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Jarvis JL, Panchal AR, Lyng JW, Bosson N, Donofrio-Odmann JJ, Braude DA, Browne LR, Arinder M, Bolleter S, Gross T, Levy M, Lindbeck G, Maloney LM, Mattera CJ, Wang CT, Crowe RP, Gage CB, Lang ES, Sholl JM. Evidence-Based Guideline for Prehospital Airway Management. PREHOSP EMERG CARE 2023; 28:545-557. [PMID: 38133523 DOI: 10.1080/10903127.2023.2281363] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/05/2023] [Indexed: 12/23/2023]
Abstract
Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.
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Affiliation(s)
- Jeffrey L Jarvis
- Office of the Medical Director, Metropolitan Area EMS Authority, Fort Worth, Texas
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - John W Lyng
- Emergency Medicine, North Memorial Health Hospital Level 1 trauma center, Minneapolis, Minnesota
| | - Nichole Bosson
- EMS, Los Angeles County Department of Health Services, Los Angeles, California
| | | | - Darren A Braude
- Department of Emergency Medicine, The University of New Mexico, Albuquerque, New Mexico
| | - Lorin R Browne
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Arinder
- EMS, Global Medical Response Inc., Greenwood Village, Colorado
| | - Scott Bolleter
- EMS, Healthcare Innovation & Sciences Centre, Spring Branch, Texas
| | - Toni Gross
- Department of Emergency Medicine, LCMC Health, New Orleans, Louisiana
| | | | - George Lindbeck
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Lauren M Maloney
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, New York
| | | | - Cheng-Teng Wang
- Department of Emergency Medicine, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | | | - Christopher B Gage
- Research, National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Alberta Health Services, Edmonton, Canada
| | - J Matthew Sholl
- National Registry of Emergency Medical Technicians, Columbus, Ohio
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Carney N, Totten AM, Cheney T, Jungbauer R, Neth MR, Weeks C, Davis-O'Reilly C, Fu R, Yu Y, Chou R, Daya M. Prehospital Airway Management: A Systematic Review. PREHOSP EMERG CARE 2022; 26:716-727. [PMID: 34115570 DOI: 10.1080/10903127.2021.1940400] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
Objective: To assess comparative benefits and harms across three airway management approaches (bag valve mask [BVM], supraglottic airway [SGA], and endotracheal intubation [ETI]) used by prehospital emergency medical services (EMS) to treat patients with trauma, cardiac arrest, or medical emergencies, and how they differ based on techniques and devices, EMS personnel and patient characteristics. Data sources: We searched electronic citation databases (Ovid® MEDLINE®, CINAHL®, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and Scopus®) from 1990 to September 2020. Review methods: We followed Agency for Healthcare Research and Quality Effective Health Care Program Methods guidance. Outcomes included mortality, neurological function, return of spontaneous circulation (ROSC), and successful advanced airway insertion. Meta-analyses using profile-likelihood random effects models were conducted, with analyses stratified by study design, emergency type, and age. Results: We included 99 studies involving 630,397 patients. We found few differences in primary outcomes across airway management approaches. For survival, there was no difference for BVM versus ETI or SGA in adult and pediatric patients with cardiac arrest or trauma. For neurological function, there was no difference for BVM versus ETI and SGA versus ETI in pediatric patients with cardiac arrest. There was no difference in BVM versus ETI in adults with cardiac arrest, but improved neurological function with BVM or ETI versus SGA. There was no difference in ROSC for patients with cardiac arrest for BVM versus ETI or SGA in adults and pediatrics, or SGA versus ETI in pediatrics. There was higher frequency of ROSC in adults with SGA versus ETI. For successful advanced airway insertion, there was higher first-pass success with SGA versus ETI for all patients except adult medical patients (no difference), and no difference in overall success using SGA versus ETI in adults. Conclusions: The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion. Strength of evidence was low or moderate; most included studies were observational. This supports the need for high-quality randomized controlled trials to advance clinical practice and EMS education and policy, and improve patient-centered outcomes.
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Peri SR, Akhter F, De Lorenzo RA, Hood RL. Portable Medical Suction and Aspirator Devices: Are the Design and Performance Standards Relevant? SENSORS (BASEL, SWITZERLAND) 2022; 22:2515. [PMID: 35408130 PMCID: PMC9002857 DOI: 10.3390/s22072515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 06/14/2023]
Abstract
Airway clearance refers to the clearing of any airway blockage caused due to foreign objects such as mud, gravel, and biomaterials such as blood, vomit, or teeth fragments using the technology of choice, portable suction devices. Currently available devices are either too heavy and bulky to be carried, or insufficiently powered to be useful despite being in accordance with the ISO 10079-1 standards. When applied to portable suction, the design and testing standards lack clinical relevancy, which is evidenced by how available portable suction devices are sparingly used in pre-hospital situations. Lack of clinical relevancy despite being in accordance with design/manufacturing standards arise due to little if any collaboration between those developing clinical standards and the bodies that maintain design and manufacturing standards. An updated set of standards is required that accurately reflects evidence-based requirements and specifications, which should promote valid, rational, and relevant engineering designs and manufacturing standards in consideration of the unique scenarios facing prehospital casualty care. This paper aims to critically review the existing standards for portable suction devices and propose modifications based on the evidence and requirements, especially for civilian prehospital and combat casualty care situations.
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Affiliation(s)
- Saketh R. Peri
- Department of Biomedical Engineering, University of Texas San Antonio, San Antonio, TX 78249, USA; (S.R.P.); (R.A.D.L.)
- Department of Emergency Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
| | - Forhad Akhter
- Department of Mechanical Engineering, University of Texas San Antonio, San Antonio, TX 78249, USA;
| | - Robert A. De Lorenzo
- Department of Biomedical Engineering, University of Texas San Antonio, San Antonio, TX 78249, USA; (S.R.P.); (R.A.D.L.)
- Department of Emergency Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
- Department of Mechanical Engineering, University of Texas San Antonio, San Antonio, TX 78249, USA;
| | - R. Lyle Hood
- Department of Biomedical Engineering, University of Texas San Antonio, San Antonio, TX 78249, USA; (S.R.P.); (R.A.D.L.)
- Department of Emergency Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
- Department of Mechanical Engineering, University of Texas San Antonio, San Antonio, TX 78249, USA;
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Strauss R, Menchetti I, Perrier L, Blondal E, Peng H, Sullivan-Kwantes W, Tien H, Nathens A, Beckett A, Callum J, da Luz LT. Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research. Trauma Surg Acute Care Open 2021; 6:e000773. [PMID: 34746434 PMCID: PMC8527149 DOI: 10.1136/tsaco-2021-000773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/27/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools. RESULTS Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2). CONCLUSIONS The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Rachel Strauss
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Isabella Menchetti
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laure Perrier
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Erik Blondal
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Henry Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Wendy Sullivan-Kwantes
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Homer Tien
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avery Nathens
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Beckett
- Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeannie Callum
- Laboratory Medicine and Molecular Diagnostics, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Luis Teodoro da Luz
- Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Hardjo S, Palmer L, Haworth MD. Prehospital Emergency Cricothyrotomy in Dogs Part 1: Experiences With Commercial Cricothyrotomy Kits. Front Vet Sci 2021; 8:705695. [PMID: 34604369 PMCID: PMC8483268 DOI: 10.3389/fvets.2021.705695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
The surgical cricothyrotomy (CTT) has been recommended for emergency front of neck airway access (eFONA) during a cannot intubate, cannot oxygenate scenario for military working dogs (MWD) and civilian law enforcement working dogs (operational K9s). In prehospital and austere environments, combat medics and emergency medical service providers are expected to administer emergency medical care to working dogs and may only have emergency airway kits designed for humans at their disposal. The objective of this article is to provide a detailed description of the application of such devices in cadaver dogs and highlight potential alterations to manufacturer guidelines required for successful tube placement. The kits evaluated included the Portex® PCK, Melker universal cricothyrotomy kit and H&H® emergency cricothyrotomy kit. A novel technique for awake cricothyrotomy in the dog is also described, which can also be considered for in-hospital use, together with the open surgical method described for the H&H® kit. To the authors' knowledge, this is the first publication documenting and providing instruction on the application of commercial cricothyrotomy kits in dogs.
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Affiliation(s)
- Sureiyan Hardjo
- UQ VETS, School of Veterinary Science, The University of Queensland, Gatton, QLD, Australia
| | - Lee Palmer
- Veterinary Medical Director, National Association of Veterinary Emergency Medical Services, Auburn, AL, United States
| | - Mark David Haworth
- UQ VETS, School of Veterinary Science, The University of Queensland, Gatton, QLD, Australia
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Coulter M, Mickelson RC, Dye JL, Myers EE, Ambrosio AA. Laryngotracheal and pharyngoesophageal traumatic injuries from US military operations in Iraq and Afghanistan, 2003-2017. BMJ Mil Health 2021; 169:231-235. [PMID: 33911010 DOI: 10.1136/bmjmilitary-2020-001769] [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: 01/13/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Laryngotracheal and pharyngo-oesophageal trauma present military providers with especially difficult, life-threatening challenges. Although effective treatment strategies are crucial, there is no clear consensus. This study of combat injuries from Iraq and Afghanistan describes initial treatment outcomes. METHODS US service members who sustained 'laryngotracheal' and 'pharyngoesophageal' injuries while deployed in military operations from 2003 to 2017 were identified from the Expeditionary Medical Encounter Database. Those with inhalation or ingestion injuries and an Injury Severity Score (ISS) <16 were excluded. Data on demographics, survival, mechanism and type of injury and diagnostic and therapeutic intervention were recorded. RESULTS A total of 111 service members met inclusion criteria. Nearly one-third (32.4%) were killed in action (KIA) or died of wounds (DoW). Fatality was not significantly associated with age, theatre of operation, type of injury or mechanism of injury, but was associated with a higher ISS and those in the Marines. Although survival rates were not significantly different, the frequency of these injuries decreased after the introduction of cervical collar protection in 2007. Of those who DoW or survived, 41.1% required a surgical airway. Tracheobronchoscopy was performed in 25.6%, oesophagoscopy in 20.0% and oesophagram in 6.7%. Of the 85 with penetrating neck injuries, 43 (50.6%) underwent neck exploration, in which 31 (72.1%) required intervention. CONCLUSIONS Severe laryngotracheal and pharyngo-oesophageal injuries have a high fatality rate and demand prompt treatment from skilled providers. Further work will elucidate preventive measures and clear management algorithms to optimise outcomes.
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Affiliation(s)
- Michael Coulter
- Otolaryngology-Head & Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA
| | - R C Mickelson
- Otolaryngology-Head and Neck Surgery, US Naval Hospital Yokosuka, Yokosuka, Yokohama, Japan
| | - J L Dye
- Axiom Resource Management, San Diego, California, USA
| | - E E Myers
- Naval Health Research Center, San Diego, California, USA
| | - A A Ambrosio
- Otolaryngology-Head & Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA
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Pandian V, Leeper WR, Jones C, Pugh K, Yenokyan G, Bowyer M, Haut ER. Comparison of surgical cricothyroidotomy training: a randomized controlled trial of a swine model versus an animated robotic manikin model. Trauma Surg Acute Care Open 2020; 5:e000431. [PMID: 32399492 PMCID: PMC7204537 DOI: 10.1136/tsaco-2019-000431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 02/08/2020] [Accepted: 02/21/2020] [Indexed: 11/04/2022] Open
Abstract
Background Airway obstruction remains a preventable cause of death on the battlefield. Surgical cricothyroidotomy is an essential skill for immediate airway management in trauma. Training for surgical cricothyroidotomy has been undertaken using simulators, cadavers or animal models. The ideal approach to training for this low volume and high-risk procedure is unknown. We hypothesized that current simulation technology provides an equal or better education for surgical cricothyroidotomy when compared with animal tissue training. Methods We performed a prospective randomized controlled study comparing training for surgical cricothyroidotomy using hands-on training on swine versus inanimate manikin. We enrolled medical students who had never performed or had formal instruction on surgical cricothyroidotomy. We randomized their instruction to use either a swine model or the inanimate version of the Operative Experience Inc. advanced surgical manikin. Participants' skills were then evaluated on human cadavers and on an advanced robotic manikin. Tests were scored using checklists modified from Objective Structured Assessment of Technical Skills and Tactical Combat Casualty Care. We compared scores between the groups using Wilcoxon rank sum tests and generalized linear models. Results Forty-eight participants were enrolled and trained; 30 participants completed the first testing session; 25 completed the second testing session. The mean time to establish an airway from the incision until the cuff was blown up was 95±52 s. There were no significant differences in any of the outcome measures between the two training groups. Discussion Measured performance was not different between subjects trained to perform surgical cricothyroidotomy on an animal model or a high fidelity manikin. The use of an advanced simulator has the potential to replace live tissue for this procedure mitigating concerns over animal rights. Levels of evidence I.
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Affiliation(s)
- Vinciya Pandian
- Department of Nursing Faculty, Johns Hopkins School of Nursing, Baltimore, Maryland, United States
| | - William Robert Leeper
- Department of Surgery, London Health Sciences Centre, Victorial Hospital, London, Ontario, Canada
| | - Christian Jones
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Kristy Pugh
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins School of Public Health, Baltimore, Maryland, United States
| | - Mark Bowyer
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
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Hudson IL, Blackburn MB, Staudt AM, Ryan KL, Mann-Salinas EA. Analysis of Casualties That Underwent Airway Management Before Reaching Role 2 Facilities in the Afghanistan Conflict 2008-2014. Mil Med 2020; 185:10-18. [PMID: 32074383 DOI: 10.1093/milmed/usz383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Airway compromise is the second leading cause of potentially survivable death on the battlefield. The purpose of this study was to better understand wartime prehospital airway patients. MATERIALS AND METHODS The Role 2 Database (R2D) was retrospectively reviewed for adult patients injured in Afghanistan between February 2008 and September 2014. Of primary interest were prehospital airway interventions and mortality. Prehospital combat mortality index (CMI-PH), hemodynamic interventions, injury mechanism, and demographic data were also included in various statistical analyses. RESULTS A total of 12,780 trauma patients were recorded in the R2D of whom 890 (7.0%) received prehospital airway intervention. Airway intervention was more common in patients who ultimately died (25.3% vs. 5.6%); however, no statistical association was found in a multivariable logistic regression model (OR 1.28, 95% CI 0.98-1.68). Compared with U.S. military personnel, other military patients were more likely to receive airway intervention after adjusting for CMI-PH (OR 1.33, 95% CI 1.07-1.64). CONCLUSIONS In the R2D, airway intervention was associated with increased odds of mortality, although this was not statistically significant. Other patients had higher odds of undergoing an airway intervention than U.S. military. Awareness of these findings will facilitate training and equipment for future management of prehospital/prolonged field care airway interventions.
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Affiliation(s)
- Ian L Hudson
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Megan B Blackburn
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Amanda M Staudt
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Kathy L Ryan
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
| | - Elizabeth A Mann-Salinas
- US Army Institute of Surgical Research is United States of America (USA), 3698 Chambers Pass, San Antonio TX 78234, USA
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Gómez-Ríos MÁ, Calvo-Vecino JM. Airway management in a prehospital combat setting. Am J Emerg Med 2018; 37:349. [PMID: 29958741 DOI: 10.1016/j.ajem.2018.06.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/21/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Manuel Ángel Gómez-Ríos
- Department of Anesthesia and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Galicia, Spain; Anesthesiology and Pain Management Research Group, Institute for Biomedical Research of A Coruña (INIBIC), A Coruña, Spain; Spanish Difficult Airway Group (GEVAD).
| | - José María Calvo-Vecino
- Department of Anesthesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, Spain
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