Page 70 - 2020 JSOM Winter

A Comparison of the iGel Versus Cricothyrotomy
by Combat Medics Using a Synthetic Cadaver Model

A Randomized, Controlled Pilot Study

Steven G. Schauer, DO, MS *; Michael D. April, MD, DPhil, MSc ; Romeo Fairley, MD ;
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Nguvan Uhaa, LPN ; Ian L. Hudson, DO, MPH ; Michelle D. Johnson, CRNA, DNP ;
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Donald E. Keen, MD, MPH ; Robert A. De Lorenzo, MD, MSCI, MSM 8
ABSTRACT
Background: Airway obstruction is the second leading cause prehospital combat setting are rare and reserved for the most
of potentially preventable death on the battlefield. Prior to critically injured casualties. 2,3
2017, the Committee on Tactical Combat Casualty Care
(CoTCCC) recommended the surgical cricothyrotomy as the Current Tactical Combat Casualty Care (TCCC) guidelines
definitive airway of choice. More recently, the CoTCCC has (1 August 2019 Edition) recommend positional maneuvers
recommended the iGel as the supraglottic airway (SGA) of followed by nasopharyngeal airway placement in casualties
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choice. Data comparing these methods in medics are limited. with airway obstruction. 4,5 If those methods do not work,
We compared first-pass placement success among combat TCCC recommends placement of a supraglottic airway (SGA),
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medics using a synthetic cadaver model. Methods: We con- specifically the iGel (Intersurgical Complete Respiratory Sys-
ducted a randomized cross-over study of United States Army tems; https://www.intersurgical.com/info/igel) as the preferred
combat medics using a synthetic cadaver model. Participants device, followed by a surgical cricothyrotomy if the SGA is un-
performed a surgical cricothyrotomy using a method of their successful. This is in converse to previous editions of the TCCC
choosing versus placement of the SGA iGel in random order. guidelines (31 January 2017 and earlier) that prioritized the
The primary outcome was first-pass success. Secondary out- cricothyrotomy as the invasive airway of choice. Previously
comes included time-to-placement, complications, placement published data demonstrate very low incidence of supraglottic
failures, and self-reported participant preferences. Results: Of airway placement, with most of the SGA use involving older
the 68 medics recruited, 63 had sufficient data for inclusion. technology such as the King LT airway (North American
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Most were noncommissioned officers in rank (54%, E6–E7), Rescue ; https://www.narescue.com/king-lt-d.html). Despite
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with 51% reporting previous deployment experience. There this, when adjusting for confounders, it appears that outcomes
was no significant difference in first-pass success (P = .847) or are similar among casualties that undergo SGA placement ver-
successful cannulation with regard to the two devices. Time- sus cricothyrotomy. 6
to-placement was faster with the iGel (21.8 seconds vs. 63.8
seconds). Of the 59 medics who finished the survey, we found With regard to the surgical cricothyrotomy, this procedure
that 35 (59%) preferred the iGel and 24 (41%) preferred the is technically challenging and anxiety provoking. Previous
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cricothyrotomy. Conclusions: In our study of active duty Army reports note a high risk of complications. Various devices
combat medics, we found no significant difference with regard are marketed to optimize performance of the cricothyrotomy.
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to first-pass success or overall successful placement between However, a previous randomized, cross-over study by these
the iGel and cricothyrotomy. Time-to-placement was signifi- authors found no difference in first-pass success, time to suc-
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cantly lower with the iGel. Participants reported preferring the cessful cannulation, or complications. With no consistently
iGel versus the cricothyrotomy on survey. Further research is demonstrated benefits with various surgical airway devices,
needed, as limitations in our study highlighted many short- and newer SGA technology on the market, namely the iGel, it
comings in airway research involving combat medics. remains unclear which method has better performance charac-
teristics and personal preferences among combat medics.
Keywords: combat, medic; airway; cricothyrotomy; supra-
glottic; extraglottic Goal of This Investigation
We compared iGel SGA placement to cricothyrotomy among
Introduction combat medics using a synthetic cadaver model. We hypothe-
sized that the proportion of first-pass success would be higher
Airway obstruction is the second most common preventable with the iGel compared to the cricothyrotomy with more rapid
cause of death on the battlefield. Airway interventions in the time-to-placement in those with successful placement.
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*Correspondence to JBSA Fort Sam Houston, 3698 Chambers Pass, TX 78234; or Steven.g.schauer.mil@mail.mil
1 MAJ Schauer is an emergency medicine physician with the US Army Institute of Surgical Research (USAISR) and the Brooke Army Medical Cen-
ter (BAMC), Fort Sam Houston, TX; an associate professor at the Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD.
2 MAJ April is a brigade surgeon for the 2nd Stryker Brigade Combat Team, 4th Infantry Division, Fort Carson, Colorado; an associate professor
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at the USUHS. Dr Fairley is an assistant professor and emergency medicine physician at the University of Texas Health at San Antonio, San An-
tonio, TX. Ms Uhaa is a licensed practical nurse at the USAISR. MAJ Hudson is an emergency medicine physician at the USAISR and BAMC.
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6 MAJ Keen is an emergency medicine physician at BAMC. LTC Johnson is a certified registered nurse anesthetist and clinical associate professor
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at the US Army Graduate Program, Fort Sam Houston. COL (Ret) De Lorenzo is a professor and emergency medicine physician at the UTHSA.
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