Original Article

Prehospital Airway Management in Iraq and Afghanistan: A Descriptive Analysis

Authors: Steven G. Schauer, DO, MS, Jason F. Naylor, PA-C, Joseph K. Maddry, MD, Denise M. Beaumont, DNAP, CRNA, Cord W. Cunningham, MD, MPH, Megan B. Blackburn, PhD, Michael D. April, MD, DPhil
diagnostic:283937

Abstract

Objectives: Airway failures are the second leading cause of potentially preventable death on the battlefield. Improvements in airway management depend on identifying current challenges. We sought to build on previously reported data on prehospital, combat airway management.

Methods: We used a series of emergency department procedure codes to identify patients within the Department of Defense Trauma Registry from January 2007 to August 2016. This is a subanalysis of those with a documented prehospital airway intervention.

Results: Of the 28,222 patients in our dataset, 1379 (4.9%) had a documented prehospital airway intervention. Airway devices consisted of 49 airway adjuncts (17 nasopharyngeal airways, 2 oropharyngeal airways, remainder listed as unspecified), 230 cricothyrotomies, 1117 endotracheal intubations, and 27 supraglottic airways. Patients undergoing airway intervention were mostly members of the US military (42.2%). Compared with those without airway intervention, they were slightly younger (median 24 vs 25 years, P < 0.001), more frequently injured by explosives (57.7% vs 55.2%, P < 0.001) and gunshot wound (28.7% vs 23.3%, P < 0.001), with higher injury severity scores (composite and by body region) except the superficial body region, and less likely to survive to discharge (73.5% vs 96.6%, P < 0.001). Vecuronium (35.4%) and midazolam (27.9%) were the most frequently used paralytic and sedative, respectively.

Conclusions: Patients undergoing airway intervention were most frequently injured by explosive or gunshot wound. Intubations and cricothyrotomies were the most frequent airway interventions performed. Patients undergoing interventions were more critically injured, with higher mortality rates. Further research is needed to determine methods to reduce mortality in this critically injured population.

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References

1. Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. J Trauma 2011;71(suppl 1):S4-S8.
 
2. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg 2012;73(6 suppl 5):S431-S437.
 
3. National Association of Emergency Medical Technicians. Tactical combat casualty care guidelines for medical providers. https://www.naemt.org/education/naemt-tccc/tccc-mp-guidelines-and-curriculum. Accessed January 31, 2017.
 
4. ATLS Subcommittee American College of Surgeons’ Committee on Trauma International ATLS Working Group. Advanced trauma life support (ATLS): the ninth edition. J Trauma Acute Care Surg 2013;74:1363-1366.
 
5. De Lorenzo RA. Medic for the millennium: the U.S. Army 91W health care specialist. Mil Med 2001;166:685-688.
 
6. Pappas CG. The Ranger medic. Mil Med 2001;166:394-400.
 
7. Deakin CD, King P, Thompson F. Prehospital advanced airway management by ambulance technicians and paramedics: is clinical practice sufficient to maintain skills? Emerg Med J 2009;26:888-891.
 
8. Mabry RL. An analysis of battlefield cricothyrotomy in Iraq and Afghanistan. J Spec Oper Med 2012;12:17-23.
 
9. Adams BD, Cuniowski PA, Muck A, et al. Registry of emergency airways arriving at combat hospitals. J Trauma 2008;64:1548-1554.
 
10. Mabry RL, Frankfurt A. Advanced airway management in combat casualties by medics at the point of injury: a sub-group analysis of the reach study. J Spec Oper Med 2011;11:16-19.
 
11. Mabry RL, Nichols MC, Shiner DC, et al. A comparison of two open surgical cricothyroidotomy techniques by military medics using a cadaver model. Ann Emerg Med 2014;63:1-5.
 
12. Blackburn MB, April MD, Brown DJ, et al. Prehospital airway procedures performed in trauma patients by ground forces in Afghanistan. J Trauma Acute Care Surg 2018;85(1 suppl 2):S154-S160.
 
13. Schauer SG, Naylor JF, Oliver JJ, et al. An analysis of casualties presenting to military emergency departments in Iraq and Afghanistan. Am J Emerg Med 2018; pii: S0735-6757(18)30363-2.
 
14. Glenn MA, Martin KD, Monzon D, et al. Implementation of a combat casualty trauma registry. J Trauma Nurs 2008;15:181-184.
 
15. Oɼ KM, Littleton-Kearney MT, Bridges E, et al. Evaluating the Joint Theater Trauma Registry as a data source to benchmark casualty care. Mil Med 2012;177:546-552.
 
16. 2017. TS-AisUhwtoasahDAS. https://www.ncbi.nlm.nih.gov/pubmed/17426553. Accessed October 22, 2018.
 
17. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield. Arch Surg 2011;146:1350-1358.
 
18. Lairet JR, Bebarta VS, Burns CJ, et al. Prehospital interventions performed in a combat zone: a prospective multicenter study of 1,003 combat wounded. J Trauma Acute Care Surg 2012;73(2 suppl 1):S38-S42.
 
19. Cobas MA, De la Pena MA, Manning R, et al. Prehospital intubations and mortality: a level 1 trauma center perspective. Anesth Analg 2009;109:489-493.
 
20. Benoit JL, Gerecht RB, Steuerwald MT, et al. Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: a meta-analysis. Resuscitation 2015;93:20-26.
 
21. Bennett BL, Cailteux-Zevallos B, Kotora J. Cricothyroidotomy bottom-up training review: battlefield lessons learned. Mil Med 2011;176:1311-1319.
 
22. Gerhardt RT, Berry JA, Blackbourne LH. Analysis of life-saving interventions performed by out-of-hospital combat medical personnel. J Trauma 2011;71(suppl 1):S109-S113.
 
23. Barnard EB, Ervin AT, Mabry RL, et al. Prehospital and en route cricothyrotomy performed in the combat setting: a prospective, multicenter, observational study. J Spec Oper Med 2014;14:35-39.
 
24. Schauer SG, Bellamy MA, Mabry RL, et al. A comparison of the incidence of cricothyrotomy in the deployed setting to the emergency department at a level 1 military trauma center: a descriptive analysis. Mil Med 2015;180(suppl 3):60-63.
 
25. McGill J, Clinton JE, Ruiz E. Cricothyrotomy in the emergency department. Ann Emerg Med 1982;11:361-364.
 
26. Nugent WL, Rhee KJ, Wisner DH. Can nurses perform surgical cricothyrotomy with acceptable success and complication rates? Ann Emerg Med 1991;20:367-370.
 
27. Spaite DW, Joseph M. Preshospital cricothyrotomy: sn investigation of indications, technique, complications, and patient outcome. Ann Emerg Med 1990;19:279-285.
 
28. Schauer SG, April MD, Cunningham CW, et al. Prehospital cricothyrotomy kits used in combat. J Spec Oper Med 2017;17:18-20.
 
29. Zobrist B, Casmaer M, April MD. Single rescuer ventilation using a bag-valve mask with internal handle: a randomized crossover trial. Am J Emerg Med 2016;34:1991-1996.
 
30. Amack AJ, Barber GA, Ng PC, et al. Comparison of ventilation with one-handed mask seal with an intraoral mask versus conventional cuffed face mask in a cadaver model: a randomized crossover trial. Ann Emerg Med 2017;69:12-17.
 
31. Schauer SG, Kester NM, Fernandez JD, et al. A randomized, cross-over, pilot study comparing the standard cricothyrotomy to a novel trochar-based cricothyrotomy device. Am J Emerg Med 2018;36:1706-1708.
 
32. Reed P, Zobrist B, Casmaer M, et al. Single rescuer ventilation using a bag valve mask with removable external handle: a randomized crossover trial. Prehosp Disaster Med 2017;32:625-630.
 
33. Rush S, Boccio E, Kharod CU, et al. Evolution of pararescue medicine during Operation Enduring Freedom. Mil Med 2015;180(suppl 3):68-73.
 
34. Pugh HE, LeClerc S, Mclennan J. A review of pre-admission advanced airway management in combat casualties, Helmand Province 2013. J R Army Med Corps 2015;161:121-126.
 
35. Gao M, Rejaei D, Liu H. Ketamine use in current clinical practice. Acta Pharmacol Sin 2016;37:865-872.
 
36. Rech MA, Barbas B, Chaney W, et al. When to pick the nose: out-of-hospital and emergency department intranasal administration of medications. Ann Emerg Med 2017;70:203-211.
 
37. Adnet F, Le Moyec L, Smith CE, et al. Stability of succinylcholine solutions stored at room temperature studied by nuclear magnetic resonance spectroscopy. Emerg Med J 2007;24:168-169.
 
38. Anectine (succinylcholine chloride injection USP). https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/008453s027lbl.pdf. Accessed September 27, 2018.
 
39. Schauer SG, April MD, Naylor JF, et al. A descriptive analysis of data from the Department of Defense Joint Trauma System Prehospital Trauma Registry. US Army Med Dep J 2017;(3-17):92-97.
 
40. Kaji AH, Schriger D, Green S. Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies. Ann Emerg Med 2014;64:292-298.
 
41. Robinson JB, Smith MP, Gross KR, et al. Battlefield documentation of tactical combat casualty care in Afghanistan. US Army Med Dep J 2016;(2â):87-94.