Page 52 - JSOM Winter 2022

Cric in the Dark

Surgical Cricothyrotomy in Low Light Tactical Environments

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Chandler W. Getz, MD *; Sean M. Stuart, DO ; Brent M. Barbour, DO ;
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Jared M. Verga, MD ; Paul J. Roszko, MD ; Emily E. Friedrich, PhD 6
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ABSTRACT
Background: Surgical cricothyrotomy (SC) is a difficult pro- and other military members by highlighting their location to
cedure with high failure rates in the battlefield environment. enemy forces.
The difficulty of this procedure is compounded in a low-light
tactical environment in which white light cannot be used. This Poor lighting in operations can have disastrous consequences.
study compared the use of red-green (RG) light and red (R) In one study, 25% of Special Operations medical providers
light in the performance of SC in a low-light environment. reported that issues with lighting contributed to a poor casu-
Materials and Methods: Tactical Combat Casualty Care- alty outcome. While there are a wide variety of commercially
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certified navy corpsmen (n = 33) were provided 15 minutes of available and standard-issue light-sources available for mili-
standardized instruction followed by hands-on practice with tary or tactical purposes, few have been evaluated and tested
the Tactical CricKit and the H&H bougie-assisted Emergency in medical procedures.
Cricothyrotomy Kit. Participants acclimated to a dark envi-
ronment for 30 minutes before performing SC on a mannequin Previous work has described similar performance by partici-
with both devices using both R and RG light in a randomized pants on contrast sensitivity and color discrimination tests in
order. Application time, success, participant preference, and low-light settings using hybrid RG light or white light. How-
participant confidence were analyzed. Results: There were ever, performance on these tests was significantly decreased
similarly high levels of successful placement (>87.5%) in all using R light alone. Additionally, both color discrimination
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four cohorts. Light choice did not appear to affect placement and perception of simulated trauma wounds under RG light
time with either of the two kits. On Likert-scale surveys, par- were found to be better and less difficult, respectively, when
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ticipants reported that RG decreased difficulty (p < .0001) and compared to blue light. RG light has yet to be extensively
increased confidence (p < .0001) in performing the procedure. compared to R light for use in low-light medical procedures.
Conclusion: RG light increased confidence and decreased per- Because SC is a relatively rare procedure that requires inci-
ceived difficulty when performing SC, though no differences in sion through multiple tissue layers and is often complicated
placement time or success were observed. by bleeding, it is an ideal model for evaluation of light sources
used in the tactical environment with the potential to extrapo-
Keywords: light source; TCCC; red light; bougie-assisted; green late findings to other procedures.
light; white light; cricothyrotomy
The First-Light Tomahawk tactical flashlight was developed
and marketed for medical use. It emits R green, or hybrid RG
Introduction light to allow enhanced contrast sensitivity in scotopic and
photopic vision. In this study, we compared the first- attempt
The ability to maintain a patient’s airway is critical in a bat- success rates and procedural speeds of SC performed by
tlefield environment. Airway compromise represents 8% of pre-hospital military providers (Table 1). We used two com-
preventable battlefield pre-hospital deaths. In the 2021 Tac- monly issued cricothyrotomy kits on a mannequin model in a
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tical Combat Casualty Care (TCCC) guidelines, the surgical low light environment, with the First-Light Tomahawk as an
cricothyrotomy (SC) is the preferred method of maintaining a R or RG light source.
casualty’s airway after repositioning, nasopharyngeal airways,
and extraglottic airways have failed. Surgical cricothyrotomy
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is a difficult procedure with reported failure rates as high as Materials and Methods
33% in casualties from Operations Iraqi and Enduring Free- Subjects and Setting
dom. An additional challenge when performing procedures in The study was a randomized, prospective, nonblinded trial
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a combat environment is the need to provide lifesaving treat- conducted at Naval Medical Center Portsmouth, Portsmouth,
ments in low-light tactical environments, as the use of ade- VA. The protocol was approved by the Naval Medical Center
quate lighting may compromise the safety of medical providers Portsmouth’s Institutional Review Board in compliance with
*Correspondence to Chandler.w.getz.mil@mail.mil
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1 LCDR Chandler W. Getz, LCDR Brent M. Barbour, LCDR Jared M. Verga, and LCDR Paul J. Roszko are all physicians affiliated with the
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Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth, VA. CDR Sean M.
Stuart is a physician affiliated with the Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine,
Bethesda, MD and the Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Portsmouth, Portsmouth,
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VA. Emily E. Friedrich is affiliated with the Combat Trauma Research Group, Department of Emergency Medicine, Naval Medical Center Ports-
mouth, Portsmouth, VA and the General Dynamics Information Technology, Fairfax, VA.
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