Advanced airway interventions in the trapped (racing) driver: a randomised cross-over trial

Casualty entrapment occurs in 12‐38.6% of road traffic incidents attended by advanced trauma teams. Half of those occupants sustaining severe trauma require advanced airway management. Suboptimal positioning and environmental restrictions make this challenging, and low success rates are described. This study uses a race car training chassis to increase scenario fidelity, and investigates airway management devices suitable for pre-hospital use.Participants (n = 72) were recruited from pre-hospital, emergency department and anaesthesia services in a teaching hospital in Singapore and stratified by experience in advanced airway management. Two supraglottic devices (Supreme Laryngeal Mask Airway, Laryngeal Tube) and three tracheal intubation devices (Airtraq, McGrath MAC, McGrath X-Blade) were tested in a simulated sitting trapped driver scenario. The primary outcome was airway intervention success (%) which was defined by the ability to place an airway and inflate the lungs of a mid-fidelity mannequin. Secondary outcomes were time to airway management, number of oesophageal intubations and perceived difficulty.Both inexperienced (n = 36) and experienced (n = 36) operators achieved 100% success rates with the supraglottic devices. The inexperienced group demonstrated the greatest success using the McGrath X-Blade (94.4%), followed by the McGrath MAC (91.6%) and the Airtraq (80.6%). The experienced group found the McGrath MAC (94.4%) the most successful, followed by the Airtraq (91.6%) and the McGrath X-Blade (77.8%). Where tracheal intubation was attempted, 12% resulted in at least one oesophageal intubation. The majority were associated with the Airtraq device (71.0%) and the inexperienced operator (78.9%).This study suggests that a supraglottic device, rather than primary intubation, should be used when the driver is trapped in the seat. If a definitive airway is required, the McGrath videolaryngoscopes are associated with a greater success rate and reduce incidence of oesophageal intubation compared with the Airtraq. Fixed radius curve blades, such as the McGrath X-Blade, may be preferred by inexperienced operators in this situation. Variable radius curve blades, such as the McGrath MAC blade, may be the more successful option when used by operators experienced in their use.