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Tsur N, Talmy T, Rittblat M, Radomislensky I, Almog O, Gendler S. Long-term Outcomes of Cricothyroidotomy Versus Endotracheal Intubation in Military Personnel: A Retrospective Comparative Analysis Cohort Study. J Surg Res 2024; 300:416-424. [PMID: 38851087 DOI: 10.1016/j.jss.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 03/16/2024] [Accepted: 05/08/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Emergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI. METHODS Data on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel. RESULTS Of the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture. CONCLUSIONS This retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings.
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Affiliation(s)
- Nir Tsur
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel; Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Tel Aviv University, Petach Tiqva, Israel.
| | - Tomer Talmy
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel; The Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Mor Rittblat
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel; The Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Irina Radomislensky
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute, Ramat-Gan, Israel
| | - Ofer Almog
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel; The Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Sami Gendler
- The Trauma and Combat Medicine Branch, Surgeon General's Headquarters, Israel Defense Forces, Ramat Gan, Israel
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April MD, Bridwell RE, Davis WT, Oliver JJ, Long B, Fisher AD, Ginde AA, Schauer SG. Interventions associated with survival after prehospital intubation in the deployed combat setting. Am J Emerg Med 2024; 79:79-84. [PMID: 38401229 DOI: 10.1016/j.ajem.2024.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/19/2023] [Accepted: 01/30/2024] [Indexed: 02/26/2024] Open
Abstract
INTRODUCTION Airway compromise is the second leading cause of potentially preventable death on the battlefield. Prehospital airway management is often unavoidable in a kinetic combat environment and expected to increase in future wars where timely evacuation will be unreliable and air superiority not guaranteed. We compared characteristics of survivors to non-survivors among combat casualties undergoing prehospital airway intubation. MATERIALS AND METHODS We requested all Department of Defense Trauma Registry (DODTR) encounters during 2007-2023 with documentation of any airway intervention or assessment within the first 72-h after injury. We conducted a retrospective cohort study of all casualties with intubation documented in the prehospital setting. We used descriptive and inferential statistical analysis to compare survivors through 7 days post injury versus non-survivors. We constructed 3 multivariable logistic regression models to test for associations between interventions and 7-day survival after adjusting for injury severity score, mechanism of injury, and receipt of sedatives, paralytics, and blood products. RESULTS There were 1377 of 48,301 patients with documentation of prehospital intubation in a combat setting. Of these, 1028 (75%) survived through 7 days post injury. Higher proportions of survivors received ketamine, paralytic agents, parenteral opioids, and parenteral benzodiazepines; there was no difference in the proportions of survivors versus non-survivors receiving etomidate. The multivariable models consistently demonstrated positive associations between 7-day survival and receipt of non-depolarizing paralytics and opioid analgesics. CONCLUSIONS We found an association between non-depolarizing paralytic and opioid receipt with 7-day survival among patients undergoing prehospital intubation. The literature would benefit from future multi-center randomized controlled trials to establish optimal pharmacologic strategies for trauma patients undergoing prehospital intubation.
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Affiliation(s)
- Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; 14th Field Hospital, Fort Stewart, GA, USA.
| | - Rachel E Bridwell
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA
| | - William T Davis
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Joshua J Oliver
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis-McChord, WA, USA
| | - Brit Long
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Adit A Ginde
- Departments of Emergency Medicine and Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Departments of Emergency Medicine and Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, CO, USA
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April MD, Fisher AD, Rizzo JA, Wright FL, Winkle JM, Schauer SG. Early Vital Sign Thresholds Associated with 24-Hour Mortality among Trauma Patients: A Trauma Quality Improvement Program (TQIP) Study. Prehosp Disaster Med 2024; 39:151-155. [PMID: 38563282 DOI: 10.1017/s1049023x24000207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Identifying patients at imminent risk of death is critical in the management of trauma patients. This study measures the vital sign thresholds associated with death among trauma patients. METHODS This study included data from patients ≥15 years of age in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database. Patients with vital signs of zero were excluded. Documented prehospital and emergency department (ED) vital signs included systolic pressure, heart rate, respiratory rate, and calculated shock index (SI). The area under the receiver operator curves (AUROC) was used to assess the accuracy of these variables for predicting 24-hour survival. Optimal thresholds to predict mortality were identified using Youden's Index, 90% specificity, and 90% sensitivity. Additional analyses examined patients 70+ years of age. RESULTS There were 1,439,221 subjects in the 2019-2020 datasets that met inclusion for this analysis with <0.1% (10,270) who died within 24 hours. The optimal threshold for prehospital systolic pressure was 110, pulse rate was 110, SI was 0.9, and respiratory rate was 15. The optimal threshold for the ED systolic was 112, pulse rate was 107, SI was 0.9, and respiratory rate was 21. Among the elderly sub-analysis, the optimal threshold for prehospital systolic was 116, pulse rate was 100, SI was 0.8, and respiratory rate was 21. The optimal threshold for ED systolic was 121, pulse rate was 95, SI was 0.8, and respiratory rate was 0.8. CONCLUSIONS Systolic blood pressure (SBP) and SI offered the best predictor of mortality among trauma patients. The SBP values predictive of mortality were significantly higher than the traditional 90mmHg threshold. This dataset highlights the need for better methods to guide resuscitation as initial vital signs have limited accuracy in predicting subsequent mortality.
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Affiliation(s)
- Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MarylandUSA
- 14th Field Hospital, Fort Stewart, GeorgiaUSA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New MexicoUSA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, MarylandUSA
- Brooke Army Medical Center, JBSA Fort Sam Houston, TexasUSA
| | - Franklin L Wright
- University of Colorado School of Medicine, Department of Surgery, Aurora, ColoradoUSA
| | - Julie M Winkle
- University of Colorado School of Medicine, Departments of Anesthesia and Emergency Medicine, Aurora, ColoradoUSA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MarylandUSA
- University of Colorado School of Medicine, Departments of Anesthesia and Emergency Medicine, Aurora, ColoradoUSA
- University of Colorado School of Medicine Center for Combat and Battlefield (COMBAT) Research, Aurora, ColoradoUSA
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Morton S, Avery P, Kua J, O'Meara M. Success rate of prehospital emergency front-of-neck access (FONA): a systematic review and meta-analysis. Br J Anaesth 2023; 130:636-644. [PMID: 36858888 PMCID: PMC10170392 DOI: 10.1016/j.bja.2023.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/11/2023] [Accepted: 01/18/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Front-of-neck access (FONA) is an emergency procedure used as a last resort to achieve a patent airway in the prehospital environment. In this systematic review with meta-analysis, we aimed to evaluate the number and success rate of FONA procedures in the prehospital setting, including changes since 2017, when a surgical technique was outlined as the first-line prehospital method. METHODS A systematic literature search (PROSPERO CRD42022348975) was performed from inception of databases to July 2022 to identify studies in patients of any age undergoing prehospital FONA, followed by data extraction. Meta-analysis was used to derive pooled success rates. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS From 909 studies, 69 studies were included (33 low quality; 36 very low quality) with 3292 prehospital FONA attempts described (1229 available for analysis). The crude median success rate increased from 99.2% before 2017 to 100.0% after 2017. Meta-analysis revealed a pooled overall FONA success rate of 88.0% (95% confidence interval [CI], 85.0-91.0%). Surgical techniques had the highest success rate at a median of 100.0% (pooled rate=92.0%; 95% CI, 88.0-95.0%) vs 50.0% for needle techniques (pooled rate=52.0%; 95% CI, 28.0-76.0%). CONCLUSIONS Despite being a relatively rare procedure in the prehospital setting, the success rate for FONA is high. A surgical technique for FONA appears more successful than needle techniques, and supports existing UK prehospital guidelines. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42022348975.
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Affiliation(s)
- Sarah Morton
- Essex and Herts Air Ambulance, Colchester, UK; Imperial College London, London, UK.
| | - Pascale Avery
- Emergency Retrieval and Transfer Service (EMRTS) Wales Air Ambulance, Dafen, UK
| | | | - Matt O'Meara
- Essex and Herts Air Ambulance, Colchester, UK; Emergency Retrieval and Transfer Service (EMRTS) Wales Air Ambulance, Dafen, UK; University Hospitals North Midlands, Stoke-on-Trent, UK
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A mixed methods end-user assessment to determine the ideal supraglottic airway device for inclusion into the medic's aid bag. J Trauma Acute Care Surg 2022; 93:S64-S70. [PMID: 35319545 DOI: 10.1097/ta.0000000000003596] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Many advancements in supraglottic airway (SGA) technology have occurred since the start of the Global War on Terrorism. While the Tactical Combat Casualty Care (TCCC) guidelines previously recommend the i-gel device, this is based on little data and minimal end-user input. OBJECTIVE We sought to use a mixed methods approach to investigate the properties of an ideal device for inclusion into the medic's aid bag. METHODS We performed prospective, serial qualitative studies to uncover and articulate themes relative to airway device usability with 68 W - combat medics. 68 W are trained roughly to the level of a civilian Advanced Emergency Medical Technician with a heavier focus on trauma care. Physicians with airway expertise demonstrated the use of each device and provided formal training on all the presented devices. We then administered performed focus groups to solicit end-user feedback along with survey data. RESULTS We enrolled 250 medics during the study. The preponderance of medics were of the rank E4 (28%) and E5 (44%). Only 35% reported ever placing an SGA in a real human. When reporting on usability, the i-gel had the highest median score, ease of manipulation, grip comfort and ease of insertion while also scoring the best in regard to requiring minimal training. The other compared devices had no clear highest score. Qualitative data saturated around a strong preference for the BaskaMask and/or the i-gel airway device, with the least favorite being the AirQ and the LMA Fastrach airway devises. There was a strong qualitative alignment in how both the BaskaMask and i-gel provided ease of use and simplicity of training. CONCLUSIONS There were strong qualitative preferences for two specific airway devices: Baska Mask and i-gel. However, many medics commented on their previous experience with the i-gel compared to the other devices which may have biased them towards the i-gel. The overall data suggests that medics would prefer a device engineered with features from several devices. LEVEL OF EVIDENCE 2.
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