Airway Management in the Combat Casualty

7/29/2019 Airway Management in the Combat Casualty

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Airway Management in the

Combat CasualtyCPT Allen Proulx, MPAS, PA-C


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References

Tactical combat Casualty Care, Butler, Hagmann,

Butler, Association of Militray Surgeons of U.S., 1996

Emergency Medicine: A Comprehensive StudyGuide, Tintinalli, 6th ed, Mcgraw-Hill, 2004.

USMC FMSS.

C.M. Bensons Anatomy Drawings (CD).

University of New Mexico.McKinley County EMS.


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Overview

Discuss why we would secure an airway in the

combat casualty

Discuss and analyze some options in

establishing an airway in the combat casualtyReview the use of the Combitube

Review the steps in performing a

cricothyroidotomy


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Scenario

You are supporting a unit operating in

western Afghanistan when a soldier is

brought in s/p his vehicle hitting a landmine.

The vehicle exploded. The casualty isunconscious and unresponsive and has 2nd

degree burns to the face and neck. You

perform your CBA initial assessment and

note no other injuries.

What do you do?


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Secure the Airway

What questions need to be answered when

we plan for airway management?

What is effective?

What is easy and quick to use?

Consider yourself inexperienced

What requires minimal equipment?

What is my back-up?

The Nasopharyngeal Airway, Combitube and

Cricothyroidotomy are excellent choices!


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Options

Endotracheal intubation in the hands ofan inexperienced provider, with acontrolled setting has about a 42%

success rate.The Combitube has a 95% success ratein the field.

Cricothyroidotomy has a 90% successrate in inexperienced physicians and a98% success rate with flight nurses.


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Nasopharyngeal Airway (NPA)

1% of all combatfatalities can besalvaged by ensuringthe airway is patent

throughout evacuation.All unconscious/alteredmental statuscasualties should havetheir airway secured

with a NPA.Oropharyngeal airwayis a poor choice formilitary.


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Elbow deflector

Suction catheter

Small syringe:

20 ml distal cuff

Large (blue) syringe:

100 ml large balloon

Ringmarks

Distalcuff

Oropha-

ryngealballon


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Pharyngeallumen No. 1

Esophago-

tracheal

lumen No. 2

Esophageal - tracheal

COMBITUBE

Oropharyngeal

balloon

Distal

cuff

Perforations


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Specially useful:

Difficult intubationBlind intubation

Difficult circumstances(space, illumination)

Combitube


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Emergency intubation

Bleeding and vomitingImmediate decompression

of esophagus and stomach

Note:The casualty must beunconscious and have no gagreflex

Indications for

Combitube


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Merits of COMBITUBE

Low price, all-in-one device

Non invasive

No preparations necessaryRapid and easy intubation

Immediate fixation

PREVENTION OF ASPIRATION


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Complications

Aspiration

Ensure there is no gag reflex

Esophageal perforation

Direct trauma to the larynx


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The Basic Procedure

Open

mouth,

pressaway

tongue

Head:

Neutral

position


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The Basic Procedure

Flat

insertionalong

tongue


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The Basic Procedure

Emergency:

No. 2: 10 mlEmergency:No. 1: 85 ml

(or more)


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The Basic Procedure

Esophageal

position

Self-fixation

Behindhard palate

Active

decom-pression

Ventilation

via longer

blue tube

No. 1


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The Basic Procedure

Ventilation

via shorterclear

tube

No. 2

Tracheal

position


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Laryngoscope May be Used


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Cricothyroidotomy

DEFINITION -

An emergency surgical procedure where

an incision is made through the skin and

cricothyroid membrane which allows forthe placement of an endotracheal tube into

the trachea when airway control is not

possible by other methods.


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Indications

Trauma to the head or neck which

would preclude the use of an ambu-

bag, oropharyngeal airway,

nasopharyngeal airway, orcombitube/endotracheal tube insertion


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Merits of the

CricothyroidotomyProvides a definitive airway for

ventilating the patient

Can be performed quickly and has few

complications associated with the

procedure


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Contraindications

Massive trauma to the larynx or cricoid

cartilage:

Damage to the affected structures will

make it impossible to perform theprocedure properly


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Complications

Hemorrhage

Esophageal perforation

Tracheoesophageal fistulaSubcutaneous air


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Basic Anatomy


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Basic Anatomy

Anterior view of the

larynx to show the

median cricothyroid

ligament.1. Thyroid lamina.

2. Arch of cricoid

cartilage.

3. Mediancricothyroid

ligament (cut here)


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Required Equipment forEmergency

Cricothyroidotomy


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Quicktrach
http://www.life-assist.com/airway/at99_7.jpg


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Quicktrach
http://www.life-assist.com/airway/at99_5.jpg


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Nu-Trake


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Required Equipment

#10 or 15 Scalpel

Endotracheal Tube

Size 6 and Larger

10 cc Syringe

Stethoscope

Curved Kelly

Hemostat, Straight

will work

Ambu-bagSterile Dressing

Vaseline / Petroleum

GauzeBetadine or Alcohol

Wipes


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Required Equipment

(continued)

Sterile or Clean Gloves

Suture Material

Suction DeviceSuture Scissors

Tape


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Performing the

cricothyroidotomyDetermine that the patient requires anemergency cricothyroidotomy.

Assemble required equipment, quickly.

Use pre-established kits

Do it. Dont hesitate

Position the patients head/neck

The patient is placed in a supine or semi-recumbant position

The neck is placed in a neutral position


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Performing the

cricothyroidotomyPalpate the thyroid

and cricoid cartilage

for orientation

A - Cricoid Cartilage

B - Cricothyroid

Membrane

C - Incision Site

D - Thyroid Cartilage


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Performing the

cricothyroidotomy

Locate the cricothyroid membrane

Stabilize the thyroid cartilage using yournon-dominant hand

This is not as easy as it sounds!

Make a vertical vs horizontal incisionthrough the skin approximately 2-5 cm (1inch+) long over the cricothyroid membrane

Visualize the cricothyroid membrane


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Performing the

cricothyroidotomyMake a transverse

incision into the

cricothyroid

membrane DO NOT make the

incision more than

1/2 inch deep or you

may perforate the

esophagus


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Performing the

cricothyroidotomy

Insert the Curved Kelly Hemostat into

the incision and blunt dissect the

incision (turn the Curved KellyHemostat or scalpel handle 90 degrees

to open up the incision)


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Performing the

cricothyroidotomy

Insert the endotracheal tube (adult

6mm or Ped smaller? whatever will

fit), into the incision, directing thetube distally down the trachea

P f i h


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Performing the

cricothyroidotomy

Ventilate the patient with two breaths

Check for proper placement of the

endotracheal tube with these first two

ventilations by:

Observing the chest rise and fall with each

ventilation

Auscultate for bilateral breath soundsPulse Oximiter would be an excellent

assessment tool!!

P f i th


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Performing the

cricothyroidotomyBilaterally Absent Breath Sounds - theendotracheal tube is not within the tracheaand has probably been placed within theesophagus or subcutaneous tissue.

Remove the tube and attempt to reinsert into thetrachea

Right main-stem placement is common.

Breath Sounds in the Right Lung Field - theendotracheal tube has been placed too fardown the bronchial tree and is in the rightmainstem bronchus. Pull back the tube 1/4 to 1/2 inch or until bilateral

breath sounds have been established

P f i th


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Performing the

cricothyroidotomyAuscultate over the epigastrium for gastric

sounds

Placement of the endotracheal tube into the

esophagus will produce gurgling sounds in theepigastric area with ventilations

Inflate the endotracheal tubes cuff with 10

ccs of air

Inflation of the cuff serves two purposes:

Holds the endotracheal tube in place

Acts as a barrier and prevents fluids from entering

the lungs

P f i th


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Performing the

cricothyroidotomyApply petroleum gauzedressing to insertionsite

Apply a dry, sterile

dressing to theinsertion site

Tape around the tubethen completely aroundthe neck.

Sutures not needed.This is a temporaryairway!!

P f i th


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Performing the

cricothyroidotomyContinue to ventilate the patient (1

breath every 5 seconds) and suction as

necessary.

Loving Gentle Squeeze 2 in, 3 out.

Continue to monitor the patient for

changes

P f i th


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Performing the

cricothyroidotomy


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Questions??