title: Combat trauma airway management: endotracheal intubation versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance combat corpsmen.
abstract: BACKGROUND
  Airway management takes precedence regardless of what type of life support is taking place. The gold standard for airway control and ventilation in the hands of the experienced paramedic remains unarguably the endotracheal tube. Unfortunately, laryngoscopy and endotracheal intubation require a skilled provider who performs this procedure on a frequent basis. Special Operations corpsmen and medics receive training in the use of the endotracheal tube, but they use it infrequently. The use of alternative airways by Navy SEAL and Reconnaissance combat corpsmen has not been evaluated. Our objective was to compare the ability of Special Operations corpsmen to use the endotracheal tube (ETT), laryngeal mask airway (LMA), and esophageal-tracheal combitube (ETC) under combat conditions.
  
  
  METHODS
  This study used a prospective, randomized, crossover design. Twelve Navy SEAL or Reconnaissance combat corpsmen participated in a 2-week Advanced Battlefield Trauma course. During the first week, instruction included the use of ETT, LMA, and ETC, viewing of videotapes for ETC and LMA, and mannequin training. The Special Operations corpsmen were required to reliably insert each airway within 40 seconds. During the second week, participants dealt with a number of active combat trauma scenarios under fire in combat conditions. Each SEAL or Reconnaissance corpsman was asked to control his "casualty's" airway with a randomized device. All participants were evaluated in the use of each of the three airways.
  
  
  RESULTS
  Thirty-six airway insertions were evaluated. No failures occurred. All incorrect placements were detected and corrected. Mean time to place the ETT was 36.5 seconds versus 40.0 seconds for the ETC. The LMA insertion time of 22.3 seconds was significantly shorter than the other times (p < 0.05). The mean number of attempts per device was similar with all devices: LMA (1.17), ETC (1.17), and ETT (1.25).
  
  
  CONCLUSIONS
  The Special Operations corpsmen easily learned how to use the ETC and LMA. In this study, they showed the ability to appropriately use the ETT as well as the ETC and LMA. For SEAL corpsmen, the alternative airways should not replace the ETT; however, on occasion an advanced combat casualty care provider may not be able to use the laryngoscope or may be unable to place the ETT. The LMA and ETC are useful alternatives in this situation. If none of these airways are feasible, cricothyrotomy remains an option. Regardless of the airway device, refresher training must take place frequently.
authors.affiliation: Walter Reed Army Medical Center and the Walter Reed Army Institute of Research, Washington, District of Columbia 20307, USA.
authors.forename: M D
authors.initials: MD
authors.lastname: Calkins
authors.forename: T D
authors.initials: TD
authors.lastname: Robinson
mesh_terms: D000488:Allied Health Personnel / Q000193:education; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D018592:Cross-Over Studies; D006801:Humans; D007442:Intubation, Intratracheal; D017214:Laryngeal Masks; D007828:Laryngoscopy; D009326:Naval Medicine; D011446:Prospective Studies; D014857:Warfare