Prehospital management of impending airway obstruction in combat trauma: a registry study

Introduction Guidelines for airway management in trauma commonly recommend immediate or prophylactic definitive airway intervention for injuries deemed at high risk for rapid airway compromise—such as inhalation injury, expanding neck haematoma or severe maxillofacial trauma, even in the absence of overt respiratory compromise. Despite widespread clinical adoption, the supporting evidence for this practice and its impact on patient outcomes remains limited. Methods This retrospective analysis linked prehospital and in-hospital data for injured Israel Defense Forces (IDF) personnel who met the IDF Medical Corps criteria for suspected impending airway compromise during an ongoing military conflict. Manual chart review was performed to identify eligible cases among patients evacuated by aeromedical transport. In-hospital data were then analysed to assess the duration of mechanical ventilation and patient outcomes. Results Of 491 suspected cases reviewed, 29 patients (5.9%) met inclusion criteria for suspected impending airway obstruction. The median age was 21 years and 85.7% sustained blast-related injuries. The most common indications for suspected impending airway compromise were facial burns (41.4%) and facial or airway deformation (24.1%). Prehospital definitive airway management was performed in 25 patients (86.2%), including 16 endotracheal intubations and 9 cricothyroidotomies. The remaining four patients were managed conservatively with supportive measures alone. Among those intubated, the median time to extubation was 2 days. All patients managed conservatively survived to hospital admission, but three were intubated on arrival. Conclusions In this small cohort of battlefield injuries with short evacuation times, some patients meeting classic criteria for suspected impending airway compromise were initially managed without definitive airway intervention and survived to hospital admission. In-hospital ventilation durations were generally short but highly variable. Further research is needed to determine whether these traditional indications reliably predict rapid airway compromise or provide a procedural advantage that justifies immediate prehospital intervention.