Fatal Airway Injuries during Operation Enduring Freedom and Operation Iraqi Freedom

Introduction. Airway compromise is the third leading cause of potentially preventable death on the battlefield. An understanding of the injuries associated with fatal airway compromise is necessary to develop improvements in equipment, training, and prehospital management strategies in order to maximize survival. Objective. To determine injury patters resulting in airway compromise in the combat setting. Methods. This was a subgroup analysis of cases previously examined by Kelly and colleagues, who reviewed autopsies of military personnel who died in combat in Iraq and Afghanistan between 2003 and 2006. Casualties with potentially survivable (PS) injuries and deaths related to airway compromise previously identified by Kelly et al. were reviewed in depth by a second panel of military physicians. Results. There were 982 cases that met the inclusion criteria. Of these, 232 cases had PS injuries. Eighteen (1.8%) cases were found to have airway compromise as the likely cause of primary death. All had penetrating injuries to the face or neck. Twelve deaths (67%) were caused by gunshot wounds, while six deaths (33%) were caused by explosions. Nine cases had concomitant injury to major vascular structures, and eight had significant airway hemorrhage. Cricothyroidotomy was attempted in five cases; all were unsuccessful. Conclusion. Airway compromise from battlefield trauma results in a small number of PS fatalities. Penetrating trauma to the face or neck may be accompanied by significant hemorrhage, severe and multiple facial fractures, and airway disruption, leading to death from airway compromise. Cricothyroidotomy may be required to salvage these patients, but the procedure failed in all instances in this series of cases. Further studies are warranted to determine the appropriate algorithm of airway management in combat casualties sustaining traumatic airway injuries.