Page 37 - JSOM Spring 2023

TABLE 4 Nasopharyngeal/Oropharyngeal Airway Results Summary In the civilian environment, prehospital intubation has become
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No. interventions less emphasized in trauma with a focus on rapid evacuation.
Study Provider type (% of total) Success However, tactical environments may require prolonged field
Blackburn et al. Total 18 — care or delayed evacuation. In such situations, securing a de-
2018 Medic 9 (50%) finitive airway via endotracheal intubation may be appropri-
Physician 5 (28%) ate. For specific mission types that warrant having high-level
medical support, or may require prolonged field care, endo-
Unknown 4 (22%) tracheal intubation may be the most appropriate technique.
Hardy et al. Total 568 — If sufficient training is invested, multiple types of providers
2018 Medic 442 (78%) can achieve similar competence in this skill. In Israel, highly
Paramedic 97 (17%) trained paramedics had the same intubation success rate as
Lairet et al. Physician 27 92.6% their physician counterparts. 1
2012
For missions that are of a high-risk nature, in which rear eche-
medical evacuation patients; 568 NPA/OPAs were utilized lon support and rapid evacuation may not be possible, a higher
(44.8%). Of those, 442 (77.8%) were performed by medics, level of airway skillset and equipment may be appropriate. In-
97 (17.1%) were performed by paramedics, 23 (4.0%) were tubation may be a good option in this context, giving a secure
performed by nurses/physicians/PAs, and six (1.1%) were by and definitive airway with less morbidity than a surgical air-
unknown practioners. Success rates were not reported. way. That patient would then need to be either connected to
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a portable ventilator or an individual committed to prolonged
bag valve ventilation. Sedation may be required, necessitating
Discussion
appropriate drugs and the skills and knowledge to use them
Airway management is a priority in trauma resuscitations, but safely. The training of the medical practitioner with respect
the acquisition and maintenance of emergency airway skills to intubation needs to be of a high level in order to intubate
can be challenging. Military medical leadership needs to plan in these adverse conditions. The designation of the provider is
the airway management strategies for their combat missions. less important than the number of airways they have managed
What level of provider will they deploy? What will be their and their airway experience. A PA from a high-readiness unit
airway management algorithm? What equipment will they who intubates patients regularly would be more appropriate
carry? By performing a systematic review of the prehospital than a physician who practices this skill rarely. If your con-
combat airway literature, this paper is intended to inform ditions allow for a highly trained airway practitioner, and the
medical military leaders of the totality and quality of the avail- equipment to sedate and ventilate your patient, endotracheal
able evidence. intubation is an excellent technique.

The nature of combat research involves limitations not typical Cricothyroidotomy is a definitive surgical airway. A small
of the civilian environment. Data collection is necessarily lower amount of equipment is required, and as such, it was readily
in importance to winning the battle and saving lives. Data incorporated into medic training during the Iraq and Afghani-
from the forward environment is often obtained indirectly stan wars. 27,28 The disadvantage of cricothyroidotomy is its in-
from the field hospital accepting the casualty. This introduces vasive nature. Some militaries have used cricothyroidotomies
confounding which cannot be easily mitigated. If information very differently than the way they are utilized in the civilian
on prehospital airway interventions is obtained from the re- context. Medics may be trained to perform cricothyroidotomy
ceiving medical facility, then information on patients who died if nasopharyngeal airway has failed, using this as their only
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in the field, who required multiple attempts at securing an air- advanced airway maneuver. Such a policy would obviously
way, or who had multiple rescue techniques attempted may bias results compared to civilian indications and expectations.
not be captured. Furthermore, the practice environment and In the literature presented, this was a rare intervention with
cohort capture vary significantly between different studies. Di- reported success rates between 66% and 93%. Compared to
rect comparison or meta-analysis of these studies is therefore endotracheal tube intubation, more medics performed this
not appropriate. Some recommendations regarding standard procedure. Mabry et al. demonstrated variable success rates
reporting for future research are included below. between medic and physician (62% versus 77%). This is a
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large difference in success rate and may support the concept
Endotracheal intubation provides a definitive airway but is a of having medical providers with advanced airway training
difficult skill to learn and requires consistent practice to main- performing surgical airways when possible. This technique
tain. This may explain why the majority of prehospital in- does produce a definitive airway with a balloon inflated be-
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tubations were performed by physicians, as well as the wide low the vocal cords and can be useful in the context of facial
distribution of reported success rates (72–97%). 1,7–9 Observed trauma or as a rescue technique. Another advantage of this
high success rates in some studies can be at least partially at- technique is greater tolerability by the patient after insertion
tributed to bias when the cohort included only those surviving and less of a need for continued sedation. Success rate with
to hospital with an endotracheal tube in place. On the other cricothyroidotomy is highly variable (67–92%) and compli-
hand, the low success rates reported by some studies may be cations such as insertion into the subcutaneous tissues have
explained by the hardships of a combat environment. Katz- been reported. We would stress the need for a high level of
enell et al. reported first attempt success rates of 41% for phy- training if this technique is to be used successfully and safely.
sicians and 39% for medics. The combat medical provider will Given that this is a rare technique in the civilian environment,
likely be in personal protective equipment, including helmet, we would advise that persons empowered to perform cricothy-
may have poor lighting, and may be in a high stress environ- roidotomy participate in frequent cadaveric and animal model
ment with poor ergonomics. training in order to mitigate skill fade.

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