Wilderness Airway Management: Keeping An Eye on the Ball

The recent report on wilderness airways was an interesting case, and the patient's life was saved by skilled and attentive care.1Wharton D.R. Bennett B.L. Surgical Cricothyrotomy in the Wilderness: A Case Report.Wilderness Environ Med. 2013; 24: 12-14Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar However, I disagree with the authors' conclusion that this suggests a need for more widespread training in wilderness operative airways. The most important element of this case was the sound reasoning behind deciding on an operative airway, and this core aspect deserves emphasis. In most circumstances, airways can be safely managed with less invasive means, thus limiting additional risk while proceeding with physiologic stabilization and evacuation. Too often, people are blinded by the opportunity to apply a procedural skill they have learned instead of concentrating on critical decision-making. Many more lives are rescued with proper use of bag-mask and suction than with intubation or tracheotomy. This general principle has recently been supported in the literature.2Hasegawa K. Hiraide A. Chang Y. Brown D.F.M. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest.JAMA. 2013; 309: 257Crossref PubMed Scopus (247) Google Scholar On a separate note, the report omits any description of what happened with the airway following hospital admission. When surgeons evaluated the airway in a controlled environment, what did they find? In particular, was the tube confirmed to traverse the cricothyroid membrane, or had it taken an unintended course? Was his voice affected? Was the cricothyrotomy converted to a formal tracheostomy, or was he immediately decannulated? If the technical success of the procedure is to be lauded, these details must be known. A wilderness provider may argue that these elements are beyond their scope, but without follow-up on our interventions, none of us can truly know how accurate or successful our actions are. Surgical Cricothyrotomy in the Wilderness: A Case ReportWilderness & Environmental MedicineVol. 24Issue 1PreviewAlthough the surgical cricothyrotomy procedure is used on combat casualties in the most challenging environments, we are unaware of any published report in the United States of surgical cricothyrotomy performed in a wilderness recreational setting. We describe a 31-year-old male rock climber who fell 24.4 m (80 feet), sustaining serious injuries and requiring rescue from the base of the cliff by a cave/cliff rescue team. Ultimately, a surgical cricothyrotomy proved necessary because of ongoing oropharyngeal bleeding, facial fractures creating an unstable airway, and the need to place the patient in the litter. Full-Text PDF In Reply to Dr Jamshidi’s LetterWilderness & Environmental MedicineVol. 24Issue 3PreviewWe would like to address the 2 general observations made by Dr Jamshidi about widespread training of the invasive skill of cricothyrotomy, and the airway clinical outcome after admission to the hospital. Our concern for enhanced cricothyrotomy training is based on recent data that identify the magnitude of the cricothyrotomy failure rates in the prehospital setting, which is primarily on the battlefield but with direct application to the wilderness setting.1 Medical care in any austere environment can be challenging and is amplified by limitations in medical resources, manpower, and delayed evacuation to definitive care. Full-Text PDF

Topic: Cardiac Arrest and Resuscitation
Subfield: Emergency Medicine
Field: Medicine
Domain: Health Sciences