Page 93 - JSOM Summer 2019

Survival of Casualties Undergoing Prehospital Supraglottic
Airway Placement Versus Cricothyrotomy

Steven G. Schauer, DO, MS *; Jason F. Naylor, PA-C ; Annie L. Chow, MD ;
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Joseph K. Maddry, MD ; Cord W. Cunningham, MD, MPH ; Megan B. Blackburn, PhD ;
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Corinne D. Nawn, BS ; Michael D. April, MD, DPhil 8
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ABSTRACT
Background: Airway compromise is the second leading cause attempting positional maneuvers, followed by nasopharyngeal
of preventable death on the battlefield. Unlike a cricothyrot- airway placement for casualties in need of airway support.
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omy, supraglottic airway (SGA) placement does not require an If these initial methods fail, the guidelines recommend the
incision and is less technically challenging. We compare the surgical cricothyrotomy as the final definitive method for a
survival of causalities undergoing cricothyrotomy versus SGA secure airway, with the use of an SGA listed as an alternative
placement. Methods: We used a series of emergency depart- option.
ment (ED) procedure codes to search within the Department
of Defense Trauma Registry (DODTR) from January 2007 to While various methods have been described, the overall princi-
August 2016. This is a subanalysis of that data set. Results: ple of the cricothyrotomy involves surgical dissection through
During the study period, 194 casualties had a documented the cricothyroid membrane with direct cannulation of the tra-
cricothyrotomy and 22 had a documented SGA as the sole chea. Despite various technologies developed to aid providers
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airway intervention. The two groups had similar proportions in this procedure, none tackle the truly problematic anxiety
of explosive injuries (57.7% versus 63.6%, p = .328), similar associated with performing a cricothyrotomy in the prehospi-
composite injury severity scores (25 versus 27.5, p = .168), tal, combat setting. Moreover, this procedure has a high rate
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and similar AIS for the head, face, extremities, and external of complications, mostly related to injury to adjacent anatomy
body regions. The cricothyrotomy group had lower AIS for or tube misplacement. 8
the thorax (0 versus 3, p = .019), a trend toward lower AIS
for the abdomen (0 versus 0, p = .077), more serious injuries On the other hand, the SGA is a less-invasive airway alter-
to the head (67.5% versus 45.5%, p = .039), and similar rates native to the cricothyrotomy. Originally designed for use in
of serious injuries to the face (4.6% versus 4.6%, p = .984). fasting patients who were sedated for medical procedures, the
Glasgow Coma Scale (GCS) scores were similar on arrival to use of SGAs has expanded into prehospital and emergency
the ED (3 versus 3, p = .467) as were the proportion of pa- settings. Casualties must, however, be significantly obtunded
tients surviving to discharge (45.4% versus 40.9%, p = .691). to tolerate the device without pharmacologic support and the
On repeated multivariable analyses, the odds ratios for sur- facial/airway structure must be intact. Complications include
vival were not significantly different between the two groups. size limitations in smaller patients, malposition, dislodge-
Conclusions: We found no difference in short-term outcomes ment, and, depending on the device in use, cuff overinflation-
between combat casualties who received an SGA vs those who associated obstruction to venous blood flow leading to
received a cricothyrotomy. Military prehospital personnel potentially life-threatening airway edema. Still, it is a min-
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rarely used either advanced airway intervention during the re- imally invasive and potentially lifesaving measure made more
cent conflicts in Afghanistan and Iraq. promising by the fact that placement has historically been
taught successfully with minimal resources. 11
Keywords: airway; supraglottic; extraglottic; prehospital;
cricothyrotomy Despite more than 15 years of combat operations, few ad-
vancements in prehospital airway management have occurred.
It remains unclear whether the SGA technology recommended
by the most recent TCCC guidelines may serve as a viable al-
Introduction
ternative to the surgical cricothyrotomy.
Background
Airway obstruction in the prehospital setting is the second Study Goal
most frequent potentially survivable cause of death among We aimed to compare the outcomes of casualties undergo-
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military combat casualties on the battlefield. The recent Tac- ing cricothyrotomy versus SGA placement in the prehospital,
tical Combat Casualty Care (TCCC) guidelines recommended combat setting.
*Correspondence to Steven G. Schauer, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234; steven.g.schauer.mil@mail.mil
1 MAJ Schauer is affiliated with the US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; 59th Medical Wing, JBSA Lackland Air
Force Base, TX; and San Antonio Military Medical Center, JBSA Fort Sam Houston, TX. LTC Naylor is affiliated with Madigan Army Medical
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Center, Joint Base Lewis McChord, WA. CPT Chow is affiliated with the San Antonio Military Medical Center, JBSA Fort Sam Houston, TX.
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4 Lt Col Maddry is affiliated with 59th Medical Wing, JBSA Lackland Air Force Base, TX; and San Antonio Military Medical Center, JBSA Fort
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Sam Houston, TX. LTC Cunningham and Dr Blackburn are affiliated with the US Army Institute of Surgical Research, JBSA Fort Sam Hous-
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ton, TX. Ms Nawn is affiliated with the the US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; and the University of Texas
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at San Antonio, San Antonio, TX. MAJ April is affiliated with the San Antonio Military Medical Center, JBSA Fort Sam Houston, TX.
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