Airway Management in the Combat Casualty

1. Airway Management in the Combat Casualty CPT Allen Proulx, MPAS, PA-C

2. 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. Benson’s Anatomy Drawings (CD). University of New Mexico. McKinley County EMS.

3. 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 use of the King LT-D Review the steps in performing a cricothyroidotomy

4. Scenario You are supporting a unit operating in western Iraq when a soldier is brought in s/p his vehicle being struck by an RPG causing the vehicle to explode. 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?

5. 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/King LT, and Cricothyroidotomy are excellent choices!

6. 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.

7. 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.

13. Complications Aspiration Ensure there is no gag reflex Esophageal perforation Direct trauma to the larynx

14. The Basic Procedure Head: Neutral position

15. The Basic Procedure

16. The Basic Procedure

17. The Basic Procedure

18. The Basic Procedure Tracheal position

19. Laryngoscope May be Used

20. KING LT-D Single use supralaryngeal airway management device designed as an alternate to tracheal intubation. Designed for both positive pressure ventilation and sponateous breathing. Designed for blind intubation. (no visualization of cord)

21. KING LT-D

22. CONTRAINDICATIONS Intact gag reflex (Conscious) Known esophageal disease Ingested caustic substance Does not protect the airway from regurgitation or aspiration

23. INSERTION INSTRUCTIONS Choose correct size based on height of patient and test cuff with recommended volume of air. Apply lubricate to distal tip and posterior aspect of tube, avoid placing lubricant near ventilatory opening. Position casualty. Sniffing best, neutral ok. With non-dominate hand, hold mouth open and apply chin lift. Insert tube laterally (45-90?), as tube tip passes under the tongue rotate back to midline.

24. INSERTION INSTRUCTIONS Advance tube until base of connector is aligned with teeth. Inflate cuff with appropriate volume. Asses ventilation. Rise & fall of chest, Pulse ox. Secure tube. Place bite block to protect King LT-D

25. Sizing & Information

27. 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

28. Merits of the Cricothyroidotomy Provides a definitive airway for ventilating the patient Can be performed quickly and has few complications associated with the procedure

29. Contraindications Massive trauma to the larynx or cricoid cartilage: Damage to the affected structures will make it impossible to perform the procedure properly

30. Complications Hemorrhage Esophageal perforation Tracheoesophageal fistula Subcutaneous air

31. Basic Anatomy

32. 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)

33. Required Equipment for Emergency Cricothyroidotomy

34. Quicktrach

35. Quicktrach

36. Nu-Trake

37. Required Equipment #10 or 15 Scalpel Endotracheal Tube Size 6 and Larger 10 cc Syringe Stethoscope Curved Kelly Hemostat, Straight will work BVM Sterile Dressing Vaseline / Petroleum Gauze Betadine or Alcohol Wipes

38. Required Equipment (continued) Sterile or Clean Gloves Suture Material Suction Device Suture Scissors Tape

39. Performing the cricothyroidotomy Determine that the patient requires an emergency cricothyroidotomy. Assemble required equipment, quickly. Use pre-established kits Do it. Don’t hesitate Position the patient’s head/neck The patient is placed in a supine or semi-recumbant position The neck is placed in a neutral position

40. Performing the cricothyroidotomy Palpate the thyroid and cricoid cartilage for orientation A - Cricoid Cartilage B - Cricothyroid Membrane C - Incision Site D - Thyroid Cartilage

41. 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

42. 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

43. 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)

44. 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

45. 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!!

46. 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

47. 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 tube’s cuff with 10 cc’s 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

48. 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!!

49. 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

50. Performing the cricothyroidotomy

51. Questions??