Page 59 - JSOM Winter 2023

Effects of Airway Localization Device Use
During Surgical Cricothyrotomy on Procedural Times and
Confidence Levels of Pre-Hospital Personnel

Caroline Schlocker, MD *; Steve Grosser, RN ;
1
2
Carmen Spaulding, PhD ; Bryan Beltrech ; Rebecca Brady, MD 5
4
3

ABSTRACT
This study evaluated the effect of an airway localization de- of civilian trauma admissions. Pre-hospital cricothyrotomy is
2
vice (ALD) on surgical cricothyrotomy (SC) success rates and associated with a failure rate of 21%–32%, with most failures
prehospital provider confidence. SC is indicated in 0.62% to related to non-tracheal placement or incomplete procedure.
24
1.8% of all patients with military trauma, especially those SC is a procedure in which the upper airway obstruction is
presenting with traumatic airway obstruction. The effect of bypassed via cricothyrotomy tube insertion directly into the
ALD was evaluated in an airway mannequin model during trachea through the cricothyroid membrane. A successful SC
SC with the Committee on Tactical Combat Casualty Care relies on accurate identification of anatomic landmarks by the
(CoTCCC)-recommended Control-Cric Cricothyrotomy Sys- healthcare provider. In one recent study, only 82% (56/68) of
tem. Outcomes included procedural time, Likert measures of paramedics accurately identified the proper SC incision site us-
operator confidence, and qualitative data/feedback for sug- ing landmark palpation alone. An airway localization device
5
gested future improvements in device design and training. The (ALD) has the potential to increase the accuracy and success of
average procedural times of the hospital corpsmen (HM) in- SC by identifying pre-incision airway and confirming the land-
cluding 20 men and 8 women were 67 seconds (without ALD) marks. An ALD can be designed from a partially fluid-filled
and 87 seconds (with ALD) respectively, which were statis- syringe that is advanced towards the airway. Upon insertion
tically significant. Provider confidence for all SC procedural of the ALD into the airway, the tracheal air is aspirated into
steps increased significantly after SC with and without ALD. the fluid-filled syringe, thereby visually establishing the intra-
The average procedural times of the Navy Special Operations airway location. The syringe may be loaded with saline, local
Forces (SOF) group comprising 8 males were 56 seconds anesthetic, or medications used in advanced cardiovascular life
(without ALD) and 64 seconds (with ALD), which was not support (ACLS) algorithm, thereby facilitating the use of the
statistically significant. Provider confidence for two SC pro- multi-purpose ALD. An ALD can be used with any SC method.
cedural steps (adequate hook retraction and first- attempt SC The Tactical Combat Casualty Care (TCCC)-recommended
tube insertion) increased significantly after SC with and with- SC method is the Control-Cric (Pulmodyne, www.pulmodyne.
out ALD. First-attempt SC success rates were 90% in each com/product/control-cric). It is an integrated device consist-
6
group. Both groups provided feedback on the Control-Cric ing of a blade, tracheal hook, and Cric-Key cricothyrotomy
and ALD, with qualitative feedback analyzed for further SC tube. The SC steps include skin incision, cricothyroid mem-
training recommendations. Procedural times were increased brane incision, tracheal hook insertion into the airway, cricoid
with ALD when compared to those without ALD, although retraction, Cric-Key insertion, stylet obturator removal, and
the increase may not be clinically significant in this classroom cuff inflation. This study evaluates the effect of an ALD. We
setting. hypothesized that the measured outcomes for ALD/no ALD
use do not show statistically significant differences. Two sep-
Keywords: airway; trauma; military medicine; surgical crico- arate groups were studied to enhance the generalizability of
thyrotomy; procedural time; operator confidence; hospital the study findings: hospital corpsmen (HM) and Navy Special
corpsmen; special operations forces; SOF Operations Forces (SOF).

Methods
Introduction
Study Groups
Based on a ten-year review of combat operations in Iraq and Af- The Study Group 1 consisted of 35 United Stated Navy HM.
ghanistan, traumatic airway obstruction accounted for 8% of The majority were male (80%, 28/35) with an average length
all fatalities. Surgical cricothyrotomy (SC) is a lifesaving inter- of service of 9.1 years (median 8.5, range 2–18). All had com-
1
vention in patients with traumatic airway obstruction. SCs are pleted the advanced TCCC course that includes airway man-
required in 0.62%–1.8% of patients presenting with military agement and training in SC skills within 12 to 36 months of
trauma, which is more than double the rate reported in studies study enrollment. Participants were recruited from a TCCC

*Correspondence to caroline.schlocker@ucsf.edu
1 CDR Caroline Schlocker, USNR is a physician affiliated with University of California, San Francisco, CA. CMDR Steve Grosser is a regis-
2
tered nurse affiliated with the Royal Australian Navy. Dr Carmen Spaulding is a scientist affiliated with Sharp HealthCare, San Diego, CA.
3
4 HM1 (EXW) Bryan Beltrech is a Navy Corpsman affiliated with the Naval Medical Research & Training Command (NMRTC), San Diego, CA.
5 Lt Rebecca Brady is an otolaryngology resident physician in San Diego, CA.
57
57