Page 34 - JSOM Spring 2023

from the Israeli Defence Force (IDF), and one from a local to hospital. The reported success rate of intubation is therefore
national Iraqi population. Seven reported whether or not the likely biased upwards.
intubation attempts were successful (Table 1).
Katzenell et al. studied prehospital airway interventions by
TABLE 1 Endotracheal Intubation Results Summary the Israeli Defense Forces (IDF). Endotracheal intubation was
1
No. interventions attempted for 406 casualties, of which 317 (78.1%) were suc-
Study Provider type (% of total) Success cessful after any number of attempts. First attempts at intu-
Adams et al. Total 253 (100%) 95.7% bation had a 44.9% success rate. Paramedics and physicians
2008 Physician 162 (64%) had similar first-attempt success rates: 76 of 185 (41.1%) and
CRNA 24 (9.5%) 222 of 587 (37.8%), respectively. These apparently low suc-
Combat medic 10 (4.0%) cess rates may reflect the particular challenges of the combat
PA 4 (1.6%) environment; this will be addressed further in the discussion.
Unknown 53 (21%)
Blackburn et al. Total 84 (100%) — Haldane reviewed 530 Medical Emergency Response Team
2018 Physician 56 (67%) (MERT) transport patients in Afghanistan during Operation
9
Herrick in 2009. Forty-three intubations were performed
Unknown 28 (33%) (8.1%), of which 42 were successful (97%). It was not re-
Gerhardt et al. Physician/PA 10 — ported how many of these were performed in-flight.
2011
Haldane 2010 Total 43 96.9% Lairet et al. studied 1,003 prehospital patients treated at six
Hardy et al. Total 4 (100%) — US surgical facilities in Afghanistan between 2009 and 2011.
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2018 Paramedic 3 (75%) Given that data was collected at admission to a surgical
Medic 1 (25%) facility, failed attempts at intubation or patients who died pre-
Katzenell et al. Total 406** 78.1%** hospital may not have been captured. Twenty-eight patients
2013 Physician 587 (71%) 41.1% (2.8%) underwent prehospital endotracheal intubation, two
(First of which were not successful (92.8% success rate). The type of
attempt) practitioner performing the intubation was not reported.
Medic 185 (23%) 37.8%
(First Mabry et al. studied two combat hospitals in Iraq between
attempt) January 2005 to March 2007. Twenty patients received pre-
11
Lairet et al. Total 28 92.9% hospital airway interventions. Four endotracheal intubations
2012 were performed, all by medics, three of which were successful
Mabry et al. Medic 4 75.0% (75.0% success rate).
2011
Maddry and Total 22 — Shavit et al. studied prehospital endotracheal intubation by the
Bebarta 2015 IDF during the Gaza conflict from 2012 to 2014. Sixty-five
12
Murad et al. Total 19 —
2012 casualties underwent attempted prehospital endotracheal in-
Pugh et al. Total 45 82.2% tubation, 47 of which were successful (72.3%). Twenty-two
2015 were performed at the point of injury and 25 intubations were
Shavit et al. Physician 65 72.3% performed in-flight. The location of the 18 failed intubation
2017 attempts was not reported. These were all performed by a
Tobin et al. Total 93 — flight physician.
2015
*CRNA = certified registered nurse anesthetist, PA = physician assistant. Pugh et al. studied all casualties that required advanced airway
**Success rate is by patient, 822 total attempts on 406 patients. management arriving at a Role 3 combat hospital in Helmand
Province, Afghanistan, during a 30-week period in 2013.
17
Adams et al. reviewed 6,875 casualties who presented to a Forty-five casualties underwent attempted intubations and 37
combat support hospital during operation Iraqi Freedom be- were successful (82%). The type of practitioner performing the
7
tween 2005 and 2007. There were 293 prehospital advanced intubation was not reported.
airways placed, of which 253 were intubation attempts (3.7%).
Of these 95.7% of intubation attempts were successful, and Blackburn et al. studied 705 patients in Afghanistan from
64.0% (162) were performed by physicians, 9.5% (24) by 2013 to 2014. Of these, 16.9% required airway management
8
certified registered nurse anesthetists, 4.0% (10) by combat (118). Eighty-four endotracheal intubations were performed
medics, 1.6% (4) by physician assistants (PA) and 20.9% (53) (11.9%), of which physicians performed 66.7%. Success rate
were by unknown practitioners. Ten attempts resulted in endo- as a proportion of attempts was not reported. 12.4% of intu-
tracheal tube placement in the right mainstem bronchus, one bations were performed at the site of injury, with 69.1% at the
in the hypopharynx; no esophageal intubations were reported. battalion aid station.
Five misplaced tubes were done by physicians, one by a com-
bat medic, one by a registered nurse anesthetist and four were Five other papers have reported on the use of prehospital en-
unspecified. It is unclear if these were first pass intubations or dotracheal intubation in the combat setting, without capturing
if multiple attempts were undertaken. A limitation is that the success rates. Tobin et al. studied patients receiving critical care
cohort was made up of patients presenting to a combat hospi- transport during Operation Enduring Freedom in Afghanistan
tal. The lack of reported esophageal intubations likely reflects from 2009 to 2010. Ninety-three intubations were performed
17
salvaged attempts in the field or patients who succumbed prior among these patients. Intubation success rate and practitioner
32 | JSOM Volume 23, Edition 1 / Spring 2023