patient ultimately lost pulses and died before arriving at the
(IED), resulting in amputations of all four extremities. A hospital, without a definitive airway.
nonmedic first responder initiated medical care and a Medic
arrived shortly after. The responders did not document pre- Discussion
hospital vital signs but did note a Glasgow Coma Scale (GCS)
score of 3. The responders placed tourniquets on all four ex- This unique case series highlights the use of prehospital crico-
tremities. The Medics placed an oropharyngeal airway and thyrotomy kits to accomplish SC in the tactical, combat envi-
ventilated the patient using a bag-valve-mask. The Medic then ronment. Previous studies have demonstrated the importance
performed an SC using the North American Rescue CricKit of airway management on the battlefield and the potential
(NARCK; https://www.narescue.com/tactical-crickit). Cardio- advantages of assistive devices for airway cannulation. 3,4,13 To
pulmonary resuscitation was performed before arriving at the our knowledge, these are the first reported cases of commercial
hospital, but the timing in correlation to the airway placement cricothyrotomy kits used on the battlefield. We believe these
was not documented. The patient underwent evacuation on a data provide proof of concept of the clinical utility of these de-
ground vehicle, followed by air transport to the hospital where vices. Early case studies of reported tourniquet use in the Joint
he arrived pulseless. Receiving providers pronounced the pa- Theater wars sparked widespread use of and improvements in
tient dead on arrival. The records do not note any complica- hemostasis technology. The presentation of these clinical cases
tions in the surgical airway placement on arrival at the combat will likely lead to further investigation of cricothyrotomy kits
support hospital. His composite Injury Severity Score (ISS) and improvement in prehospital airway management. 15,16
was 75.
The results of these four cases demonstrate the need for train-
ing protocols and clinical guidelines, along with medical de-
Case 2
vices that simplify essential lifesaving procedures such as SC.
A U.S. Special Operations Servicemember sustained injuries Cricothyrotomy kits may help improve the Combat Medic’s
from an improvised IED that resulted in bilateral lower ex- ability to secure surgical airways under the challenging condi-
tremity amputations, a fracture to the left arm, and laceration tions of medical care on the battlefield. Improving outcomes in
to the head. A Medic and a medical officer provided prehospi- patients with impending airway-related death depends on both
tal treatment. His prehospital vital signs included a heart rate the prehospital provider’s medical decision-making process
(HR) of 120/min, respiratory rate (RR) of 5/min, and a GCS and the clinical expertise to perform a lifesaving intervention.
score of 3. The providers placed tourniquets on both injured
lower extremities. They then placed a surgical airway using Surgical airway kits are not a substitute for training; however,
the NARCK. The medical providers wrapped the patient in a they may hone the prehospital provider’s medical decision-
heating blanket. The patient then underwent air evacuation. making process to commit to performing this procedure. This
The records do not report any prehospital complications. No case series demonstrates that surgical airway device kits may
information beyond the prehospital actions is available for help improve the ability and technical confidence of the pre-
review. hospital care provider to successfully execute this clinical chal-
lenging procedure. Based on previous literature, the inability
to cannulate the trachea is a significant contributor in fail-
Case 3
ing to perform an SC successfully. Tools with the potential
17
A U.S. Special Operations Servicemember sustained a gun- to improve the prehospital care provider’s technical ability to
shot wound to the head during a small arms firefight with perform the procedure may have a material impact on opti-
local insurgent forces. A Medic attempted SC using an H&H mizing outcomes from combat casualty care.

Airway Kits in Combat | 19