Airway Management in the Combat Casualty

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Airway Management in the Combat Casualty

• CPT 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 Study Guide,
  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 casualty
• Review 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 is unconscious 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 of an
  inexperienced provider, with a controlled setting
  has about a 42 success rate.
• The Combitube has a 95 success rate in the
  field.
• Cricothyroidotomy has a 90 success rate in
  inexperienced physicians and a 98 success rate
  with flight nurses.

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Nasopharyngeal Airway (NPA)

• 1 of all combat fatalities can be salvaged by
  ensuring the airway is patent throughout
  evacuation.
• All unconscious/altered mental status casualties
  should have their airway secured with a NPA.
• Oropharyngeal airway is a poor choice for
  military.

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Large (blue) syringe 100 ml large balloon
Elbow deflector
Distal cuff
Ringmarks
Oropha- ryngeal ballon
Small syringe 20 ml distal cuff
Suction catheter
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Esophageal - tracheal COMBITUBE
Pharyngeal lumen No. 1
Perforations
Distal cuff
Esophago- tracheal lumen No. 2
Oropharyngeal balloon
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Combitube

• Specially useful
• Difficult intubation
• Blind intubation
• Difficult circumstances
• (space, illumination)

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Indications for Combitube

• Emergency intubation
• Bleeding and vomiting
• Immediate decompression
• of esophagus and stomach
• Note The casualty must be unconscious and have
  no gag reflex

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Merits of COMBITUBE

• Low price, all-in-one device
• Non invasive
• No preparations necessary
• Rapid 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

• Head
• Neutral
• position

Open mouth, press away tongue
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The Basic Procedure
Flat insertion along tongue
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The Basic Procedure
Emergency No. 2 10 ml
Emergency No. 1 85 ml (or more)
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The Basic Procedure
Ventilation via longer blue tube No. 1
Esophageal position
Self- fixation Behind hard palate
Active decom- pression
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The Basic Procedure

• Tracheal
• position

Ventilation via shorter clear tube No. 2
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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 for the 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, or combitube/endotracheal
  tube insertion

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Merits of the Cricothyroidotomy

• Provides 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 the procedure properly

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Complications

• Hemorrhage
• Esophageal perforation
• Tracheoesophageal fistula
• Subcutaneous 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. Median cricothyroid
  ligament (cut here)

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Required Equipment for Emergency Cricothyroidotomy
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Quicktrach
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Quicktrach
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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-bag
• Sterile Dressing
• Vaseline / Petroleum Gauze
• Betadine or Alcohol Wipes

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Required Equipment (continued)

• Sterile or Clean Gloves
• Suture Material
• Suction Device
• Suture Scissors
• Tape

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Performing the cricothyroidotomy

• Determine that the patient requires an emergency
  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 cricothyroidotomy

• Palpate 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 your
  non-dominant hand
• This is not as easy as it sounds!
• Make a vertical vs horizontal incision through
  the skin approximately 2-5 cm (1 inch) long over
  the cricothyroid membrane
• Visualize the cricothyroid membrane

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Performing the cricothyroidotomy

• Make 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 Kelly Hemostat 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 the tube distally down the trachea

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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 sounds
• Pulse Oximiter would be an excellent assessment
  tool!!

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Performing the cricothyroidotomy

• Bilaterally Absent Breath Sounds - the
  endotracheal tube is not within the trachea and
  has probably been placed within the esophagus or
  subcutaneous tissue.
• Remove the tube and attempt to reinsert into the
  trachea
• Right main-stem placement is common.
• Breath Sounds in the Right Lung Field - the
  endotracheal tube has been placed too far down
  the bronchial tree and is in the right mainstem
  bronchus.
• Pull back the tube 1/4 to 1/2 inch or until
  bilateral breath sounds have been established

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Performing the cricothyroidotomy

• Auscultate over the epigastrium for gastric
  sounds
• Placement of the endotracheal tube into the
  esophagus will produce gurgling sounds in the
  epigastric 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

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Performing the cricothyroidotomy

• Apply petroleum gauze dressing to insertion site
• Apply a dry, sterile dressing to the insertion
  site
• Tape around the tube then completely around the
  neck.
• Sutures not needed. This is a temporary airway!!

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Performing the cricothyroidotomy

• Continue 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

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Performing the cricothyroidotomy
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Questions??