Page 38 - JSOM Spring 2023

Unlike endotracheal intubation and cricothyroidotomy, supra- in which the airway is managed (prehospital or hospital, con-
glottic airways (such as King LT, Combitube and LMA) are not ditions, etc.); medications used; number of attempts; success
definitive airways. They do not have a balloon inflated below rate; complications; and need for rescue technique. The hetero-
the vocal cords and may not provide the same protection from geneity of the reviewed literature limited our ability to make
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aspiration. In prehospital combat literature, supraglottic air- more specific comparisons and recommendations.
ways are more often used by medics than by physicians. 7–9,13,21
This is likely because this skill is relatively easier to learn and This systematic review has summarized the existing prehos-
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there is less associated risk of morbidity. Reported success pital combat airway data. We found the evidence base to be
rates ranged from 50% to 92%, 7,9,12,21,22 and if only reports heterogeneous. Much of this is the result of the reality of
containing greater than six supraglottic airways are included, conducting science in the combat prehospital environment.
the success rate ranged from 89% to 92%. 7,12,21 Less equipment Lack of highest-quality research by evidence-based medicine
is required for this technique compared to intubation and standards does not obviate the responsibility for analysis and
cricothyroidotomy. Supraglottic airways also have a role as a appreciation of the evidence available. This information is
rescue airway for failed cricothyroidotomy or intubation. 7,12 If intended to inform the decision-making of military medical
having a practitioner with an intubating skillset is not possible leadership regarding their combat prehospital airway policy.
or appropriate, then an airway management tool that is eas- It is advisable that commanders prospectively measure the
ier to use with a higher success rate could be considered. The performance of their airway protocols so that data from their
problem of subsequent ventilation remains, requiring either a combat experience can refine their policies. Injured soldiers
portable ventilator and the skills and knowledge to utilize it, or deserve to have the best possible airway management and it
dedicated personnel for manual bag-valve ventilation. In either behooves us to further high-quality research in this field.
case the requirement for sedation remains a consideration.
References
Nasopharyngeal and oropharyngeal airways are also not de- 1. Katzenell U, Lipsky AM, Abramovich A, et al. Prehospital intu-
finitive airways, but they are the go-to option for many medics bation success rates among Israel Defense Forces providers: Epi-
trained in combat medicine because of ease and rapidity of demiologic analysis and effect on doctrine. J Trauma Acute Care
use. They are temporizing measures to reduce the risk of air- Surg. 2013;75(2 SUPPL. 2).
way obstruction and to facilitate bag-valve mask ventilation 2. Butler FK. Tactical combat casualty care: Update 2009. J Trauma –
(BVM) in obtunded patients. In combat, they have often been Inj Infect Crit Care. 2010;69(SUPPL. 1).
performed by medics. 8,13 One paper reported a high success 3. Savage LE, Forestier MC, Withers LN, et al. Tactical combat casu-
rate for placement of these airways (93%). 10 alty care in the canadian forces: Lessons learned from the afghan
war. Can J Surg. 2011;54(6 SUPPL.).
4. Smith SA, McAlister VC, Dubois L, et al. Managing junctional
In formulating the airway management plan for a forward haemorrhage in the combat environment. BMJ Mil Health. 2021;
environment, medical leadership will need to plan according 167(2):114–117.
to the nature and threat level of their mission, the evacuation 5. Smith SA, Hilsden R, Beckett A, McAlister VC. The future of re-
timeline, the amount of equipment that will be carried, and suscitative endovascular balloon occlusion in combat operations.
J R Army Med Corps. 2017;163(5):296–300.
most importantly, the level of training and airway manage- 6. Crewdson K, Lockey DJ, Røislien J, et al. The success of pre-
ment skillset of their medical personnel. There is no one-size- hospital tracheal intubation by different pre-hospital providers: A
fits-all plan. However, we have some suggestions based on systematic literature review and meta-analysis. Crit Care. 2017;
experience and analysis of the data. 21(1):1–10.
7. Adams BD, Cuniowski PA, Muck A, De Lorenzo RA. Registry of
1. Your team should have a designated airway expert. This emergency airways arriving at combat hospitals. J Trauma – Inj
Infect Crit Care. 2008;64(6):1548–1554.
will allow for concentration of training and experience to 8. Blackburn MB, April MD, Brown DJ, et al. Prehospital airway
optimize performance in the field. procedures performed in trauma patients by ground forces in
2. Airway experts must have regular opportunities to manage Afghanistan. J Trauma Acute Care Surg. 2018;85(1S Suppl 2):
airways. Provide them with as much civilian experience as S154–S160.
possible between missions. 9. Haldane AG. Advanced airway management—a medical emer-
3. Practitioners empowered to perform cricothyroidotomy gency response team perspective. J R Army Med Corps. 2010;156
must have regular cadaveric and animal model training. (3):159–161.
4. If this high level of airway training is not achievable, then 10. Lairet JR, Bebarta VS, Burns CJ, et al. Prehospital interventions
performed in a combat zone: A prospective multicenter study of
more easily learned techniques like NPA/OPA and supra- 1,003 combat wounded. J Trauma Acute Care Surg. 2012;73(2
glottic airways should be used. SUPPL. 1):38–42.
5. Regardless of specific modality, periodic re-training should 11. Mabry RL, Cuniowski PA, Frankfurt A, Adams BD. Advanced
continue to be utilized to offset skill fade. airway management in combat casulaties by medics at the point
of injury: A sub-group analysis of the reach study. J Spec Oper
Med. 2011;11(2):16–19.
As with other rare-event skills, there is a paucity of evidence 12. Shavit I, Aviram E, Hoffmann Y, et al. Laryngeal mask airway
upon which to base specific recommendations on minimum as a rescue device for failed endotracheal intubation during
training standards, recertification frequency, or specific pro- scene-to-hospital air transport of combat casualties. Eur J Emerg
vider level required. Med. 2018;25(5):368–371.
13. Hardy G, Maddry JK, Ng PC, et al. Impact of prehospital airway
We recommend that ongoing or future studies on the topic of management on combat mortality. Am J Emerg Med. 2019;37(2):
349–350.
prehospital airway management standardize the reporting of 14. Gerhardt RT, Berry JA, Blackbourne LH. Analysis of life- saving
success in order that comparison between studies and meth- interventions performed by out-of-hospital combat medical
ods is possible. Specifically, the following should be explicitly personnel. J Trauma – Inj Infect Crit Care. 2011;71(SUPPL. 1):
captured: the level of training of the provider(s); environment 109–113.

36 | JSOM Volume 23, Edition 1 / Spring 2023