Page 26 - JSOM Winter 2017

Figure 1 The i-gel EGA. corpsman, or PJ to assess the adequacy of the airway and
ventilation.

Summary
The lack of ongoing experience on the part of combat medical
personnel at performing ETI and the lack of data for efficacy
and improved outcomes for ETI in trauma patients makes this
a potentially hazardous airway maneuver in the prehospital
arena, especially if RSI is not available. The NPA and sit-up
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and lean-forward positioning will be adequate for some com-
bat casualties, and a surgical airway is the preferred option for
casualties with maxillofacial injuries when less invasive airway
interventions are not effective.

individuals who are unconscious from hemorrhagic shock or For combat casualties who are unconscious, but do not have
TBI, however, without direct trauma to airway structures, the direct airway trauma, EGAs should be considered as a poten-
use of EGAs to manage the casualty’s airway offers an oppor- tial airway intervention. These casualties are unable to pro-
tunity to protect the airway with a device that is easy to insert tect their airway and may need assisted ventilation as well as
and that does not entail the small risk of intracranial insertion supplemental oxygen. EGAs are a good option to maintain a
that NPAs do. Although intracranial insertion of NPAs is rare patent airway in such casualties.
and has not, to the authors’ knowledge, occurred in US casual-
ties from Iraq and Afghanistan, this complication of NPA use The i-gel meets the criteria established by the CoTCCC New
has been reported in the literature. 19–23 TCCC training stresses Technology Subcommittee and has been shown to perform
the correct angle of insertion for NPA, which is to avoid the well in comparison to other EGAs in multiple studies. Fur-
inclination to insert the device at the angle that the long axis ther, eliminating the need to fill an EGA cuff with air and then
of the nose forms with the face. NPAs should be inserted at monitor the cuff pressure throughout the evacuation process
the more perpendicular angle that tracks along the base of the with a cuff manometer is another very desirable aspect of se-
nasal cavity. This avoids an unwanted cephalad positioning of lecting the i-gel as the EGA of choice; this choice reduces both
the device. 76 the equipment and the number of tasks required for the medic
to care for his or her casualty.
Extraglottic airways are an important, safe, and easy-to-use
option that can be added to the combat medic’s kit to help The i-gel EGA has been shown to be easily trained and there is
manage the airway during Tactical Field Care. no good reason not to include its use by ground medics, corps-
men, and PJs in the TFC phase of TCCC in addition to its use
Although there is ample evidence to support the use of EGAs by evacuation platform personnel during the TACEVAC phase
in prehospital patients without direct trauma to airway struc- of care.
tures, as outlined above, there is less evidence to document the
efficacy of EGAs in patients with maxillofacial trauma and PROPOSED CHANGE TO THE TCCC GUIDELINES
airway obstruction. 77,78 Although one of the authors (E.J.O.)
has used the i-gel successfully to secure the airway in two pa- Current wording
tients with maxillofacial trauma, should the airway become Tactical Field Care
obstructed as a result of injuries of this type, a surgical airway
remains the intervention of choice in TCCC if less invasive 4. Airway Management
measures to open the airway are not successful. 75 a. Unconscious casualty without airway obstruction:
– Chin lift or jaw thrust maneuver
In February 2017, one of the authors (E.J.O.) presented a rec- – Nasopharyngeal airway
ommendation at a CoTCCC meeting that the use of EGAs be – Place casualty in the recovery position
extended to the TFC phase of TCCC as well as the TACEVAC b. Casualty with airway obstruction or impending airway
phase. 74 obstruction:
– Chin lift or jaw thrust maneuver
– Nasopharyngeal airway
Confirmation of Correct Placement of EGAs
– Allow a conscious casualty to assume any position
A 2017 study by Vithalani et al. examined 344 attempts at that best protects the airway, to include sitting up.
EGA placement (King LTS-D) by prehospital EMS personnel. – Place an unconscious casualty in the recovery position.
Successful placement of the EGA was evaluated subjectively by c. If the previous measures are unsuccessful, perform a sur-
the EMS provider and then confirmed by waveform capnog- gical cricothyroidotomy using one of the following:
raphy. While 85% of placements were both subjectively and – Cric-Key technique (preferred option)
objectively judged to be successful, 14% of EGA placements – Bougie-aided open surgical technique using a flanged
that were believed successful by the EMS provider were sub- and cuffed airway cannula of less than 10mm outer
sequently found to be misplaced by capnography. The authors diameter, 6–7mm internal diameter, and 5–8cm of in-
emphasize the importance of confirming correct placement of tratracheal length
EGAs by EMS personnel through the use of waveform cap- – Standard open surgical technique using a flanged
nography. Pulse oximetry can also help the combat medic, and cuffed airway cannula of less than 10mm outer
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24 | JSOM Volume 17, Edition 4/Winter 2017