Journal of Pediatric Surgery 53 (2018) 352–356

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Definitive airway management after prehospital supraglottic rescue

airway in pediatric trauma☆
Matthew C. Hernandez b, Ryan M. Antiel a, Karthik Balakrishnan c, Martin D. Zielinski b, Denise B. Klinkner a,⁎
a
Department of Pediatric Surgery, Mayo Clinic, Rochester, MN
b
Department of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN
c
Department of Otolaryngology, Mayo Clinic, Rochester, MN

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Supraglottic airway (SGA) use and outcomes in pediatric trauma are poorly understood. We com-
Received 3 October 2017 pared outcomes between patients receiving prehospital SGA versus bag mask ventilation (BVM).
Accepted 4 October 2017 Methods: We reviewed pediatric multisystem trauma patients (2005–2016), comparing SGA and BVM. Primary
outcome was adequacy of oxygenation and ventilation. Additional measures included tracheostomy, mortality
Key words: and abbreviated injury scores (AIS).
Supraglottic airway
Results: Ninety patients were included (SGA, n = 17 and BVM, n = 73). SGA patients displayed increased median
Trauma
Pediatric
head AIS (5 [4–5] vs 2 [0–4], p = 0.001) and facial AIS (1 [0–2] vs 0 [0–0], p = 0.03). SGA indications were mul-
Prehospital tiple failed intubation attempts (n = 12) and multiple failed attempts with poor visualization (n = 5). Median
ATLS intubation attempts were 2 [1–3] whereas BVM patients had none. Compared to BVM, SGA patients demonstrat-
ed inadequate oxygenation/ventilation (75% vs 41%), increased tracheostomy rates (31% vs 8.1%), and increased
24-h (38% vs 10.8%) and overall mortality (75% vs 14%) (all p b 0.05).
Conclusions: Escalating intubation attempts and severe facial AIS were associated with tracheostomy. Inadequacy
of oxygenation/ventilation was more frequent in SGA compared to BVM patients. SGA patients demonstrate poor
clinical outcomes; however, SGAs may be necessary in increased craniofacial injury patterns. These factors may
be incorporated into a management algorithm to improve definitive airway management after SGA.
© 2017 Elsevier Inc. All rights reserved.

Inadequate airway management may lead to cardiovascular arrest
and complicate subsequent life-saving interventions in the injured pa-
tient [1]. Several airway control devices and techniques are available
to assist prehospital providers in order to maintain ventilation and oxy-
genation. These include bag valve mask (BVM) ventilation, direct laryn-
goscopy with endotracheal intubation (ETI) and adjunct supraglottic
airway devices such as the laryngeal mask airway, Combitube, and
King Airway Device (King LT-D; King Systems, Noblesville, IN) [2]. De-
spite the variety of options available to secure the airway, there is a pau-
city of data evaluating the outcomes of supraglottic rescue airway
devices, especially in pediatric trauma.
In the pediatric population, prehospital airway interventions may
not be superior to BVM ventilation. Previous work has demonstrated
moderate prehospital ETI failure rates with subsequent tube malposi-
tion [7–11]. These studies concluded that prehospital pediatric
☆ The authors have no financial conflicts for the generation of this work. This research
did not receive any specific grant from funding agencies in the public, commercial, or
not-for-profit sectors.
⁎ Corresponding author at: Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
E-mail addresses: Hernandez.matthew@mayo.edu (M.C. Hernandez),
Antiel.ryan@mayo.edu (R.M. Antiel), Balakrishnan.karthik@mayo.edu (K. Balakrishnan),
Zielinski.martin@mayo.edu (M.D. Zielinski), Klinkner.denise@mayo.edu (D.B. Klinkner).
advanced airway interventions may not be necessary to achieve ade-
quate ventilation/oxygenation while also recognizing that a proportion
of patients may require advanced airway control maneuvers, including
supraglottic rescue airway insertion. Supraglottic rescue airway devices
may provide an alternative method to achieve airway control. Currently,
no studies (1) describe supraglottic rescue airway utilization in pediat-
ric trauma patients or (2) compare this adjunct to the standard of care
(BVM). This makes it difficult to estimate how these devices might affect
airway and trauma outcomes [12].
Supraglottic rescue airways provide more facile airway control for
difficult airway patients. However, they are not without risk and may
have size limitations in smaller pediatric patients [2,13–15]. Complica-
tions from insertion range from malposition to dislodgement [16–18].
Furthermore, the optimal method for safe transition to a definitive air-
way and the most appropriate definitive airway type have yet to be de-
termined [19,20]. Therefore, the objective of this study is to compare
outcomes, specifically adequacy of oxygenation and/or ventilation at
time of admission among pediatric patients who received prehospital
supraglottic airways versus BVM ventilation. We hypothesize that pa-
tients with increased craniofacial injury patterns and difficult airways
in the prehospital setting would be more likely to require advanced air-
way techniques, including surgical tracheostomy, as a definitive airway.

https://doi.org/10.1016/j.jpedsurg.2017.10.004
0022-3468/© 2017 Elsevier Inc. All rights reserved.
 M.C. Hernandez et al. / Journal of Pediatric Surgery 53 (2018) 352–356
1. Methods
1.1. Patient identification
This study was approved by the Mayo Clinic Institutional Review
Board. We performed a single center retrospective study that examined
patients who were ≤18 years old and incurred multisystem trauma dur-
ing 2005–2016. Multisystem trauma was defined as an Injury Severity
Score of ≥9. Patients were identified from the Mayo Clinic Trauma Cen-
ter database for (1) insertion of a supraglottic rescue airway (King
Airway Device, King LT-D, Noblesville, IN) or (2) prehospital bag valve
mask ventilation (BVM) with subsequent endotracheal intubation
(ETI) in the resuscitation bay after airway evaluation. Patients who re-
ceived endotracheal intubation in the prehospital setting, received a
supraglottic rescue airway device other than a King LT-D, refused con-
sent to research, and who did not display multisystem trauma (ISS
b9) were excluded.
1.2. Institutional prehospital airway care
Patients were transported by rotor wing or via ground transporta-
tion. Patients that were transported by rotor wing received care from
critical care trained flight nurses. Patients that were transported via
ground transportation received care from paramedics. At our institu-
tion, injured patients that require advanced prehospital airway man-
agement meet criteria for our highest level trauma team activation.
Emergency Medicine, Surgery, and Anesthesia physicians are present
in the trauma resuscitation bay at patient arrival. For patients
≤ 14 years of age, the pediatric surgeon responds within 15 min, and
the pediatric critical care physician also responds. Each prehospital air-
way intervention is reviewed in detail by the directors of Medical Trans-
portation, Emergency Medicine, Trauma Surgery, and Anesthesia. A
prehospital advanced airway control algorithm has been defined and
implemented by this group for standardized practice and safe patient
care. See Fig. 1.
1.3. Primary outcome and secondary predictors
Primary outcome was adequacy of oxygenation and ventilation at
the time of hospital arrival. Inadequate oxygenation saturation was de-
fined as (b 92%) using pulse oximetry or a partial pressure of carbon di-
oxide (PCO2) of (N 45 mmHg) using arterial blood gas. Secondary
outcomes included need for tracheostomy, mortality and abbreviated
injury scores (AIS). Patient demographics, transportation method and
duration, traumatic mechanism, trauma severity (ISS and abbreviated
injury scores (AIS)), admission vital signs (heart rate, respiratory rate,
systolic and diastolic blood pressure and oxygen saturation), Glasgow
Coma Score (GCS), 24 h and overall mortality, frequency and type of
prehospital airway complications, and number of prehospital airway at-
tempts, durations of intensive care, mechanical ventilation and overall
hospital stay were abstracted from the electronic record.
1.4. Statistical analyses
Summary statistical and univariate analyses were performed. Con-
tinuous variables were described using means with standard deviations
(SD) if normally distributed and medians with interquartile ranges
[IQR] for non-normally distributed data. Two-tailed t-tests were per-
formed between prehospital airway groups (supraglottic rescue airway
versus BVM with subsequent inpatient ETI). In order to assess which
factors were associated with an increased need for surgical definitive
airway (open tracheostomy), logistic nominal regression was applied
to statistically significant and clinically important variables. Categorical
variables were summarized as proportions, and differences were evalu-
ated using chi-square analysis. Statistical inferences were based on 2-
tailed tests with significance set at P b 0.05. All patients meeting
353
inclusion criteria were included in the analysis; a priori power analysis
was not performed owing to lack of data to suggest an appropriate effect
size for the primary outcome of tracheostomy. Data were analyzed with
JMP (SAS Institute, Inc. Cary NC). We utilized GraphPad Prism
(GraphPad Software, Inc. La Jolla CA) for all visual graphics.
2. Results
2.1. Patient characteristics
The study population consisted of 90 patients with multisystem
trauma. Of these, 17 patients received prehospital supraglottic rescue
airway insertion and 73 BVM with subsequent inpatient ETI. Inadequate
oxygenation and ventilation were demonstrated more frequently in pa-
tients that required supraglottic rescue airway (75%) compared to BVM
(41%), p = 0.01. Table 1 presents patient demographics, admission vital
signs, and measures of trauma severity between the supraglottic rescue
airway and BVM groups. Sixty percent of patients were male. Between
prehospital airway groups, patients that received a supraglottic rescue
airway demonstrated increased head AIS scores compared to those re-
ceiving BVM (median [IQR]: 5 [4-5] versus 2 [0–4]. p = 0.001). Similar-
ly, facial AIS scores were increased in patients receiving supraglottic
rescue airways (median [IQR]: 1 [0–2]) compared to those with BVM
(0 [0–0]), p = 0.03). Finally, patients that received BVM demonstrated
increased rates of tachycardia compared to those managed with
prehospital supraglottic rescue airways (p = 0.01). There were no sig-
nificant differences between prehospital airway groups for patient sex,
age, blunt traumatic mechanism, transport duration, cervical AIS, oxy-
gen saturation at admission, respiratory rate, systolic or diastolic blood
pressure.
a. Prehospital airway outcomes
Among the 17 patients, the indications for supraglottic rescue air-
way were multiple failed intubation attempts (n = 12) and multiple
failed attempts with poor visualization (n = 5). Two cases of craniofa-
cial trauma and three cases oropharyngeal trauma specifically affected
airway visualization and thus prevented the successful placement of
an endotracheal tube, leading to the insertion of a supraglottic airway
device. In patients that received a prehospital supraglottic rescue air-
way, the overall median number of prehospital attempts at endotrache-
al intubation was 2 [1-3]. There was a significant increase in the median
number of prehospital attempts at endotracheal intubation in patients
who received surgical tracheostomy compared to endotracheal tube in-
tubation (3 versus 2, p = 0.01). Conversely, no patient receiving BVM
(n = 73) had an attempt at ETI; none of these patients experienced a
prehospital airway related complication. At admission to the trauma
resuscitation bay, the indications for ETI were copious vomiting in 3
patients and decreased Glasgow coma score (b 8) in the remaining 70
patients.
2.2. Definitive airway and overall outcomes
After prehospital transport, all patients were evaluated by a multi-
disciplinary trauma team in the resuscitation bay per our institutional
protocol (Fig. 1). The rate of tracheostomy was increased in patients
with prehospital supraglottic rescue airway compared to those with
BVM and inpatient ETI (31% versus 8%, p = 0.02). The patients that re-
quired tracheostomy after BVM and inpatient ETI (n = 3) were because
of prolonged ventilator requirements. The twenty-four hour mortality
was increased in patients with supraglottic rescue airways compared
to BVM (38% versus 10.8%, p = 0.01). The overall mortality rate was dra-
matically increased in patients receiving prehospital supraglottic rescue
airway (75%) compared to BVM (14%) p = 0.0001, Table 2. The causes of
mortality between prehospital airway groups are outlined in Table 3.
There were three cases of subglottic narrowing diagnosed via laryngos-
copy in patients that received BVM and subsequent inpatient ETI. There
354 M.C. Hernandez et al. / Journal of Pediatric Surgery 53 (2018) 352–356

Fig. 1. Institutional prehospital transport airway management algorithm (after first failed attempt).

were no significant differences in intensive care duration of stay or ven-
tilator days between prehospital airway groups, Table 2. There was,
however, an increased duration of total stay in patients that received
BVM with subsequent inpatient ETI compared to prehospital
supraglottic rescue airway insertion (median [IQR]: 6 [3–14] versus 4
[1–6], p = 0.01), which is expected given the lower mortality rate for
this group. Table 4 reports independent risk factors for requiring surgi-
cal tracheostomy after prehospital airway interventions. Placement of a
supraglottic rescue airway, increased number of attempts at ETI in the
prehospital setting, and an elevated (≥ 3) facial AIS were all indepen-
dently associated with the use of surgical tracheostomy as a definitive
airway (p b 0.05). When combined, this group of predictors produced
an R2 of 0.73, explaining 73% of the variation in tracheostomy risk.
3. Discussion
This study represents the first comparison of prehospital supraglottic
rescue airways and bag valve mask ventilation among pediatric trauma
 M.C. Hernandez et al. / Journal of Pediatric Surgery 53 (2018) 352–356 355

Table 1
Patient characteristics in those receiving prehospital airway interventions; values are reported as medians with [interquartile range] unless specified.

Variable All (n = 90) Supraglottic (n = 17) BVM P value

(n = 73)

Sex, female, n (%) 36 (40) 3 (18) 32 (43) 0.06

Age 14 [4–17] 16 [10–17] 13 [4–17] 0.4
Blunt n (%) 79 (88) 12 (75) 67 (91) 0.2
Transport duration (minutes) 26 [15–41] 24 [12–33] 27 [17–42] 0.4
ISS 26 [19–34] 28 [25–44] 26 [17–34] 0.1
Head AIS 3 [0–5] 5 [4–5] 2 [0–4] 0.001
Face AIS 0 [0–1] 1 [0–2] 0 [0–0] 0.03
Cervical AIS 0 [0–0] 0 [0–0] 0 [0–0] 0.5
Glasgow Coma Score 4 [3–7] 3 [3–3] 3 [3–5] 0.1
Oxygen Saturation 99 [90–100] 93 [71–93] 99 [94–100] 0.1
Partial Pressure Carbon Dioxide 42 [36–49] 46 [42–50] 41 [36–48] 0.3
RR 22 [18–26] 19 [16–26] 23 [19–26] 0.1
HR 111 [88–129] 90 [48–114] 112 [91–130] 0.01
SBP 113 [93–132] 98 [72–121] 115 [97–134] 0.1
DBP 69 [58–83] 68 [25–73] 71 [58–84] 0.2

patients. We highlight the specific challenges, potential prehospital air-
way complications, and important clinical outcomes among patients re-
ceiving supraglottic airway insertion. While both groups in this study
displayed similar overall injury patterns, the need for tracheostomy was
increased in patients with increased craniofacial injury patterns. Specifi-
cally, increased craniofacial injury scores reflected by AIS N 3 in the
head, face, and neck; the number of attempts at endotracheal intubation
prior to supraglottic airway deployment; and utilization of a supraglottic
rescue airway all predicted definitive airway management using surgical
tracheostomy. The combination of these factors explained nearly three
fourths of the variation in subsequent tracheostomy placement. More-
over, both prehospital BVM ventilation and supraglottic rescue airway
demonstrate inadequate oxygenation or ventilation at time of admission
(40%–75%). This was increased in patients that received supraglottic res-
cue airways compared to BVM ventilation. Beyond these results, this anal-
ysis provides an initial exploratory query into the role of adjunct airways,
the complication profile, and subsequent definitive airway management
in the pediatric trauma population.
Airway assessment and control are a primary objective during trau-
ma resuscitation [21]. In the setting of a supraglottic airway and trauma,
minimal evidence exists to guide definitive airway management for
children and adolescents [12,22]. One recent analysis evaluating adults
with supraglottic airways found that an overwhelming majority of pa-
tients had their supraglottic airway exchanged for an endotracheal
tube [23]. However, the majority of these patients underwent medical
resuscitations, not necessarily trauma. The mixture of trauma and med-
ical resuscitation patients complicates the identification of optimal
methods for definitive airways after supraglottic airway utilization. A
strength of this analysis is that our cohort is restricted to multisystem
pediatric trauma patients.
Our findings will play an important role guiding prehospital trans-
port, the goal of which is preventing further injury and expediting trans-
port to definitive care [24]. Airway adjuncts, such as the King LT™,
provide temporary restoration of oxygenation and ventilation for
Table 2
Comparison of outcomes by prehospital airway type; values are reported as medians with
[interquartile range] unless specified.
Variable Supraglottic airway BVM ventilation
(n = 17) (n = 73)
difficult airway patients [3–6,25,26]. Previous work demonstrates infe-
rior outcomes of endotracheal intubation compared to bag valve mask
oxygenation in pediatric patients [27–30]. These findings were further
confirmed demonstrating that patients with intubation did not display
superior outcomes compared to BVM patients [7]. Despite this litera-
ture, some patients will require advanced airway care in the prehospital
setting [1]. Our study confirms that for some multisystem pediatric
trauma patients, the standard of care (BVM) may not safely provide air-
way control, necessitating placement of a supraglottic device.
While the prehospital setting provides airway control and triaged in-
terventions, definitive care and focused management according the Ad-
vanced Trauma Life Support protocols are the critical next step. An
actionable definitive airway plan must be defined and executed amidst
multiple organ system priorities. Since definitive airway management is
poorly understood, especially in pediatric trauma patients, this current
investigation provides useful preliminary data to suggest further analy-
ses. This comparison of similarly injured patients with airway control
provided by prehospital BVM versus supraglottic airway insertion
found that increased craniofacial injury, prehospital ETI attempts, and
need for supraglottic rescue airway were all independently associated
with later surgical tracheostomy as a definitive airway. This analysis
provides evidence to suggest that a prospective analysis of appropriate
pediatric definitive airway management after supraglottic device inser-
tion is needed. Recognition of patients who require advanced airway
management and definitive airway control with a surgical airway may
prevent unnecessary placement of tracheostomy and permit more indi-
vidualized decision-making for patients requiring supraglottic rescue
airways [31].
There are several limitations to this study. This is a retrospective sin-
gle institutional study focusing on small but specific subset of pediatric
patients. Only one device, the King LT, was used and may not be equiv-
alent to a laryngeal mask airway. Anecdotally, the EMS practice has
shifted to use of the i-Gel (Intersurgical, East Syracuse, New York)
with no attempts at ETI, which may decrease the additional trauma to
the airway (verbal communication). Review of these other devices
and comparison of different supraglottic devices in this clinical context
would add to our understanding of best practices for pediatric airway
management in the trauma patient and may change institutional
prehospital algorithms. Future research is necessary to confirm these
P value findings through a more controlled analysis. Despite these limitations,

Overall Duration of Stay (d) 4 [1–6] 6 [3–14] 0.01

Mechanical Ventilation (d) 2 [1–4] 2 [1–2] 0.4 Table 3
ICU duration of stay (d) 3 [1–5] 2 [1–7] 0.4 Causes of mortality between prehospital airway intervention groups.
24 h mortality n (%) 6 (38) 8 (10.8) 0.01
Variable Supraglottic airway BVM ventilation
Overall mortality n (%) 12 (75) 10 (14) 0.0001
Tracheostomy n (%) 5 (31) 6 (8.1) 0.01 Traumatic Brain Injury 7 7
Subglottic/tracheal 1 (5.9) 3 (4.1) 0.08 Hemorrhagic Shock/Exsanguination 4 3
stenosis n (%) Respiratory Failure owing to Pneumonia 1 0
356 M.C. Hernandez et al. / Journal of Pediatric Surgery 53 (2018) 352–356

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