Page 21 - JSOM Winter 2017

Extraglottic Airways in Tactical Combat Casualty Care

TCCC Guidelines Change 17-01
28 August 2017

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Edward J. Otten, MD ; Harold Montgomery, ATP ; Frank K. Butler, MD 3
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ABSTRACT
Extraglottic airway (EGA) devices have been used by both needed to remove blood and vomitus); (6) clarifies the word-
physicians and prehospital providers for several decades. The ing regarding cervical spine stabilization to emphasize that it is
original TCCC Guidelines published in 1996 included a rec- not needed for casualties who have sustained only penetrating
ommendation to use the laryngeal mask airway (LMA) as an trauma (without blunt force trauma); (7) reinforces that surgi-
option to assist in securing the airway in Tactical Evacuation cal cricothyroidotomies should not be performed simply be-
(TACEVAC) phase of care. Since then, a variety of EGAs have cause a casualty is unconscious; (8) provides a reminder that,
been used in both combat casualty care and civilian trauma for casualties with facial trauma or facial burns with suspected
care. In 2012, the Committee on TCCC (CoTCCC) and the inhalation injury, neither NPAs nor EGAs may be adequate for
Defense Health Board (DHB) reaffirmed support for the use airway management, and a surgical cricothyroidotomy may be
of supraglottic airway (SGA) devices in the TACEVAC phase required; (9) adds that pulse oximetry monitoring is a useful
of TCCC, but did not recommend a specific SGA based on adjunct to assess airway patency and that capnography should
the evidence available at that point in time. This paper will also be used in the TACEVAC phase of care; and (10) rein-
use the more inclusive term “extraglottic airway” instead of forces that a casualty’s airway status may change over time
the term “supragottic airway” used in the DHB memo. Cur- and that he or she should be frequently reassessed.
rent evidence suggests that the i-gel (Intersurgical Complete
®
Respiratory Systems; http://www.intersurgical.com/info/igel) Keywords: extraglottic airway; i-gel; TCCC; Tactical Combat
EGA performs as well or better than the other EGAs available Casualty Care; guidelines
and has other advantages in ease of training, size and weight,
cost, safety, and simplicity of use. The gel-filled cuff in the i-gel
both eliminates the need for cuff pressure monitoring during Proximate Cause for This Proposed Change
flight and reduces the risk of pressure-induced neuropraxia to
cranial nerves in the oropharynx and hypopharynx as a com- The Joint Trauma System (JTS) has been designated by the
plication of EGA use. The i-gel thus makes the medic’s tasks US Congress as the Lead Agency for trauma care in the De-
simpler and frees him or her from the requirement to carry a partment of Defense (DoD). In that capacity, the JTS forwards
cuff manometer as part of the medical kit. This latest change recommendations about best-practice, evidence-based trauma
to the TCCC Guidelines as described below does the following care to the four US Armed Services and to the US Military
things: (1) adds extraglottic airways (EGAs) as an option for Combatant Commands. The Committee on Tactical Combat
airway management in Tactical Field Care; (2) recommends Casualty Care (CoTCCC) is the prehospital component of
the i-gel as the preferred EGA in TCCC because its gel-filled the JTS.
cuff makes it simpler to use than EGAs with air-filled cuffs
and also eliminates the need for monitoring of cuff pressure; In the interval since the last airway change to the TCCC
(3) notes that should an EGA with an air-filled cuff be used, Guidelines in 2012, a number of developments have resulted
the pressure in the cuff must be monitored, especially during in the need for this change:
and after changes in altitude during casualty transport; (4) em-
phasizes COL Bob Mabry’s often-made point that extraglottic 1. The use of EGAs has expanded rapidly in the civilian sec-
airways will not be tolerated by a casualty unless he or she is tor—in prehospital care, in the emergency department
deeply unconscious and notes that an NPA is a better option (ED), and in the operating room (OR). EGAs are easy to
if there is doubt about whether or not the casualty will toler- insert and have proven very effective. 1–18
ate an EGA; (5) adds the use of suction as an adjunct to air- 2. In the JTS weekly trauma teleconferences, combat med-
way management when available and appropriate (i.e., when ics have been observed to perform surgical airways on a
1 CAPT (Ret) Otten is a Distinguished Professor of Emergency Medicine and Pediatrics and director, Division of Toxicology, at the University of
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Cincinnati Medical Center, Cincinnati, OH. MSG (Ret) Montgomery, USA, currently is the Operational Medicine Liaison for the Joint Trauma
System and the Committee on Tactical Combat Casualty Care. CAPT (Ret) Butler, USN, is an ophthalmologist and a Navy Undersea Medical
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Officer with over 20 years of experience providing medical support to Special Operations Forces. Dr Butler is currently the chairman of the Com-
mittee on TCCC and Chief of Prehospital Trauma Care at the Joint Trauma System.
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