Page 28 - JSOM Winter 2017

– Endotracheal intubation or Considerations for Further Research and Development
– Perform a surgical cricothyroidotomy using one of
the following: 1. For how many casualties in Iraq and Afghanistan would
– Cric-Key technique (Preferred option) extraglottic airways have been an appropriate airway
– Bougie-aided open surgical technique using a flanged intervention?
and cuffed airway cannula of less than 10mm outer 2. How many casualties in Iraq and Afghanistan had surgi-
diameter, 6–7mm internal diameter, and 5–8cm of in- cal airways performed when they had no maxillofacial
tratracheal length trauma or trauma to other airway structures?
– Standard open surgical technique using a flanged and 3. The data in the DoD Trauma Registry should be searched
cuffed airway cannula of less than 10mm outer diam- periodically for prehospital care reports of EGA use (both
eter, 6–7mm internal diameter, and 5–8cm of intratra- i-gel and other) with attention to; the number of uses;
cheal length (Least desirable option) indications for use; whether or not other airway interven-
– Use lidocaine if the casualty is conscious. tions were also attempted; reported complications; and
e. Cervical spine stabilization is not necessary for casual- the success rates for the various types of EGAs.
ties who have sustained only penetrating trauma. 4. The data in the DoD Trauma Registry should be searched
f. Monitor the hemoglobin oxygen saturation in casualties periodically for prehospital care reports of NPA use with
to help assess airway patency. Use capnography moni- attention to: the number of uses; indications for use;
toring in this phase of care if available. whether or not other airway interventions were also at-
g. Always remember that the casualty’s airway status may tempted; reported complications; and the success rate of
change over time and requires frequent reassessment. NPA use.
*The i-gel is the preferred extraglottic airway because its gel- 5. The data in the DoD Trauma Registry should be searched
filled cuff makes it simpler to use and avoids the need for cuff for prehospital care reports to determine how many surgi-
inflation and monitoring. If an extraglottic airway with an air- cal airway attempts might have been avoided through use
filled cuff is used, the cuff pressure must be monitored to avoid of an EGA or an NPA.
overpressurization, especially during TACEVAC on an aircraft 6. Ongoing preventable death reviews in US combat fatali-
with the accompanying pressure changes. ties should be performed to determine which fatalities
*Extraglottic airways will not be tolerated by a casualty who were caused by an unrelieved airway obstruction and
is not deeply unconscious. If an unconscious casualty without which air way interventions were attempted for these
direct airway trauma needs an airway intervention, but does fatalities.
not tolerate an extraglottic airway, consider the use of a naso- 7. Ongoing preventable death analysis in US combat fatali-
pharyngeal airway. ties should be performed to determine whether or not
*For casualties with trauma to the face and mouth, or facial there are any deaths identified in which the casualties
burns with suspected inhalation injury, nasopharyngeal air- were unconscious and lost their airway, but did not have
ways and extraglottic airways may not suffice and a surgical direct trauma to airway structures.
cricothyroidotomy may be required. 8. Ongoing preventable death reviews in US combat fatali-
*Surgical cricothyroidotomies should not be performed on un- ties should be performed to determine whether or not any
conscious casualties who have no direct airway trauma unless deaths resulted from casualties with a decreased state of
use of a nasopharyngeal airway and/or an extraglottic airway consciousness having an NPA or extra glottic airway used
have been unsuccessful in opening the airway. to manage their airway. (As might occur with an episode
of vomiting with aspiration and subsequent respiratory
Vote: This proposed change to the TCCC Guidelines was failure.)
approved by the required 2/3 or more of the Committee on 9. The DoD should fund prospective comparative studies
TCCC voting members on 28 August 2017. of EGA use in trauma patients, both with and without
maxillofacial injuries, comparing the i-gel to other EGA
Level of evidence: options.
The levels of evidence used by the American College of Cardi- 10. The DoD should fund prospective studies of i-gel use in
ology and the American Heart Association were described by comparison to NPA use in trauma patients, both with
Tricoci in 2009: and without maxillofacial injuries, and with and without
– Level A: Evidence from multiple randomized trials or blunt head trauma.
meta-analyses. 11. Attention should be directed during JTS trauma tele-
– Level B: Evidence from a single randomized trial or conferences to identifying casualties in whom attempted
nonrandomized studies. placement of an EGA or an NPA resulted in vomiting
– Level C: Expert opinion, case studies, or standards of and/or aspiration during the insertion attempt or subse-
80
12
81
care. 79 quently. Field intubation and hypoxia have been as-
sociated with worsened outcomes in TBI patients. Studies
Using this taxonomy for evidence, the Levels of Evidence that should be performed to observe the efficacy of airway
support the following statements is shown below: management with NPAs and EGAs in TBI patients.
1. Extraglottic airways can be safely and effectively used by
prehospital personnel to maintain a patent airway in pa- Acknowledgments
tients without direct trauma to airway structures. The authors gratefully acknowledge the research assistance pro-
Level B vided by Mrs Danielle Davis of the Joint Trauma System and
2. The i-gel is the EGA of choice for combat medical person- the editorial assistance provided by CAPT (Ret) Stephen Gieb-
nel in TCCC. ner. The authors also thank the Department of Defense Trauma
Level C Registry for providing the casualty data discussed in this paper.

26 | JSOM Volume 17, Edition 4/Winter 2017