Cricothyroidotomy Bottom-Up Training Review ... - Semantic Scholar

MILITARY MEDICINE, 176, 1l:1311. 2011

Cricothyroidotomy Bottom-Up Training Review: Battlefield Lessons Learned CAPT Brad L Bennett, MSC USN (Ret.)*; CDR Barbara Cailteux-ZevaJlos, NC USN (Ret.)t; LCDR Joseph Kotora, MC USN:t ABSTRACT Challenges with surgical cricothyroidotomy on the battlefield can be attri~ute~ to limited freque~cy of use, procedure unfamiliarity, and limited knowledge base of anatomicallandmru:ks of WhlC~ 1.S furthe~ ~el~hten In t~e tactical environment. The objective was to identify ways to enhance the cn7othyroldoto~y traIn~ng to m~mmlze pot~n:lal preventable procedural errors. A training review was conducted to detemune the gaps In the cncothyrOidoto~y traInIng in a 4-day Tactical Combat Casualty Care course at the Naval Medical Center Portsmouth. An ad hoc Workmg Group team identified five specific gap areas in the cricothyroido:omy training: 1) limit~d g~os~ ~rwa~ atlatomy review: 2)I~ck of "hatlds-on" humatl laryngeal anatomy; 3) nonstandardlzed step-by-step surgIcal InCISion sk~ll. procedure; 4) mfeI?-0r standards for anatomically correct cricothyroid matlnequins; 5) lack of standardized refresher traInIng frequency. S.peclfic training enhancements are recommended across each day in the classroom, simulation laboratory, atld field exerCIse.

INTRODUCTION

Background of Tactical Combat Casualty Care The evolution and status of the Tactical Combat Casualty Care (TCCC) guidelines have been extensively presented elsewhere.'-3 TCCC guidelines recognize that trauma care in the tactical environment has three goals: (I) treat the casualty; (2) prevent additional casualties; and (3) complete the mission. The TCCC project began within the Naval Special Warfare Command and continued by the U.S. Special Operations Command as a set of tactically appropriate battlefield trauma care guidelines that were initially published in 1996 and peri odically updated, most recently in November 20 lOin the sev enth edition of the Prehospital Trauma Life Support manual.,,2 On the basis of published reports and reports collected from combat first responders, use of the TCCC guidelines saves lives and improves the tactical flow of missions on which casualties have occurred. 4,5 The TCCC guidelines serve as the basis for training for deploying operational medical and com bat personnel. Airway obstruction ranks third as a preventable cause of death on the battlefield following severe hemorrhage and ten sion pneumothorax, respectively.6 In the first edition (1996) of the TCCC guidelines, aggressive use of surgical airways was recommended in the Tactical Field Care phase when maxillofa cial trauma makes the use of a nasopharyngeal airway contrain dicated and other noninvasive techniques are inadequate to open the airway. This recommendation firmly remains in place in the recent Prehospital Trauma Life Support manual (2010) release. 2 *Clinical Investigation Research Division, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth. VA 23708. tResuscitative Medicine Training Division. Staff Education and Training Department. Naval Medical Center Portsmouth, 620 John Paul Jones Circle. Portsmouth, VA 23708. *Emergency Medicine Department, Naval Medical Center Portsmouth. 620 John Paul Jones Circle, Portsmouth, VA 23708.

Recently the Armed Forces Medical Examiner System (AFMES) in collaboration with the Defense Material Medical Program Office (DMMPO) have highlighted unsuccessful battlefield trauma skill interventions through a series of eight PowerPoint presentations called Feedback to the Field (Ff2F), including two series on surgical cricothyroidotomy, as battle field lessons learned in an effort to increase the education and training of these procedures across the operational forces 7.8 (Maj Mazuchowski, USAF MC, AFMES. personal communi cation). These cases were identified via complete postmortem examinations, including multidetector computed tomography and digital x-ray, performed on all combat casualties received at the Dover Port Mortuary.9 The release of the eighth Ff2F series by the AFMES and DMMPO included 13 case presentations on cricothyroido tomy observations that were reviewed at autopsy during a 6-month period (June to December 2010). During this report ing period, it was noted that surgical airways were less fre quent than endotracheal intubation (ETI) (n = 13 vs. n 55). Furthermore, 3 of 13 surgical airway interventions were not in the trachea, but in the surrounding tissues including one tube placement in the esophagus. While other attempts were found misplaced not through the cricothyroid membrane (CM) and were unsuccessfuL8 The joint recommendation from the AFMES and DMMPO in the Fr2F series stated that each ser vice should review their training procedures and equipment for this technical skill. It is also noted by AFMES and DMMPO that the clinical circumstances and specific details surround ing the delivery of emergent care in these cases are unknown. Following the release of the first of two AFMES battle field surgical airway casualty lessons learned presentations a preliminary analysis was conducted from the Joint Theater Trauma Registry (JTTR) for surgical airway interventions in an effort to obtain some additional objective data. (LTC Robert Mabry, MC USA, U.S. Army Institute of Surgical Re search, personal communication). In brief, these preliminary

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Surgical Airway Training

data were presented to the Committee on Tactical Combat Casualty Care (CoTCCC), August 2010, outlining the num ber of surgical airways attempted, success rate, and the num ber of failed attempts into get into the trachea.lO It was noted that the surgical airway procedure was initially coded for data entry in the JTTR starting in 2007, and not from the begin ning of the Operation Enduring Freedom (OEF) conflict. This retrospective analysis (approximately 3 years) showed that a total of 72 surgical airways (72 out of 20,066 total casualties with combined Killed in Action and Wounded in Action dur ing 2007-2010; Department of Defense Casualty Statistics) were performed on the battlefield or aid station in OEF and Operation Iraqi Freedom (OIF) resulting in a 26% unsuc cessful cricothyroidotomy rate.lO These data from the JTIR are supported by indirect evidence from surgeons in the Joint Theater Trauma System who frequently brief the CoTCCC that during their surgical rotations in the operational theater they see many failed surgical airways that were attempted either, e.g., too high above the thyroid cartilage, with some attempts below the CM and other surgical airway attempts that resulted in false tissue passages running parallel to the trachea. 11 .12 Is it possible that the current approach for surgical air way training, as taught by each service and by outside con tract trauma support, is not standardized sufficiently resulting in a source of confusion to rapidly access the trachea in a most challenging battlefield environment? The key principle of this skill is successful trachea access, but the preference, how it is achieVed, may be too variable (e.g., hand and body position, varying procedure methods, multiple airway kits, inferior anatomy landmarks on airway mannequins) for far forward providers on the battlefield. Thus, the purpose of this bottom-up training review was to determine the training gaps, if any, for the cricothyroidotomy procedures in the TCCC course, Naval Medical Center Portsmouth, and, if identified, then make recommendations in an effort to standardize and enhance the TCCC training methods and prevent unsuccess ful surgical airway attempts on the battlefield.

METHODS The TCCC curriculum at the Naval Medical Center Ports mouth, Virginia (NMCP) is a 4-day course offered primarily to all Hospital Corpsman both Active Duty and Reserve and is used for initial, refresher, or predeployment trauma training. It is mandated training for all deploying Hospital Corpsmen and Physician Assistants to receive within 180 days of deploy ment. 11 On occasion, NMCP also trains other Department of Defense Uniformed and Civilian personnel who are in receipt of deployment orders. The TCCC course includes didactic classroom lectures, skill laboratory training and final skill evaluations conducted in the Medical Simulation Center, outdoor tactical movement and medical skill stations, and final field day exercise. For the cricothyroidotomy skill training, the students initially receive the standardized TCCC curriculum PowerPoint overview of these skill procedures on their Day 1 of the course. 3 The

PowerPoint includes two airway anatomy slides, 16 step by step procedure slides, and a video clip of the procedure being performed on a cadaver. Day 2 of the course involves instruc tors demonstrating the skill procedures on an airway manne quin followed by students performing each step with the aid of the TCCC cricothyroidotomy skill sheet. On Day 3, each student is evaluated on the cricothyroidotomy performance steps on a mannequin (Simulab TraumaMan System). Day 4 comprises a physical and psychological intensive trauma lane which includes tactical movement by each student to all five evaluated trauma skill stations (i.e., tactical drag and tourni quet placement, cricothyroidotomy, intraosseus device, nee dle decompression, patient drag, and a final 9-line casualty air evacuation report). At the end of the field day, an exercise debrief is conducted as a method to receive student feedback. An internal ad hoc working group at NMCP (hereafter referred to as the WG) was formed to conduct a bottom-up review of training provided for the cricothyroidotomy proce dure as part of the TCCC course. Bottom-up review refers to use of junior Hospital Corpsman, along with midgrade and senior personnel on the WG. Additionally, in this study it refers to all aspects of cricothyroidotomy training from the most basic to complex training aspects. The WG consisted of seven personnel including TCCC Course Coordinator (Fleet Marine Force Corpsman), Course Administrator (Resuscita tive Medicine Training Division Head), TCCC Medical Director (Emergency Medicine Resident and former United States Marine Corps [USMC] nattalion Surgeon), TCCC instructors (Fleet Marine Force Corpsman), and Combat Casualty Care Research Coordinator (WG Chair, and 9-year member of CoTCCC). The WG Chair, as a long-term member of the CoTCCC, sought to form an informal group of members from Fleet Marine Force corpsman, a nurse, and physicians who have direct or indirect relationship to TCCC training. All WG members have unique experience with surgical airway training and/or clinical practice within the United States Navy (USN) and USMC fleet operations, Field Medical Service School, the TCCC course, the Advance Trauma Life Support Course, Emergency War Surgery Course, and other surgi cal airway training as provided by the Emergency Medicine Department monthly vivarium skills training. The WG reviewed and/or examined all aspects of surgical airway training within the 4-day TCCC course starting with: (l) Surgical airway PowerPoint slides and video procedure; (2) Surgical airway skill evaluation sheet; (3) Items within the surgical airway kit; (4) Various types of airway mannequins available in the Simulation Center; (5) TCCC instructor meth ods for surgical airway training and final skill evaluation; and 6) Methods used to assess surgical airway skills in the field day exercise as conducted offsite in a more austere military field site. The specific intent of the WG was to identify any training gaps and areas that could be easily enhanced with out a significant addition of time in an already dense 4-day training course. The expected deliverable from the WG would be to: (1) make specific training recommendations based on

DeliverWby Publishing Technology to: Uniformed Services University of the ~'~~~rrSl) 1116: !lfS"f.~. t4 ETI attempts, or requir ing other airway procedures, inc1uding 11 surgical cricothy roidotomy (8%). Use of cricothyroidotomy on the battlefield is also reported to have low frequency of use as reported by Mabry et al (201 0),10 but this procedure is deemed essential because it well accepted that airway obstruction deaths are potentially survivable with timely intervention. 22 The Joint Theater Trauma System and JTTR were implemented for the same expected benefits as seen in the civilian trauma registry mod els for improving patient outcome~ after the point of injury on the battlefield.l3 As of April 2009, data from approximately 35,000 casualties have been entered in the JTIR from OIFI OEF conflicts. Analysis from the JTTR reveals that approxi mately 68% of battlefield casualties have penetrating injuries and 32% are from blunt injuries. This is an opposite pattern of

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TABLE I.

Cricothyroidotomy complication and prevention techniques

Complications Thyroid (Thyrohyoid) membrane incision Bleeding Subglotic Stenosis Dysphonia/hoarseness Laryngeal damage Tube misplacement in bronchus Pulmonary aspiration Tracheal stenosis Recurrent laryngeal nerve damage Esophageal perforation LaceratelFracture of thyroid or cricoid cartilage Tube occlusion with blood or secretions Tube dislodgement Creation of false tube passage into surrounding tissues

Prevention Techniques Know anatomy; vertical incision: confirm position of CM Incise over the CM in the midline; horizontal staff in the lower half of membrane; avoid thymus isthmus Use a small-bore tube (6 mm); avoid long-term use if possible (>72 hrs) Use a small tube; point inferiorly to avoid cords; avoid tracheal cartilage damage by not forcing tube; use tracheal hook on cricoid cartilage Avoid oversize tube and excessive traction on the cricQid cartilage during insertion Avoid insertion of too much of endotracheal tube (Ef) length so as not to enter the right main bronchus Protect the upper airway by suction and positioning Use low pressure balloon cuff Staff midline and avoid the posterior subglottic wall by not inserting instruments too far Do not insert scalpel blade deeply 1.3 cm «0.5 in) Do not make initial incisions deeply into the cartilages; avoid oversize tubes Monitor ventilation and oxygen saturation; feel for air movement through tube Maintain positive control until tube is secure; cut down ET tube; monitor insertion depth on tube Know anatomy landmarks; assess airflow through tube, monitor ventilation and oxygen saturation

what is reported in U.S. civilian trauma centers. Of the cases reporting cricothyroidotomy intervention, most cases were conducted on premorbid casualties resulting in a limited ben efit from a surgical airway intervention as reported at autopsy. Of those casualties with airway obstruction from improvised explosive device blast or gun shot wound (GSW) to the face or neck that present with a high Glasgow Coma Score, a cri cothyroidotomy procedure is reported to be lifesaving in these cases. (LTC R. Mabry, MC, US Army Institute of Surgical Research, personal communication). Mabry et al (2010) reported that 18 of 982 cases (1.8%) during a 3-year period (2003-2006) had significant airway compromise as the likely primary cause of death.24 Of these 18 cases with traumatic injury to the face and neck, 12 had GSWs, with seven sustaining single GSW and five casualties sustaining multiple GSWs, while six deaths were the result of explosions. There were nine casualties with multiple inju ries to major vascular structures and significant airway hemor rhage. In five of nine cases (56%), it was noted at autopsy that there was evidence of a surgical cricothyroidotomy, but all were unsuccessful, i.e., no trachea access. These preliminary data from the J'ITR show that the use of cricothyroidotomy is infrequent as reported in the prehospital setting in the civilian emergency medical service. Unsuccessful surgical cricothyroidotomy can be attributed to a number of factors, e.g., lack of familiarity with the proce dures, inadequate teaching of the underlying anatomy, limited hands-on training with human anatomical landmarks, inade quate human training simulation models, and low refresher training frequency.25 Each one of these factors is deemed to be essential to perform this procedure successfully. Other circumstances influencing timely delivery and effective bat tlefield care are the multitude and severity of the casualty's injuries (polytrauma), the total number of casualties, ongo

ing tactics and situational confusion, low light or blackout conditions, environmental extremes, rugged terrain, limited resources of personnel and supplies, and fatigue, to name a few. Even though it is noted in many cases that the cricothy roidotomy was unsuccessful, it is not clear in J'ITR retrospec tive analysis why this procedure was unsuccessful. Was it due to a surgical attempt, but failed to correctly access the tra chea, or that the casualty died because it was an unsuccess ful attempt? It could also be a slllccessful trachea access, but the casualty died anyway due the associated vascular trauma, as was the most likely scenario in the five unsuccessful cases presented by Mabry et al (2010).14 The review by the WG identified five specific areas for enhancing cricothyroidotomy trqining that have in common a deficit in knowledge and exposure to gross airway anat omy and lack of a standardized step by step surgical incision procedure. With the low frequency of skill use, no set standard time line for refresher skill training, lack of laryngeal anatomy familiarity, and a trauma management procedure typically conducted in an emergent situatiM on the battlefield, a stan dardized step-by-step procedure should be taught. The liter ature describes many techniques, many cricothyroidotomy tools, and approaches for gainini airway access through the eM, but not all are equally effective or applicable on the bat tlefield. 26 Thus, the surgical cricothyroidotomy technique is the preferred method to gain a definitive airway by corps man/medics with minimal amount of equipment and with the minimal amount of steps to gain access through the CM. An excellent presentation of an emergency cricothyroidotomy procedure from Hsiao and Pacheco-Fowler (2008) and the accompanying online clinical video can be easily adapted with slight modifications for battlefield use by corpsman/medic. 27 These steps presented below are written for a right-handed

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Surgical Ainvay Training

provider. The opposite directions would be used in left-hand dominate provider:

TABLE II.

Preferred features for cricothyroidotomy kits·

An open technique is preferred over percutaneous or Seldinger techniques The set or its individual components must be FDA-approved - Place patient in a supine position with neck in a neutral Sterile position.

Scalpel: number 10 blade Kneel to the right side at the casualties shoulder

Should include a tracheostomy hook or other similar instrument position.

5 cc syringe to inflate cuff Puncture resistant packaging - Assemble surgical cricothyroidotomy equipment and Long shelflife prepare the skin for an incision. See Table II for TCCC Lightweight, durable material preferred equipment recommendations. Ruggedized-(Military Standard 8.1(0) - Palpate the thyroid notch. thyroid and cricoid carti Inexpensive lages, cricoid membrane. and sternal notch for anatomi Minimized weight and cube Good clinical outComes after review of battlefield use data cal orientation. Easy to use in battlefield environment - If swelling is present, the CM may be estimated to be High rate of user acceptance about 2 to 3 ern (-0.75-L25 in.) inferior to the laryngeal Configured for ease of use in low-light environments prominence or 4 finger breadths above the sternal notch. Devise to secure tube after insertion - With the left hand. stabilize the trachea and keep the "Note: The CoTCCC is working closely with the Defense Medical Material skin taut over the thyroid cartilage with middle finger Program Office, Fort Detrick, MD, to select preferred features of trauma and thumb-palpate the cricoid membrane with index equipment for use in the tactical setting. Reference: Fulton J. Preferred finger (See Fig. 2). Features for Cricothyroidotomy Kits. Co'I'CCC Meeting Minutes. Edited by Butler FK Jr., April 20, 2010. Available at www.health.milffCCC. - With right hand, make a 2.5 cm (1.0 in.) vertical inci sion midline through the skin and subcutaneous tissues down to the thyroid and cricoid cartilages, and palpate the CM with left index finger again to confirm correct location. a) Greater opportunity to locate CM if incision not opti mally placed and can easily be extended as needed b) Minimizes bleeding complications c) A vertical incision will avoid injury to the recurrent laryngeal nerves, which run parallel to the trachea d) Best method to locate anatomical landmarks after the initial vertical incision in a severely traumatized neck and face With right hand, turn the scalpel horizontally to the midline and make a transverse stab 1.5 ern (-0.5 inches) through the lower half of the CM just superior to the cricoid cartilage. Make sure only the lower 1.3 cm ( -0.5 FIGURE 2. Correct hand placement for surgical incision (Redrawn from in.) portion of the scalpel enters into the airway to avoid Rosen P, Chan TC, Vilke GM, Sternbach G [eds.1: Atlas of Emergency trauma to the posterior side of the trachea. To minimize Procedures, 2001). the risk of esophageal perforation, hold the scalpel between your thumb and index finger, and allow your middle finger to extend down the side of the scalpel, location will minimize the risk of vocal cords trauma as leaving the distal 1.3 cm of the blade exposed. On the compared to tracheal hook placement on the edge of the basis of the diameter of the tube (5.0-7.5 mm), extend thyroid cartilage with slight upward (cephalic) traction. the incision no greater than 1 cm (-0.5 inches) on each - Insert the cuffed 6.0-mm endotracheal tube (ET) or tra side of the midline (avoid critical vasculature) to facili cheostomy tube through the opening and direct the tube tate tube entry. distally toward into the trachea (see Fig. 3). Maintain firm control of the tube at all times until secured to pre - Without removing the scalpel from the airway (never vent dislodging of the tube. remove a blade until hook is securely inside trachea) Inflate the cuff with the 100c syringe. Assess air move and with the left hand insert the tracheal hook into the inferior portion of the opening, hook the cricoid carti ment through the tube. As needed, apply suction to the lage edge, and pull slight traction downward (caudally) tube to remove blood or secretions to keep tube patent. Look for symmetric chest rise and fall. toward the patient's feet. Once the hook is in place, If an ET is used in place of a tracheostomy tube, make remove the scalpel blade. Placement of the tracheal sure the tube is not inserted to a depth of more than 2 to hook on the cricoid cartilage is preferred since this

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FIGURE 3. Correct orientation of the tracheostomy tube through cricothy roid membrane (Redrawn from Rosen P, Chan TC, Vilke GM. Sternbach G [eds.]: Atlas of Emergency Procedures, 2001). PoIp... tbe tbyrold Mteh, thyrotd aud cricoJd cartllag£5,

3 cm (-0.75-1.25). Deeper placement of the tube may cause it to go down the right mainstem bronchus. Secure ET tube with roller gauze by creating a girth hitch knot (a girth or cow hitch knot is used to attach a rope to an object) around the ET tube and taking both ends of the gauze around each side and under the patient's neck and secure around the ET tube. The use of an effective commercial device around the ET tube is an acceptable method. These procedural steps (see Fig. 4 Cricothyroidotomy Algorithm) follow the preferred surgical cricothyroidotomy technique on the battlefield or forward based military surgi cal unit, which is based on disrupted anatomy or the loss of anatomical landmarks from an improvised explosive device blast, or a high velocity gun shot wound to the face and neck as described recently in the textbook on War Surgery in Afghanistan and Iraq, and as stated by others. 28- JO Because of the large variation of surgical airway kits and tools, two surgical approaches to access the trachea through the CM, inferior laryngeal anatomy on airway mannequins and potentially a large variation for how each military service teaches cricothyroidotomy in the initial training school houses, TCCC courses, refresher training locations, Advanced Trauma Life Support courses, Emergency War Surgery courses, and contracted TCCC trauma training, are all potential sources of variation in what should be a training standard. The detailed procedures and supporting video by Hsiao et al and the recom mendations by others are a more consistent training standard to pursue for all operating forces. This is in effort to minimize the variability in training and the potential unsuccessful sur gical airway attempt far forward on the battlefield and in the aid stations before casualty arrival at an echelon oLcare with surgical service. 27- 3o Simulation training for cricothyroidotomy and other trauma skills is an integral part of combat trauma training. At present, it is not known what proportion of corpsman/medics receive training experience on mannequin simulation only or

cricoid membnloc

,--__J::===:::::;---j With tke nou"iJomlllate band

stabilize tlte trachea and k.eep

tile skin taut over tbe thyroid , canDage

FIGURE 4.

If swell~ng " preteDt, tbe crh:oVtyroid membrltne may be ettlmated to be aboot 2

to 3 cmiillferlor to t!teJaryngeal promh:\eoce or 4 finger breadth. above tbe lItemallOOteD

Standardized surgical cricothyroidotomy algorithm.

with some form of live tissue models as the standard for air way obstruction, hemorrhage coatrol, and other trauma man agement procedures for final preparation before deploying to a theater of operation. Live tissue trauma training for deploy ing Hospital Corpsman was recently highlighted as "rec ommended" by the Navy Surgeon General in a recent Navy Bureau of Medicine and Surgery pre deployment trauma train ing matrix (NAVMED Policy 10-012, August 09, 2010).31 The implementation of the Navy Medicine policy along with these additional cricothyroidotomy training enhancements will provide a greater sense of competence and confidence in corpsman and medics with this essential battlefield trauma procedure. The WG Chairman briefed the CoTCCC at the November 11, 2010, quarterly meeting with sp~cific recommendations how the TCCC curriculum should be updated to reflect these changes in the surgical airway didactic, video, skills training, and evaluation sections. 32 Consequently, the outcome of recent briefs on surgical air way training, preliminary battlefield intervention data, and procedure outcomes as noted by JITS surgeons, the CoTCCC has listed surgical airway training in the 2011 battlefield Trauma Care RDT&E priority list for eventual approval by the Defense Health Board, a senior advisory board to the Assistant Secretary of Defense Health Affairs. 10-12,32,33

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The WG recommends additional studies to evaluate corps man/medics skill enhancement of objective criteria by con trasting efficiency, competence, and skill retention with the use of mannequins and live tissue models. Currently, a Program Announcement called for the development of a Combat Casualty Training Consortium (CCTC). The CCTC will make future recommendations using models such as animalsnive tissue and simulation-based systems to replicate the perfor mance of life saving trauma procedures and skills, including cricothyroidotomy, by comparing animalnive tissue models that may be used currently for trauma training and education with those of technology-driven, simulation-based systems. Over a 3-year period, the CCTC will make recommendations to the newly formed Armed Forces Simulation Institute of Medicine for the best currently available trauma skill simula tion, gap areas in simulation trauma technology, and for spe cific recommendation for future directions in trauma training using simulation technology and/or live tissue models. 34 CONCLUSION The outcome of this bottom-up review of cricothyroidotomy training provided at NMCP as part of the TCCC course allows for key enhancements that emphasize identification of ana tomicallandmarks and hands-on human laryngeal assessment. These factors are known limitations for rapid and effective cri cothyroid airway intervention. In general, corpsman/medics get minimal anatomy review for this procedure and receive few practice sessions before the final skill evaluation, which is typically conducted with poor quality and misleading simu lated laryngeal anatomy in airway mannequins. The WG is in agreement with AFMES and DMMPO recommendations that all services should consider reviewing surgical airway training procedures and equipment. It is essential that all providers of surgical cricothyroido tomy: (1) Learn the critical anatomical landmarks for this procedure and practice in austere settings; (2) Train with a stan dardized cricothyroidotomy procedure; (3) Obtain annual (at a minimum) refresher training; (4) Use effective and anatomi cally correct cricothyroidotomy simulators (Le., mannequins) and/or live tissue training models. These training recommen dations are easily incorporated into any cricothyroidotomy training and/or TCCC course. Finally, it is recommended that the CoTCCC accept these recommendations, as briefed in November 2010, and make changes to enhance the current sur gical airway training PowerPoint slides, skill sheet evaluation, and provide an improved surgical airway video consistent with procedural recommends in the theater of operation. 30 ACKNOWLEDGMENTS The authors greatly appreciate the manuscript review and comments by CDR Lanny Littlejohn, MC USN. Additionally, authors are grateful for the assistance and motivation of the Naval Medical Center Portsmouth TCCC Instructor Staff: HM2 (FMFIPJ) H. K. Jones, USN, Course Coordinator, Tactical Combat Casualty Care course, HM3 (FMF) T. Harris, USN, and HM3 (FMF) C. Hutchison, USN.

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Surgical Airway Training 23. Eastridge B1, Costanzo G,1enkins D. et al: Impact of joint theater trauma system initiatives on battlefield injury outcomes. Am 1 Surgery 2009; 198: 852-7. 24. Mabry RL, Edens JW, Pearse L. Kelly JF, Harke H: Fatal airway inju ries during Operation Enduring Freedom and Operation Iraqi Freeedom. Prehosp Emerg Care 2010; 14(2): 272-7. 25. Boon JM, Abrahams PH, Meiring JH, Welch T: Cricothyroidotomy: a clinical anatomy review. Clin Anat 2004; 17: 478-86. 26. Scare I, Wollard M: Needle vs. surgical cricothyroidotomy: a short cut to effective ventilation. Anaesthesia 2006; 61: 962--74. 27. Hsiao J, Pacheco-Flower V: Cricothyroidotomy. NEJM 2008; 358: e35. 28. DiGiaccomo JC, Neshat KK. Angus G. et al: Emergency cricothyrotomy. Mil Med 2003; 168: 541-4. 29. Macdonald JC. Tien HCN: Emergency battlefield cricothyroidotomy. CMAJ 2008; 178: 1133-5. 30. Nessen SC. Lounsbury DE. Hetz SP (editors): Emergency surgical air way management. In: War Surgery in Afghanistan and Iraq-A series

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of cases 2003-2007. Washington, DC, Office of The Surgeon General. United States Army; Borden Institute, Walter Reed Army Medical Center, 2008. Bureau of Medicine and Surgery. Predeployment Trauma Training for Deploying Navy Medical Department Personnel, NAVMED Policy 10-012, August 09, 2010. Bennett B: Surgical Airway Training. Committee on Tactical Combat Casualty Care Meeting Minutes. Edited by Butler FKIr., November 16. 2010. Available at http://www.healtb.mil/tccc; accessed May 09,2001. Butler F: Battlefield Trauma Car~ RDT&E Priorities. Appendix 1, Committee on Tactical Combat Casualty Care Meeting Minutes. Edited by Butler FK Jr.• November 16.201 Q. Available at http://www.health.mill tcce; accessed May 09, 2011. JPCl-MedSim Combat Casualty Training Consortium. Funding Opportunity Number: W81XWH-1O-HJPC-MedSim-CCTC. U.S. Army Medical Research and Material Command. Available at http://www. grants.gov; accessed May 09. 2011.

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