Page 88 - JSOM Fall 2019

Survival of Casualties Undergoing Prehospital Supraglottic
Airway Placement Versus Cricothyrotomy

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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

ABSTRACT
Background: Airway compromise is the second leading cause military combat casualties on the battlefield. Recent Tacti-
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of preventable death on the battlefield. Unlike a cricothyrot- cal Combat Casualty Care (TCCC) guidelines recommended
omy, supraglottic airway (SGA) placement does not require attempting positional maneuvers, followed by nasopharyngeal
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an incision and is less technically challenging. We compare airway placement for casualties in need of airway support.
survival of causalities undergoing cricothyrotomy versus SGA If these initial methods fail, the guidelines recommend the
placement. Methods: We used a series of emergency depart- surgical cricothyrotomy as the final definitive method for a
ment (ED) procedure codes to search within the Department secure airway, with the use of an SGA listed as an alternative
of Defense Trauma Registry (DoDTR) from January 2007 to option.
August 2016. This is a subanalysis of that dataset. Results:
During the study period, 194 casualties had a documented While various methods have been described, the overall princi-
cricothyrotomy and 22 had a documented SGA as the sole ple of the cricothyrotomy involves surgical dissection through
airway intervention. The two groups had similar proportions the cricothyroid membrane with direct cannulation of the tra-
of explosive injuries (57.7% versus 63.6%, p = .328), similar chea. Despite various technologies developed to aid providers
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composite injury severity scores (25 versus 27.5, p = .168), in this procedure, none tackle the truly problematic anxiety
and similar AIS for the head, face, extremities, and external associated with performing a cricothyrotomy in the prehospi-
body regions. The cricothyrotomy group had lower AIS for tal, combat setting. Moreover, this procedure has a high rate
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the thorax (0 versus 3, p = .019) a trend toward lower AIS of complications mostly related to injury to adjacent anatomy
for the abdomen (0 versus 0, p = .077), more serious inju- or tube misplacement. 8
ries to the head (67.5% versus 45.5%, p = .039), and similar
rates of serious injuries to the face (4.6% versus 4.6%, p = On the other hand, the SGA is a less invasive airway alterna-
.984). Glasgow Coma Scale (GCS) scores were similar upon tive to the cricothyrotomy. Many of these devices were origi-
arrival to the ED (3 versus 3, p = .467) as were the propor- nally designed for use in fasting patients who were sedated for
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tion of patients surviving to discharge (45.4% versus 40.9%, medical procedures. Their use has since been expanded into
p = .691). On repeated multivariable analyses, the odds ratios the prehospital and emergency setting. However, casualties
(ORs) for survival were not significantly different between the must be significantly obtunded to tolerate the device without
two groups. Conclusion: We found no difference in short-term pharmacologic support and the facial/airway structure must
outcomes between combat casualties who received an SGA vs be intact. Complications include size limitations in smaller
cricothyrotomy. Military prehospital personnel rarely used ei- patients, malposition, dislodgement, and depending on the
ther advanced airway intervention during the recent conflicts device in use, a cuff overinflation-associated obstruction to
in Afghanistan and Iraq. venous blood flow leading to potentially life-threatening air-
way edema. Still, it is a minimally invasive and potentially
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Keywords: airway; supraglottic; extraglottic; prehospital; cri- life-saving measure made more promising by the fact that
cothyrotomy; injury; explosive placement has historically been taught successfully with min-
imal resources. 11
Despite over 15 years of combat operations, few advance-
Introduction
ments in prehospital airway management have occurred. It
Background remains unclear whether the SGA technology recommended
Airway obstruction in the prehospital setting is the second by the most recent TCCC guidelines may serve as a viable al-
most frequent potentially survivable cause of death among ternative to the surgical cricothyrotomy.
*Correspondence to 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; San Antonio Military Medical Center, JBSA Fort Sam Houston; and Uniformed Services University of the Health Sciences,
Bethesda, MD. MAJ Naylor is affiliated with the Madigan Army Medical Center, Joint Base Lewis McChord, WA. CPT Chow is affiliated with
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the San Antonio Military Medical Center, JBSA Fort Sam Houston. Maj Maddry is affiliated with the 59th Medical Wing, JBSA Lackland Air
Force Base; and San Antonio Military Medical Center, JBSA Fort Sam Houston. COL Cunningham is affiliated with the US Army Institute of
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Surgical Research, JBSA Fort Sam Houston. Dr Blackburn is affiliated with the US Army Institute of Surgical Research, JBSA Fort Sam Houston.
7 Ms Nawn is affiliated with the US Army Institute of Surgical Research, JBSA Fort Sam Houston; and University of Texas at San Antonio, San
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Antonio, TX. MAJ April is affiliated with the San Antonio Military Medical Center, JBSA Fort Sam Houston.
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