Airway Management in the Combat Casualty

CPT Allen Proulx, MPAS, PA-C

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.

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

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?

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!

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.

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.

Elbow deflector

Large (blue) syringe: 100 ml large balloon

Distal cuff
Oropharyngeal ballon

Ringmarks

Small syringe: 20 ml distal cuff

Suction catheter

Esophageal - tracheal

COMBITUBE
Pharyngeal lumen No. 1
Perforations

Esophagotracheal lumen No. 2

Distal cuff

Oropharyngeal balloon

Combitube
Specially useful: Difficult intubation Blind intubation Difficult circumstances (space, illumination)

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

Merits of COMBITUBE
Low price, all-in-one device Non invasive No preparations necessary Rapid and easy intubation Immediate fixation PREVENTION OF ASPIRATION

Complications
Aspiration
Ensure there is no gag reflex

Esophageal perforation Direct trauma to the larynx

The Basic Procedure

Head: Neutral position

Open mouth, press away tongue

The Basic Procedure

Flat insertion along tongue

The Basic Procedure

Emergency: No. 2: 10 ml

Emergency: No. 1: 85 ml (or more)

The Basic Procedure

Esophageal position Ventilation via longer blue tube No. 1

Selffixation Behind

hard palate

Active decompression

The Basic Procedure

Tracheal position

Ventilation via shorter clear tube No. 2

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.

Indications
Trauma to the head or neck which would preclude the use of an ambubag, oropharyngeal airway, nasopharyngeal airway, or combitube/endotracheal tube insertion

Merits of the Cricothyroidotomy

Provides a definitive airway for ventilating the patient Can be performed quickly and has few complications associated with the procedure

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

Complications
Hemorrhage Esophageal perforation Tracheoesophageal fistula Subcutaneous air

Basic Anatomy

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)

Required Equipment for Emergency Cricothyroidotomy

Quicktrach

Quicktrach

Nu-Trake

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

Required Equipment (continued)

Sterile or Clean Gloves Suture Material Suction Device Suture Scissors Tape

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 semirecumbant position The neck is placed in a neutral position

Performing the cricothyroidotomy

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

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

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

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)

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

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!!

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

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

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!!

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

Performing the cricothyroidotomy

Questions??