38 hours until CASEVAC?!? Now what!?! Prolonged Field Care

1. www.ProlongedFieldCare.org www.ProlongedFieldCare.org Downloadable Resources Subscribe Now Instant Updates 38 hours until CASEVAC?!? Now what!?! Prolonged Field Care Improving Far Forward Medicine @PFCwgMedicine Get Prepared @FOAMedPFC Why We Started This -Fills gaps in current protocol and references -Reach out and get a question answered by the community -Download resources to any mobile device eReader -Join the working group and let your voice be heard -Your chance to contribute to your own training and education before it becomes mandatory from above -In partnership with SOF Medics and Docs in 40 countries -Access to Training resources and Recommendations Get the Info You Need Now! PFC Videos on our YouTube Channel 10 Essential Capabilities - you must have Tourniquet Conversion Paper - Answers nagging questions Analgesia and sedation Paper - Easy, long term sedation Airway Recommendation Paper – Best practices PEEP Valve - Are you using them? Long-Term Patient Care Flowsheet – Easy to trend vitals Fresh Whole Blood Trans. FAQs – Answered

2. So You Saved the day With a Cric! Best Practice Airway Care What’s Next? Adapted from: Scott Weingart’sEMCrit Podcast #84 “Post Intubation Package” Bob Mabry and Rich Levitan’s Tactical Airway PFC WG Airway Recommendations PFCWG Sedation and Analgesia Recommendations NAP4 Study

3. Special Operations/Tactical /PFC Airway Algorithm • If in doubt, Cricothyroidotomy • 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! • 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 • You won’t have to fight the gag reflex with narcotics and paralytics

4. Immediate SC Near Death? Tolerates SGA? No No No No No

5. Airway Recommendations: Why not intubation! • Post ET intubation pain and sedation drips requiring a lot of meds • Having a tube in the back of your throat is extremely uncomfortable • CN IX constantly sending signal to CN X to gag (Pharyngeal Reflex Arc) • Initial training not uniform or evaluated live • Veterinary models not similar to human anatomy • Skills maintenance not likely with: • Deployments and other training requirements • 1-4 week MPT rotation every 4 years • Large volume of medics • Limited access to low volume community hospital • No civilian cert accrediting medics to intubate on the streets

6. 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 O2sats 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 cricotyroidotomy?

7. Click for NAP4 StudyResus.me comments • “In appropriate circumstances (prophylactic cricothyroidotomy) has numerous advantages, not least the potential to secure and check the ‘rescue airway’ in a calm and unhurried manner, without hypoxia, before an emergency arises” • Quantitative wave-form ETCO2 should be the standard of care for EVERY ED and ICU intubation • Needle cricothyrotomy seems to fail more often than surgical cricothyrotomy • Awake intubation was not used when it was indicated • Junior resident anesthesiologists were often responding to the ED and ICU • There was a failure to plan for failure • Obesity figured into a large percentage of the airway disasters • Airway operators were not prepared or just did not properly progress to surgical airway

8. The Awake Cricothyroidotomy Checklist • Most military SOF medics are extremely comfortable and practiced at this skill • Patient can remain sitting up breathing on their own during the procedure • Pretreat with 8mg zofran • Give 1-2mg IV of Versed to take the edge off and cause amnesia • Give pain control dose of Ketamine 0.1mg/kg IV slow push over 2 mins • 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 • 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

9. Confirm and Reconfirm Placement • Qualitative Single Use Color Changing Capnometer • Can give false positives, wait 6 breaths • ETD Bulb • Can detect if tube is sub cutaneous and not in the airway • Quantitative Numeric Capnometer • Better, Waveform capnographybest • Stethoscope if environment permits

10. Check Depth of Tube • 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 main-stem bronchus • Tube placement is routinely checked with X-Ray in hospitals • Ultrasound can be used as well

11. Secure in Place • Suture with a Box suture sandal wrapping and taping to the tube • Further secure with commercial device or tied IV tubing • Check under this device every 8 hours for signs of pressure necrosis

12. 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 (Pill Pack?!) • 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

13. Lung Protective Strategy • This may mean a BVM with a PEEP valve for us • 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 • If you have a real vent available be sure to watch: • Scott Weingart’sDominatingthe Vent

14. Raise Head of Bed • Fowlers Position Ideal • 30-45degrees • 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

15. Keep out Debris and Humidify the Air • ICU ventilators have humidification built in • So do humans • Our option to replicate it: • Heat Moisture exchanger ($5.00) • Retains patient’s own moisture • Blocks out sand and debris from helicopter rotor wash if no vent available

16. Place and Use Inline Suction Every Hour • Suction the mouth when you suction the tube • If not using in-line Ballard suction use best sterile technique possible

17. 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

18. Check ET Tube Cuff Pressure • Too low and you risk micro-aspiration and VAP • That’s bad • 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 or cuff safe ($140.00-$300.00) • If replacing air in cuff with Saline be sure to get ALL the air out • Small amount of air mixed with water may be more dangerous than air alone • Water is not compressible and forces expanding air pressure to befocused on one area

19. NG OG Tube • Can be done procedurally prior to tubing if the situation permits • Use Ketamine and suck out stomach contents if patient is known to have large amount of stomach contents • Complete after the cric if it was done emergently

20. 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 Absent ETCO2 • Falling or Absent Pulse Ox • Change respiratory rate • Change in Heart Rate • Change in Blood Pressure • Change in Glucose • Change in Lactate

21. Begin Pulmonary Hygeine or Chest Physical Therapy Once Tubed • Consists of: • Adequate analgesia will facilitate everything else • Initial clorahixadine swab of mouth • Rotating patient positioning periodically (6-8hrs) • Flushing (2cc saline) and Suctioning of tube causing a cough • Flushing and suctioning mouth • Oral care such as Brushing teeth, applying chap stick • Percussing injured side to loosen blood and mucus • If attempting to squeegee a tube out with foleycath balloon keep the procedure sterile

22. The Post Cric Checklist • Confirm and reconfirm placement • Check Depth of tube • Secure the Tube Well • Achieve Adequate Analgesia and Sedation • Confirm Lung Protective Strategy/BVM with PEEP • Raise the Head of the Bed to 30 - 45° • Protect Tube inlet and Humidify the Air • Place In-Line Suction and suction the mouth • Double check that Quantitative ETCO2 capnometry is in place • Check Cuff Pressure • Place an NG Tube and Prevent Aspiration past the Cuff of the ETT • Get a Blood Gas if possible • Put a BVM at the Bedside ± PEEP Valve • Have a Plan for Vent Alarms and changing vitals • Pulmonary Hygiene

23. www.ProlongedFieldCare.org www.ProlongedFieldCare.org Downloadable Resources Subscribe Now Instant Updates 38 hours until CASEVAC?!? Now what!?! Prolonged Field Care Improving Far Forward Medicine @PFCwgMedicine Get Prepared @FOAMedPFC Why We Started This -Fills gaps in current protocol and references -Reach out and get a question answered by the community -Download resources to any mobile device eReader -Join the working group and let your voice be heard -Your chance to contribute to your own training and education before it becomes mandatory from above -In partnership with SOF Medics and Docs in 40 countries -Access to Training resources and Recommendations Get the Info You Need Now! PFC Videos on our YouTube Channel 10 Essential Capabilities - you must have Tourniquet Conversion Paper - Answers nagging questions Analgesia and sedation Paper - Easy, long term sedation Airway Recommendation Paper – Best practices PEEP Valve - Are you using them? Long-Term Patient Care Flowsheet – Easy to trend vitals Fresh Whole Blood Trans. FAQs – Answered