Page 25 - JSOM Spring 2023

Improving Outcomes Associated with
Prehospital Combat Airway Interventions—
An Unrealized Opportunity

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Steven G. Schauer, DO, MS *; Ian L. Hudson, DO, MPH ; Andrew D. Fisher, MD, MPAS ;
Gregory Dion, MD ; Brit Long, MD ; Megan B. Blackburn, PhD ;
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Robert De Lorenzo, MD, MSM, MSCI ; Travis Shaw, NRP ; Michael D. April, MD, DPhil, MSc 9
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ABSTRACT
Background: Airway obstruction is the second leading cause showed no sustained change during the study period. These
of potentially survivable death on the battlefield. Assessing findings suggest that advances in airway resuscitation are nec-
outcomes associated with airway interventions is import- essary to achieve mortality improvements in potentially sur-
ant, and temporal trends can reflect the influence of training, vivable airway injuries in the prehospital setting.
technology, the system of care, and other factors. We assessed
mortality among casualties undergoing prehospital airway Keywords: prehospital; trend; airway; combat; outcome; sur-
intervention occurring over the course of combat operations vival; military
during 2007–2019. Methods: This is a retrospective analysis
of a previously described dataset from the Department of De-
fense Trauma Registry (DODTR). We included only casualties Introduction
with documented placement of an endotracheal tube, cricothy-
rotomy, or supraglottic airway (SGA) in the prehospital setting. The landmark 2012 paper by Eastridge et al. identified airway
Results: Within the DODTR from January 2007 to December compromise as the second leading cause of potentially pre-
2019, there were 25,849 adult encounters with documentation ventable death on the battlefield. A sophisticated follow-up
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of any prehospital activity. Within that group, there were 251 study by Mazuchowski et al. further reinforced the contribu-
documented cricothyrotomies, 1,147 documented intubations, tion of airway (and breathing) problems to potentially pre-
and 35 documented supraglottic airways placed. Cricothyrot- ventable deaths. However, over the course of the past decade
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omy recipients had a median age of 25. Within this group, the or so, few airway advances have been introduced to the bat-
largest proportion were non-North Atlantic Treaty Organiza- tlefield. Objective studies on airway compromise are generally
tion (NATO) military personnel (35%), were injured by explo- lacking. As a result of the study by Eastridge et al., Tactical
sives (54%), had a median injury severity score (ISS) of 24, and Combat Casualty Care (TCCC) guidelines on airway man-
60% survived to hospital discharge. Intubation recipients had agement have evolved primarily on prioritization of different
a median age of 24. Within this group, the largest proportion SGA devices (e.g., i-gel (Intersurgical Complete Respiratory
®
were non-NATO military personnel (37%), were injured by Systems, www.intersurgical.com/info/igel) in lieu of the King
explosives (57%), had a median ISS of 18, and 76% survived Laryngeal Tracheal device (Ambu USA, www.ambuusa.com/
to hospital discharge. SGA recipients had a median age of 28. airway-management-and-anaesthesia/laryngeal-tubes/product
Within this group, the largest proportion were non-NATO /ambu-king-lts-d-disposable-laryngeal-tube)). Other develop-
military (37%), were injured by firearms (48%), had a median ments include changes to recommended airway interventions.
ISS of 25, and 54% survived to hospital discharge. A down- Specifically, while previous TCCC guidelines recommended
ward trend existed in the quantity of all procedures performed the cricothyrotomy as the preferred intervention, more recent
during the study period. In both unadjusted and adjusted re- iterations recommend performing this procedure only after
gression models, we identified no year-to-year differences in failed efforts to place a supraglottic device, or in the setting of
survival after prehospital cricothyrotomy or SGA placement. major facial trauma or facial burns. Many of these guideline
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In the unadjusted and adjusted models, we noted a decrease in changes have likely had limited impact on battlefield airway
mortality during the 2007–2008 (odds ratio [OR] for death management, though comprehensive outcome studies have not
0.47, 95% CI 0.26–0.86) and an increase from 2012–2013 been reported. The incidence of facial trauma (0.06%) or burns
(OR 2.10, 95% CI 1.09–4.05) for prehospital intubation. (0.09%) among casualties undergoing an airway intervention is
Conclusion: Mortality among combat casualties undergoing negligible, limiting the applicability of the new cricothyrotomy
prehospital or emergency department airway interventions recommendation. 5
*Correspondence to steven.g.schauer.mil@health.mil
1 LTC Steven G. Schauer and MAJ Gregory Dion are physicians affiliated with the US Army Institute of Surgical Research and the Brooke Army
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Medical Center, JBSA Fort Sam Houston, TX, and the Uniformed Services University of the Health Sciences, Bethesda, MD. MAJ Ian L. Hudson
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is a physician and Dr Megan B. Blackburn is a scientist affiliated with the US Army Institute of Surgical Research, JBSA Fort Sam Houston,
TX. MAJ Andrew D. Fisher is a physician affiliated with the University of New Mexico School of Medicine, Albuquerque, NM, and the Texas
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National Guard, Arlington, TX. Maj Brit Long is a physician affiliated with the Uniformed Services University of the Health Sciences, Bethesda,
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MD, Brooke Army Medical Center, JBSA Fort Sam Houston, TX, and 59th Medical Wing, JBSA Lackland, TX. Dr Robert De Lorenzo is a
physician affiliated with the University of Texas Health San Antonio, San Antonio, TX. CMSgt Travis Shaw is a paramedic affiliated with the
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Headquarters, US Air Forces in Europe, Air Forces Africa, Ramstein Air Base, Germany. LTC Michael D. April is a physician affiliated with the
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Uniformed Services University of the Health Sciences, Bethesda, MD, and the 40th Forward Resuscitation and Surgical Detachment, 1st Medical
Brigade, Fort Carson, CO.
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