2024 brought with it a lot of things: some good, some bad. Which of those categories this particular subject falls within seems to be a matter of debate.
Last month, the US DOD Joint Trauma System's Committee on Tactical Combat Casualty Care (CoTCCC) released an update to the tactical field care guidelines which last saw an update in 2017.
The major changes were to, in their words, "simplify" the airway management sequence in tactical field care, which in large part has just involved eliminating the use of extraglottic airways and providing more specific indications for surgical cricothyroidotomy.
The airway management section [1] now reads as follows:
a. Assess for unobstructed airway.
b. If there is a traumatic airway obstruction or impending traumatic obstruction, prepare for possible direct airway intervention.
c. Allow a conscious casualty to assume any position that best protects the airway, to include sitting up and/or leaning forward.
d. Place unconscious casualty in the recovery position, head tilted back; chin away from chest.
e. Use suction if available and appropriate.
f. If the previous measures are unsuccessful, and the casualty’s airway obstruction (e.g. facial fractures, direct airway injury, blood, deformation or burns) is unmanageable, perform a surgical cricothyroidotomy using one of the following:
Bougie-aided open surgical technique using a flanged and cuffed airway cannula of less than 10 mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intratracheal length.
Standard open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intra-tracheal length.
Verify placement with continuous EtCO2 capnography.
Use lidocaine if the casualty is conscious.
g. Frequently reassess SpO2, EtCO2, and airway patency as airway status may change over time.
h. Cervical spine stabilization is not necessary for casualties who have sustained only penetrating trauma.
The tactical evacuation care guidelines likewise contain the following statement:
Endotracheal intubation may be considered in lieu of cricothyroidotomy if trained.
To me, jumping directly to a surgical airway seems to put the cart before the horse. Now - in fairness - I can see some logic behind the de-emphasis of extraglottic devices. To my mind, the injured combat casualty will need an airway secured for one of two reasons.
There is maxillofacial or neck trauma, or an inhalational burn, that is causing, or is threatening to cause, a loss of airway patency.
There is a reduction in GCS due to head injury that is causing a loss of airway protection.
You could argue that there are other reasons - things like significant flail segments with respiratory compromise, where airway control is a means to achieve positive pressure ventilation, or major burns where anaesthetic induction is being performed for humanitarian reasons.
But if we think about those two core reasons to secure an airway in combat casualty care, the answer to the former probably will be securing a tube below the level of obstruction, so extraglottic devices (EGDs) may not be be sufficient - and these patients may very well require a surgical airway. After all, these patients are by definition the anatomically difficult airway.
Likewise if we think about the second reason, those patients who are sufficiently unconscious as to require intubation probably shouldn't just have an EGD for the prolonged period of time it may take to evacuate them to higher-level care.
So like I say, I can see some logic in the change in practice whereby EGDs have been removed. What I struggle to fully understand is why there's no nuance regarding the options available to medics for back-up airways (which is all it really ever was anyway), and why, once conservative measures have failed, the only option elucidated on in the guideline is to proceed straight to cricothyroidotomy.
They set out to simplify, and simplify they did. I love simplifying things as much as the next man, but there can be too much of a good thing and all. Airways probably deserve a slightly more nuanced approach (and if it being slightly more complex than "need airway? cut neck" is too complex for you, then I would suggest that perhaps securing airways in unstable patients is not for you).
There will be some patients with maxillofacial, neck, or burn injuries where airway control is necessary, but not imminently so, and orotracheal intubation may still be suitable. While these require a more nuanced approach and an understanding of the specifics one must take into consideration in securing the difficult airway, it still might be more appropriate than the black and white decision to automatically attempt cricothyroidotomy in an awake patient or to continue with conservative measures until your hand is ultimately forced (and therefore mean performing the most stressful fine motor task of your life under even more sub-optimal conditions). Yes direct laryngoscopy may be tougher, but video laryngoscopy has been used in the field for many many years now [2]. Likewise, there will be unconscious head injured casualties who are perfectly amenable to orotracheal intubation - especially given that we are usually talking about a young, fit cohort with sufficiently ample safe apnoea times to allow you to explore multiple non-mutilative options, and thereby minimise your risk of iatrogenic fratricide. This is also before we even consider all the other nebulous examples of patients who need to be intubated for all those other many and varied reasons.
But whatever technique you employ in your attempt to secure an airway, you will want a back up option. If you've never done a cricothyroidotomy before and suddenly find yourself knuckle deep in your borderline obese platoon sergeant's neck blubber, finding out how much blood can come from those little cricothyroid arteries, and more importantly not finding the cricothyroid membrane - you will want to have options.
An EGD, while not ideal, allows you breathing room (if you'll pardon the pun) to later attempt bougie exchange or even semi-elective cricothyroidotomy under more controlled conditions, with better pre-oxygenation, analgesia, and sedation. But, like many things, they have drifted in and out of vogue [3]. It's important we all practice the range of options available to us - the deployed medic may be faced with a wide variety of non-tactical airway scenarios, some of which will benefit from endotracheal intubation, and yes, maybe even an EGD.
In summary:
TLDR; Don't be a fool, carry more than one tool.
Credit:
DR1
References:
[1] Deployed Medicine. TCCC guidelines. Available from: https://deployedmedicine.allogy.net/learner/collections/11.
[2] Rush S, Boccio E, Kharod CU, D'Amore J. Evolution of pararescue medicine during operation enduring freedom. Mil. Med. 2015;180(2):68-7.
[3] Otten DJ, Montgomery HR, Butler Jr FK. Extraglottic airways in tactical combat casualty care: TCCC guidelines changes 17-01 28 August 2017. J Spec Oper Med. 2017;17(4):19-28.