Airway Management in PFC

1. Airway Management in PFC Developed by 91 Civil Affairs Presented/modified by 1BCT, 82D ABN DIV

2. Agenda • Back to the basics • Intubation • SOF Tactical Airway Algorithm • Critical Care Airway checklist • SORT Airway checklist • MSMAID

3. Intubation

4. Special Operations Tactical Airway Algorithm,Awake Cricothyroidotomy and What to Do Next

5. Special Operations/Tactical /PFC Airway Algorithm • This was meant for Medics who are not able to maintain proficiency on Direct Endotracheal Intubation defined by • Initial training and evaluation • Recommending medics watch 50 video intubations prior to picking up laryngoscope! • Mannequin should be used for stress inoculation training • 6-8 live intubations per quarter • Cuffed Cricothyroidotomy tube can remain in place up to 72 hours

7. #4 Airway Recommendations: Why Cric?! • Post ET intubation pain and sedation drips requiring a lot of meds • Having a tube in the back of your throat is extremely uncomfortable • Initial intubation training not uniform or evaluated on live patients • Veterinary models not similar to human anatomy • Skills maintenance for RSI not likely with: • Deployments and other training requirements • 1-4 week MPT rotation every 4 years (for SOF) • 125 medics in BDE! (250 in BCT) • one low hospital that was just established • No civilian cert accrediting us to intubate on the streets

8. What About all Those Other Techniques? • Oxygenation – Limited supplies, Concentrator low FiO2 • Supraglottic Airways like the King LT and LMA – Not secure for evac, may allow aspiration, suppressing gag reflex still an issue • RSI – Paralytics, suppressing gag reflex, Maintaining skills • RSA - Paralytics (Rapid Sequence Airway –LMA-see life in the fast lane website) • DSI – Maintaining Analgesia Drip (delayed sequence intubation) • Awake Intubation – Maintaining pharyngeal anesthetization,

9. Indications for the Cric • If a patient has massive facial trauma and is conscious you will need to take control of the airway • Take it early • If you sedate one of these guys you will need to take their airway. Don’t wait until it is emergent • Do you plan on them sleeping sitting up bleeding from their face? • If they are bleeding enough from their facial trauma they may develop hypovolemia and accompanying anxiety and agitation • They will be come fatigued at some point and will lose the ability to protect their own airway • If a patient has sustained burns of the upper airway they will likely develop edema and lose their airway • Do the cric early before it is an emergency • If a patient has chest wall injury and cannot maintain O2 sats even while sleeping they will need positive pressure ventilations • Will they tolerate bagging with BVM and facemask? • Any other disease process that limits their ability to maintain saturation or protect their own airway • Cerebral or meningeal diseases • If a patient had any of the processes described earlier you will need to take control of the airway • Awake cricothyroidotomy?

10. Anatomy and Landmarks

11. Pre-Oxygenate if Available • If limited supply available… This is the time to use it! • Nasal Cannula 15Lpm or • NRB + Nasal Cannula 15Lpm each or • Patient can hold a BVM with PEEP valve to his own mouth if he can maintain a seal

12. The Awake Cricothyroidotomy Checklist • Military SOF medics should be extremely comfortable and practiced at this skill • Patient can remain sitting up breathing on their own until ready to cut • Preoxygenate if possible with Nasal cannula 15Lpm/NRB 15Lpm Combo or BVM w/ PEEP and O2(patient can just breath through it ) • Pretreat with 8mg zofran • Give 1-2mg IV of Versed to take the edge off and cause amnesia • Have an assistant hold the patient upright • Give sedation dose of Ketamine 1-2mg/kg IV slow push • Adequately clean area with povidine iodine and allow it to dry • Inject wheal of 2% lidocane over Cricothyroid Membrane and clean area where you will incise • Advance the needle while aspirating • When you see bubbles you are in the Trachea • Squirt 3mls into the trachea causing them to cough and distribute the lidocaine • Lean the patient back and hyperextend the neck • Make your vertical incision like normal • Make horizontal stabbing incision ensuring the hole is wide enough for the tube to easily pass • Secure with cric hook or bougie • Insert the tube and inflate the cuff • Confirm and reconfirm Placement like you would with ET intubation • Failures by inexperienced operators usually end up under the skin but outside the airway

13. Bougie Aided Cric? • YouTube videos • After incising the cricothyroid membrane… • With the scalpel still holding the hole open insert the bougie • If the patient is unconscious the bougie can easily go down to the carina (about 11cm) • Remove the Scalpel • Slide the tube over the Bougie • Double check placement

14. The Post Cric Checklist • Quantitative or Waveform Capnography • Check Tube Depth • Secure the Tube Well • BVM with PEEP Valve / Lung Protective Strategy • Achieve Adequate Analgesia and Sedation • Raise the Head of the Bed to 30 - 45° • Filter and Humidify the Air with a (0.45 cent) Heat Moisture Exchanger • Place In-Line Suction and suction the mouth • Cuff Pressure • Prevent Aspiration past the Cuff of the ETT • Gastric Tube, if not done yet • Get a Blood Gas if possible • Put a BVM at the Bedside ± PEEP Valve • Have a Plan for Vent Alarms • Decontaminate the mouth with chlorhexidine swab

15. Confirm and Reconfirm Placement • Qualitative Single Use Color Changing Capnometer • ETD Bulb • Can detect if tube is sub cutaneous and not in the airway • Quantitative Numeric Capnometer • Stethoscope if environment permits

16. Check Tube Depth • If you used a full size ET tube and buried it to the hilt you may need to pull it back until you can see or feel it in the lower airway in the neck. • 3cm should be good enough • Use stethoscope to ensure tube is not in right mainstem bronchus • Tube placement is routinely checked with X-Ray in hospitals • Ultrasound can be used as well

17. Secure in Place • Suture in place • Further secure with commercial device or tied tubbing from IV or cannula • Check under this device every 8 hours for signs of pressure necrosis

18. Sedation and Analgesia • From SOCOM PFC WG Analgesia/Sedation Comments(February, 2014) • "Any procedure that involves sedation should also include monitoring the patient, ideally with end tidal CO2 (with a waveform), and at a minimum, have oxygen saturation (pulse ox) monitoring." • Many of the drugs available to 18Ds can cause nausea. Pre-treat with 8mg Zofran • If ketamine is given in analgesia doses it should not be done as a drip. Do boluses over at least 2 mins. You can give a Ketamine sedation drip for transport or procedure as follows: • Add 750mg of to a 250mg bag of normal Saline (some providers add up to 25mg of versed also.) The initial drip rate is kg bodyweight/2=cc/hr. For example a 100 kg patient would be started at 50cc/hr drip rate. At this rate, you can calculate the bag lasting about 5 hours. In practice, it is observed that the majority of the time, the drip rate could be cut in half after 20-30min, and the bag may last 8-9hrs. • (For reference, the initial doses are ketamine: 1.5mg/kg/hr, and versed:0.05mg/kg/hr). • If any other questions see the SOCOM PFC WG Analgesia/Sedation Comments(February, 2014) at www.prolongedfieldcare.org

19. Raise Head of Bed • Fowlers Position Ideal • 30-45 degrees • This natural position will improve lung function • May prevent micro aspiration from stomach contents around the cuff • Help ICP in head injured patients • More comfortable if patient is aware

20. Lung Protective Strategy • This may mean a BVM with a PEEP valve for medics • SAVent (which has no PEEP) should only be used when absolutely necessary for a couple hours at most • Initial transport when all personnel are required to drive • High threat/ High security needed • Should get back to BVM with PEEP valve ASAP • If older Impact 752 vent available see Rule of 5s Checklist

21. Keep out Debris and Humidify the Air • ICU ventilators have humidification built in • So do Humans… • Our option: • Heat Moisture exchanger ($0.45 cents) • Retains patient’s own moisture • Blocks out sand and debris from helicopter rotor wash or ground evac if no vent available • Can remain in place up to 72 hours • Med Log Reference #14412

22. Place and Use Inline Suction Every Hour • Suction the mouth when you suction the tube • Use a Ballard in-line suction to maintain sterility Reference #2205

23. If Quantitative End Tidal CO2 isn’t Hooked up yet DO IT! • If transporting or transferring this will immediately alert you to a problem • $1300-$2500 • SPO2 Pulse Oxs may take minutes to let you know, especially if the patient is on 100% O2

24. Check ET Tube Cuff Pressure • Too low and you risk micro-aspiration and VAP • That’s bad (aspiration pneumonia) • Too high and the patient has the potential for tracheal ischemia • Also bad • The ideal pressure is between 20-30 cm H20, hard to guessimate. • Use a cufflator

25. Think Twice About Replacing Air with Saline • Many people recommend replacing the air in the cuff with saline prior to air evac due to the increased pressure • This can cause more harm than just leaving air! • The small bubbles that remain cause can cause • the pressure to be focused in one area. • It is extremely difficult to remove all the air • Once at altitude check cuff pressure and again after decending

26. NG OG Tube • Can be done procedurally prior to tubing if the situation permits • Use Ketamine and suck out stomach contents if patient is tubed • Complete after the cric if it was done emergently

27. Have a Plan for alarms or vital signs out of normal range • Each member of the team who is not “medically” trained should know what constitutes an emergency and when to seek help. • Rising or No ETCO2 • Falling or No Pulse Ox • Change respiratory rate • Change in Heart Rate • Change in Blood Pressure • Change in Glucose • Change in Lactate

28. Decontaminate the mouth with Chlorhexidine • This should be done as soon as possible after the patient is tubed • Oral hygiene is usually done every 4 hours thereafter • You can alternate between brushing teeth and swabbing with chlorhexidine Oral Rinse • Don’t forget chap stick or vaseline • for the lips

30. MSMAID • If you are going to sedate, you need to have MSMAID covered. Monitor, Suction, Machine, Airway, IV, Drugs. A professional will have access to some form of these items if they are going to sedate. A BVM can be your machine, a pulse ox can be your monitor, but you must have these items covered in some form before you sedate.

31. Airway basics for PFC • Airway management (and subsequent supplemental oxygen, ventilator support, gastric decompression, and a suction device) is a core capability for Prolonged Field Care.

32. Basics Save Lives • Every medic should be trained and maintained with the following airway skills at a minimum: opening and maintaining an airway (with adjunctive NP/OP), bag-valve-mask ventilation, placing a supraglottic airway, and cricothyrotomy.

33. Conclusion • Airway management is essential • Think long-term for PFC • Pre planning and preparation saves lives • Basics save lives