Current Pulmonology Reports

, Volume 6, Issue 3, pp 206–213 | Cite as

Airway Management in Combat Trauma

  • David M. Ferraro
  • Edward T. McCann
  • David G. Bell
Pulmonology in Combat Medicine (G Eapen, Section Editor)
First Online:
Part of the following topical collections:
  1. Topical Collection on Pulmonology in Combat Medicine

Abstract

Purpose of Review

Airway compromise remains a leading cause of death in battlefield trauma. The purpose of this review is to examine the impact of airway compromise on survival in the combat trauma population and assess the challenges in providing effective airway management in the combat environment when contrasted with the civilian peacetime environment.

Recent Findings

Management approaches in the civilian trauma setting are not necessarily applicable in the combat environment due to differences in injury patterns and extent of prehospital airway operator training. Although outcomes with airway management in both combat and civilian trauma environments are improved when more skilled providers are involved, this is not always a feasible option in the combat environment.

Summary

The prehospital setting represents the area of greatest difference in planning and practice between the civilian and combat trauma systems. Further research is necessary to improve training strategies and equipment used in combat airway management.

Keywords

Trauma Airway Combat Cricothyroidotomy 
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Notes

Compliance with Ethical Standards

Conflict of Interest

David Bell, David Ferraro, and Edward McCann declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Disclaimer

The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of Defense or the U.S. Government.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance ••Of major importance

  1. 1.
    • Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, et al. Death on the battlefield (2001–2011). J Trauma Acute Care Surg. 2012;73:S431–7. This review of US combat deaths over a 10-year period revealed that of potentially survivable injuries, airway compromise accounted for 8% of deaths, second only to hemorrhage. CrossRefPubMedGoogle Scholar
  2. 2.
    Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the bronze age to the space age. Intensive Care med. 2007;34(2):222–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Beecher HK. Early care of the seriously wounded man. J am med Assoc. 1951;145(4):193–200.CrossRefPubMedGoogle Scholar
  4. 4.
    Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil med. 1984;149(2):55–62.PubMedGoogle Scholar
  5. 5.
    McNamara JJ, Stremple JF. Causes of death following combat injury in an evacuation hospital in Vietnam. The journal of trauma: injury, infection, and critical care. 1972;12(12):1010–2.Google Scholar
  6. 6.
    Cloonan CC. Immediate care of the wounded [Internet]. USA: Brookside Associates; 2007. 246 p. Available from: http://operationalmedicine.org/TextbookFiles/Immediate_Care_of_the_Wounded.htm Google Scholar
  7. 7.
    Adams BD, Cuniowski PA, Muck A, De Lorenzo RA. Registry of emergency airways arriving at combat hospitals. The journal of trauma: injury, infection, and critical care. 2008;64(6):1548–54.CrossRefGoogle Scholar
  8. 8.
    Burkle FM, Newland C, Meister SJ, Blood CG. Emergency medicine in the Persian Gulf war—part 3: battlefield casualties. Ann Emerg med. 1994;23(4):755–60.CrossRefPubMedGoogle Scholar
  9. 9.
    Davis DP, Peay J, Sise MJ, Vilke GM, Kennedy F, Eastman AB, et al. The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. The journal of trauma: injury, infection, and critical care. 2005;58(5):933–9.CrossRefGoogle Scholar
  10. 10.
    Lockey D, Crewdson K, Weaver A, Davies G. Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians. Br J Anaesth. 2014;113(2):220–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Lockey DJ, Healey B, Crewdson K, Chalk G, Weaver AE, Davies GE. Advanced airway management is necessary in prehospital trauma patients. Br J Anaesth. 2015;114(4):657–62.CrossRefPubMedGoogle Scholar
  12. 12.
    Mabry RL, Edens JW, Pearse L, Kelly JF, Harke H. Fatal airway injuries during Operation Enduring Freedom and Operation Iraqi Freedom. Prehospital emergency care. 2010;14(2):272–7.CrossRefPubMedGoogle Scholar
  13. 13.
    • HEJ P, Le Clerc S, Mclennan J. A review of pre-admission advanced airway management in combat casualties, Helmand Province 2013. J R Army med Corps. 2015;161(2):121–6. This study of results from prehospital airway management in Afghanistan suggested a lower success rate as compared to in-hospital management, especially for cricothyroidotomy. CrossRefGoogle Scholar
  14. 14.
    Combes X, Jabre P, Jbeili C, Leroux B, Bastuji Garin S, Margenet A, et al. Prehospital standardization of medical airway management: incidence and risk factors of difficult airway. Acad Emerg med. 2006;13(8):828–34.CrossRefPubMedGoogle Scholar
  15. 15.
    National EMS scope of practice model [Internet]. 2006. 42 p. Available from: https://www.ems.gov/education/EMSScope.pdf.
  16. 16.
    Wang HE, Yealy DM. Out-of-hospital endotracheal intubation: where are we? Ann Emerg med. 2006;47(6):532–41.CrossRefPubMedGoogle Scholar
  17. 17.
    ACGME Program requirements for graduate medical education in emergency medicine [Internet]. 2016. 36 p. Available from: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/110_emergency_medicine_2016.pdf.
  18. 18.
    ACGME Program requirements for graduate medical education in anesthesiology [Internet]. 2016. 35 p. Available from: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/040_anesthesiology_2016.pdf.
  19. 19.
    Kotwal RS. Eliminating preventable death on the battlefield. Arch Surg. 2011;146(12):1350–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Prehospital trauma life support: military edition (8th Edition). National association of emergency medical technicians. C.V. Mosby Co., 2014.Google Scholar
  21. 21.
    •• Tactical combat casualty care guidelines for medical personnel [Internet]. 2016. pp. 1–16. Available from: https://mhs.health.mil/References/REF_TCCC.cshtml. The US Department of Defense’s guidelines for trauma care on the battlefield.
  22. 22.
    Sebesta J. Special lessons learned from Iraq. Surg Clin N am. 2006;86(3):711–26.CrossRefPubMedGoogle Scholar
  23. 23.
    Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–48.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    •• EBG B, Ervin AT, Mabry RL, Bebarta VS. Prehospital and en route cricothyrotomy performed in the combat setting: a prospective, multicenter, observational study. J Spec Oper med. 2014;14(4):35–9. This review of battlefield cricothyroidotomy demonstrated better success rates than previous studies in combat. Google Scholar
  25. 25.
    •• Mabry RL. An analysis of battlefield cricothyrotomy in Iraq and Afghanistan. J Spec Oper med. 2012;12(1):17–23. This review of battlefield cricothyroidotomy identified failure rates higher than comparable civilian studies and incentivized further research to improve training and equipment for this potentially life-saving procedure. PubMedGoogle Scholar
  26. 26.
    Schauer SG, Bellamy MA, Mabry RL, Bebarta VS. 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(3S):60–3.CrossRefPubMedGoogle Scholar
  27. 27.
    Jacobson LE, Gomez GA, Sobieray RJ, Rodman GH, Solotkin KC, Misinski ME. Surgical cricothyroidotomy in trauma patients: analysis of its use by paramedics in the field. The journal of trauma: injury, infection, and critical care. 1996;41(1):15–20.CrossRefGoogle Scholar
  28. 28.
    Fortune JB, Judkins DG, Scanzaroli D, McLeod KB, Johnson SB. Efficacy of prehospital surgical cricothyrotomy in trauma patients. The journal of trauma: injury, infection, and critical care. 1997;42(5):832–6. discussion 837–8CrossRefGoogle Scholar
  29. 29.
    Spaite DW, Joseph M. Prehospital cricothyrotomy: an investigation of indications, technique, complications, and patient outcome. Ann Emerg med. 1990;19(3):279–85.CrossRefPubMedGoogle Scholar
  30. 30.
    Bennett BL, Cailteux-Zevallos B, Kotora J. Cricothyroidotomy bottom-up training review: battlefield lessons learned. Mil med. 2011;176(11):1311–9.CrossRefPubMedGoogle Scholar
  31. 31.
    •• Mabry RL, Nichols MC, Shiner DC, Bolleter S, Frankfurt A. A comparison of two open surgical cricothyroidotomy techniques by military medics using a cadaver model. Ann Emerg med. 2014;63(1):1–5. Elsevier. This prospective crossover study demonstrated improved first-time success and mean procedure time for the Cric-Key method as compared to standard surgical cricothyroidotomy methods when performed by combat medics, and led to a fundamental change for cricothyroidotomy training and equipment for TCCC. CrossRefPubMedGoogle Scholar
  32. 32.
    Elliott DSJ, Baker PA, Scott MR, Birch CW, Thompson JMD. Accuracy of surface landmark identification for cannula cricothyroidotomy. Anaesthesia. 2010;65(9):889–94.CrossRefPubMedGoogle Scholar
  33. 33.
    Aslani A, Ng S-C, Hurley M, McCarthy KF, McNicholas M, McCaul CL. Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesth Analg. 2012;114(5):987–92.CrossRefPubMedGoogle Scholar
  34. 34.
    Lamb A, Zhang J, Hung O, Flemming B, Mullen T, Bissell MB, et al. Accuracy of identifying the cricothyroid membrane by anesthesia trainees and staff in a Canadian institution. Can J Anaesth. 2015;62(5):495–503.CrossRefPubMedGoogle Scholar
  35. 35.
    Narrod JA, Moore EE, Rosen P. Emergency cricothyrostomy—technique and anatomical considerations. The Journal of Emergency Medicine. 1985;2(6):443–6.CrossRefPubMedGoogle Scholar
  36. 36.
    Walls RM. Cricothyroidotomy. Emerg med Clin North am. 1988;6(4):725–36.PubMedGoogle Scholar
  37. 37.
    ATLS. Advanced trauma life support for doctors. Chicago: Amer College of Surgeons; 2008.Google Scholar
  38. 38.
    Emergency surgical airway management. In: Nessen SC, Lounsbury DE, Hetz SP (eds.). War surgery in Afghanistan and Iraq. A series of cases, 2003–2007. Washington, D.C.: Borden Institute; 2008. p. 24–27.Google Scholar
  39. 39.
    Cricothyroidotomy and transtracheal jet ventilation. In: Roberts JR, Hedges JR, (eds.). Clinical procedures in emergency medicine, 5th Ed. Philadelphia: Saunders Elsevier; 2010.Google Scholar
  40. 40.
    Mabry RL, Frankfurt A, Kharod C, Butler F. Emergency cricothyroidotomy in tactical combat casualty care. J Spec Oper Med. 2015;15(3):11–19.Google Scholar
  41. 41.
    Timmermann A, Russo SG, Rosenblatt WH, Eich C, Barwing J, Roessler M, et al. Intubating laryngeal mask airway for difficult out-of-hospital airway management: a prospective evaluation. Br J Anaesth. 2007;99(2):286–91.CrossRefPubMedGoogle Scholar
  42. 42.
    Studer NM, Horn GT, Studer LL, Armstrong JH, Danielson PD. Feasibility of supraglottic airway use by combat lifesavers on the modern battlefield. Mil med. 2013;178(11):1202–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Defense health board: supraglottic airway use in tactical evacuation care 2012–06. 2012 17:1–16. Available from: http://www.health.mil/Reference-Center/Reports/2012/09/17/Supraglottic-Airway-Use-in-Tactical-Evacuation-Care.
  44. 44.
    •• Joint theater trauma system clinical practice guideline [Internet]. U.S. Army Institute of Surgical Research. 2012 [cited 2016 Nov 25]. pp. 1–7. Available from: http://www.usaisr.amedd.army.mil/cpgs/Trauma_Airway_Management_11_Jun_12.pdf. The US Department of Defense’s clinical practice guideline for trauma airway management at the combat support hospital.
  45. 45.
    Boston M. Otolaryngology/head and neck surgery combat casualty care. In: Brennan JA, Hold GR, Thomas RW, editors. Operation Iraqi Freedom and Operation Enduring Freedom [Internet]. Fort Sam Houston: Borden Institute; 2015. 14 p. Available from: http://www.cs.amedd.army.mil/borden/Portlet.aspx?id=d86a2495-e997-4bf1-b2a5-b9d167ea8cc7.
  46. 46.
    Lairet JR, Bebarta VS, Burns CJ, Lairet KF, Rasmussen TE, Renz EM, et al. Prehospital interventions performed in a combat zone. J Trauma Acute Care Surg. 2012 Aug;73:S38–42.CrossRefPubMedGoogle Scholar
  47. 47.
    Apfelbaum JL, Hagberg CA, Caplan RA, Nickinovich DG, Benumof JL, Berry FA, et al. Practice guidelines for management of the difficult airway. Anesthesiology. 2013 Feb;118(2):251–70.CrossRefPubMedGoogle Scholar
  48. 48.
    Chan RK, Siller-Jackson A, Verrett AJ, Wu J, Hale RG. Ten years of war: a characterization of craniomaxillofacial injuries incurred during operations Enduring Freedom and Iraqi Freedom. J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):S453–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA) 2017

Authors and Affiliations

  • David M. Ferraro
    • 1
  • Edward T. McCann
    • 1
  • David G. Bell
    • 2
  1. 1.Pulmonary Diseases Service, Department of Medicine, Brooke Army Medical CenterFort Sam HoustonUSA
  2. 2.Graduate Medical Education, Brooke Army Medical CenterFort Sam HoustonUSA

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