Page 28 - Journal of Special Operations Medicine - Fall 2015

Conclusions Proposed Change
Of the techniques and cannula types reviewed in this Current Wording in the TCCC Guidelines
report, we recommend an open technique via a vertical, Care Under Fire:
midline incision. This approach will maximize anatomic N/A
exposure, minimize bleeding, and allow for extension
of the incision at either end if the initial incision is not Tactical Field Care
optimally placed.
2. Airway Management
Once the incision through the skin and CTM is accom- a. Unconscious casualty without airway obstruction:
plished, the most effective airway instrument type, in – Chin lift or jaw thrust maneuver
our review, is the CK, which eliminates multiple sources – Nasopharyngeal airway
of difficulty. In contrast, the techniques below pose ad- – Place casualty in the recovery position
ditional risks for procedural difficulty and potential fail- b. Casualty with airway obstruction or impending
ure to cannulate the airway. airway obstruction:
– Chin lift or jaw thrust maneuver
• The standard surgical approach (horizontal skin inci- – Nasopharyngeal airway
sion) is challenging for nonsurgeons who are less fa- – Allow casualty to assume any position that best
miliar with external landmarks and anatomy. protects the airway, to include sitting up.
• The rapid four-step technique poses an additional – Place unconscious casualty in the recovery
bleeding risk and opportunity for misplacement, as position.
well as the potential for injury to the airway and ad- – If previous measures unsuccessful:
jacent structures. – Surgical cricothyroidotomy (with lidocaine if
• The wire-guided approach has too many steps, re- conscious)
quires very fine motor control, and is predisposed to
wire kinking Tactical Evacuation Care
• The tube-over-needle approach can lead to perfora-
tion of the posterior tracheal wall and subsequent 1. Airway Management
cannulation of the esophagus and increased risk for a. Unconscious casualty without airway obstruction:
aspiration. – Chin lift or jaw thrust maneuver
– Nasopharyngeal airway
The preferred airway cannula type, based on our review, – Place casualty in the recovery position
is the Melker or similar airway cannula, which has an b. Casualty with airway obstruction or impending
appropriate external diameter to internal diameter ra- airway obstruction:
tio and has external wings allowing the airway to be – Chin lift or jaw thrust maneuver
secured without compressing the patient’s neck. Dire – Nasopharyngeal airway
circumstances may require innovative use of existing – Allow casualty to assume any position that best
supplies, but improvised use of other airway cannulas protects the airway, to include sitting up.
in the setting of an acutely injured and compromised – Place unconscious casualty in the recovery
airway can lead to additional complications. Traditional position.
tracheostomy tubes are too rigid and do not mold well – If above measures unsuccessful:
to the patient’s anatomy, while the excess length of – Supraglottic airway or
ETTs, even when “cut to size,” can lead to main-stem – Endotracheal intubation or
bronchial intubation and external entanglement, espe- – Surgical cricothyroidotomy (with lidocaine if
cially in tactical settings. conscious).
c. Spinal immobilization is not necessary for casual-
At this time, the CK has the best supporting evidence for ties with penetrating trauma.
enabling successful performance of surgical airways by
Combat medical personnel and is recommended as the Proposed New Wording
device of choice for TCCC.
Changes are in red text:
Care Under Fire:
Whatever surgical airway procedure is used, training for N/A
this procedure should include a minimum of five repeti-
tions of the procedure and the student should demon- Tactical Field Care
strate his or her mastery of the precise location for the
skin incision by marking the proposed incision site on a 2. Airway Management
fellow TCCC student as part of the training evolution. a. Unconscious casualty without airway obstruction:

16 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2015