Page 51 - JSOM Winter 2024

than an ETT. Additionally, they were unable to identify a sta- The Israel Defense Force (IDF) conducted a retrospective
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tistically significant cuff width/altitude trend. Some LMA registry analysis (2006–2018) to determine the association
products now include integrated cuff pressure indicators that between a successful advanced airway placement (ETI or cri-
may render the CASEVAC/MEDEVAC cuff pressure compli- cothyrotomy) in prehospital trauma patients (n=566) and their
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cation obsolete. While rotary wing medical personnel would survival. Of the cohort, 425 received a successful advanced
still be required to actively monitor cuff pressure, the esti- airway, while advanced airway attempts were unsuccessful in
mation of cuff pressures during ascent and descent would be 141 patients. The survival rates between the successful and un-
resolved. successful airway groups were similar (77.6% vs. 78%). The
Level of Evidence: B-NR and C-LD (Nonrandomized and Lim- authors observed that the placement of a definitive airway did
ited Data) not change the survival rate, even when adjusting for injury
characteristics. Notably, the authors observed:
What are the concerns regarding extraglottic airway
placement in trauma patients? . . . survival rates were high among trauma patients in
which the provider deemed a definitive airway as nec-
EGAs are generally considered easy to train and simple to place essary yet failed in securing one. … this study provides
airway adjuncts, but complications and misplacements do oc- another layer in the growing evidence that supports
cur. EGA misplacement rates were found to be 14.4% (341 the need for revisions of the current practice of prehos-
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misplacements) in one postmortem study, and EGA place- pital advanced airway management for trauma. These
ment complications included regurgitation and aspiration of results suggest that the liberal use of these invasive air-
gastric contents, nerve injury, pharyngeal rupture, pneumome- way procedures in the prehospital setting should be
diastinum, mediastinitis, and arytenoid dislocation. 32 reconsidered. 35
TCCC guidelines continue to not support the use of rapid se- A subgroup analysis of the Registry of Emergency Airways
quence induction (RSI) in battlefield trauma care. Without pre- Arriving at Combat Hospitals (REACH) study examined pa-
hospital RSI, deep sedation or muscle relaxants, none of which tients who had advanced airways placed for trauma by an
are advised in the TCCC guidelines, insertion of an EGA will enlisted medic at the point of injury. Of the 20 traumatic
9
not be tolerated unless the casualty is deeply comatose. A study injury patients who had advanced airways placed, 12 were
by Lockey et al. examined the survival of trauma patients who EGAs. From the EGA cohort, 11 died and 1 had data lost
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were intubated without anesthesia or muscle relaxants. Of upon hospital transfer. Mabry et al. summarized the findings
the 486 patients in the study, there was a 99.8% mortality thusly:
rate. The one survivor of the cohort had a cardiac arrest after
penetrating chest trauma and underwent a thoracotomy on While these supraglottic airway (SGA) devices have gained
scene to relieve pericardial tamponade and suture the injured popularity in the military setting, there are a number of
myocardium. The author of the study noted: concerns that question their utility. These devices were
designed for use in patients in cardiac arrest or in the case
As almost all the trauma patients intubated without the of the LMA: sedated, fasting, elective surgical patients.
use of drugs died, the value of this practice is doubtful. To All of these devices can also be used in the “can’t intu-
allow easy passage of a tracheal tube without anesthetic bate, can’t ventilate” scenario where the patient has un-
drugs, a patient must be profoundly unconscious, and a dergone sedation and paralysis (RSI) and intubation has
high likelihood of death might be expected. failed. None of these circumstances are applicable to the
battlefield. 9
While the patients in the above study were intubated, the suc- Level of Evidence: B-NR and C-LD (Nonrandomized and Lim-
cessful insertion of an ETT or EGA device in a trauma patient ited Data)
would imply a deep level of unconsciousness, most often due
to severe TBI or profound hemorrhagic shock. Lockey et al.’s How do extraglottic airways compare to bag valve
comments echo those of Mabry et al. in their study of airway masks in terms of battlefield survival rates?
management in combat casualties:
A robust literature review was conducted comparing outcomes
If patients on the battlefield are obtunded enough to of patients treated with basic and advanced airway interven-
tolerate an SGA, they likely have profound hemorrhage tions. The preponderance of patient survival data comparing
shock and/or significant traumatic brain injury. The likeli- the efficacy of BVMs and advanced airways are derived from
hood these patients will survive with a favorable outcome civilian retrospective cohorts. Brief summaries encompassing
is extremely small. 9 a portion of the CoTCCC reviewed studies are included be-
low, specifically comparing advanced EGA placement to basic
CoTCCC continues to not recommend RSI in the guidelines BVM treatment:
and does not recommend prehospital deep patient sedation or
paralytics, especially in hemodynamically compromised pa- • A prehospital airway management meta-analysis reviewed
tients. A case series of military members highlights the risks of 99 studies encompassing 630,397 patients, of which 22
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RSI in combat-related trauma. The 7 Servicemember patients (n=70,718) compared SGA and BVM patient outcomes.
all experienced pulseless arrest after RSI in a Role 2 or 3 set- The meta-analysis concluded:
ting. Six out of the 7 patients exhibited signs of hemodynamic
instability prior to the RSI procedure. The author concluded, For survival, there was no difference for BVM versus ETI or
“Our case series underscores the lethality of performing RSI SGA in adult and pediatric patients with cardiac arrest or
on a patient with hemorrhagic shock.” trauma. The currently available evidence does not indicate

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