Page 144 - JSOM Fall 2018

• If the bleeding site is amenable to use of a junctional *For casualties with trauma to the face and mouth, or facial
tourniquet, immediately apply a CoTCCC­recom­ burns with suspected inhalation injury, nasopharyngeal air­
mended junctional tourniquet. Do not delay in the ways and extraglottic airways may not suffice and a surgical
application of the junctional tourniquet once it is cricothyroidotomy may be required.
ready for use. Apply hemostatic dressings with direct
pressure if a junctional tourniquet is not available or *Surgical cricothyroidotomies should not be performed on un­
while the junctional tourniquet is being readied for conscious casualties who have no direct airway trauma unless
use. use of a nasopharyngeal airway and/or an extraglottic airway
3. Airway Management have been unsuccessful in opening the airway.
a. Conscious casualty with no airway problem identified: 4. Respiration/Breathing
• No airway intervention required a. Assess for tension pneumothorax and treat as necessary.
b. Unconscious casualty without airway obstruction: 1. Suspect a tension pneumothorax and treat when
• Place casualty in the recovery position a casualty has significant torso trauma or primary
• Chin lift or jaw thrust maneuver or blast injury and one or more of the following:
• Nasopharyngeal airway or – Severe or progressive respiratory distress
• Extraglottic airwa – Severe or progressive tachypnea
c. Casualty with airway obstruction or impending airway – Absent or markedly decreased breath sounds on
obstruction: one side of the chest
• Allow a conscious casualty to assume any position – Hemoglobin oxygen saturation < 90% on pulse
that best protects the airway, to include sitting up. oximetry
• Use a chin lift or jaw thrust maneuver – Shock
• Use suction if available and appropriate – Traumatic cardiac arrest without obviously fatal
• Nasopharyngeal airway or wounds
• Extraglottic airway (if the casualty is unconscious) Note:
• Place an unconscious casualty in the recovery *If not treated promptly, tension pneumothorax may prog­
position ress from respiratory distress to shock and traumatic cardiac
d. If the previous measures are unsuccessful, assess the arrest.
tactical and clinical situations, the equipment at hand, 2. Initial treatment of suspected tension pneumothorax:
and the skills and experience of the person provid­ – If the casualty has a chest seal in place, burp or
ing care, and then select one of the following airway remove the chest seal.
interventions: – Establish pulse oximetry monitoring.
• Endotracheal intubation or – Place the casualty in the supine or recovery po­
• Perform a surgical cricothyroidotomy using one of sition unless he or she is conscious and needs to
the following: sit up to help keep the airway clear as a result of
– Cric­Key technique (Preferred option) maxillofacial trauma.
– Bougie­aided open surgical technique using a – Decompress the chest on the side of the injury
flanged and cuffed airway cannula of less than with a 14­gauge or a 10­gauge, 3.25­inch needle/
10mm outer diameter, 6­7mm internal diameter, catheter unit.
and 5­8cm of intratracheal length – If a casualty has significant torso trauma or pri­
– Standard open surgical technique using a flanged mary blast injury and is in traumatic cardiac arrest
and cuffed airway cannula of less than 10 mm out­ (no pulse, no respirations, no response to painful
er diameter, 6–7mm internal diameter and 5–8cm stimuli, no other signs of life), decompress both
of intratracheal length (Least desirable option) sides of the chest before discontinuing treatment.
– Use lidocaine if the casualty is conscious. Notes:
e. Cervical spine stabilization is not necessary for casual­ *Either the 5th intercostal space (ICS) in the anterior axillary
ties who have sustained only penetrating trauma. line (AAL) or the 2nd ICS in the mid­clavicular line (MCL) may
f. Monitor the hemoglobin oxygen saturation in casualties be used for needle decompression (NDC). If the anterior (MCL)
to help assess airway patency. Use capnography moni­ site is used, do not insert the needle medial to the nipple line.
toring in this phase of care if available. *The needle/catheter unit should be inserted at an angle per­
g. Always remember that the casualty’s airway status may pendicular to the chest wall and just over the top of the lower
change over time and requires frequent reassessment. rib at the insertion site. Insert the needle/catheter unit all the
Notes: way to the hub and hold it in place for 5–10 seconds to allow
*The i­gel is the preferred extraglottic airway because its gel­ decompression to occur.
filled cuff makes it simpler to use and avoids the need for cuff
inflation and monitoring. If an extraglottic airway with an air­ *After the NDC has been performed, remove the needle and
filled cuff is used, the cuff pressure must be monitored to avoid leave the catheter in place.
overpressurization, especially during TACEVAC on an aircraft 3. The NDC should be considered successful if:
with the accompanying pressure changes. – Respiratory distress improves, or
– There is an obvious hissing sound as air escapes from
*Extraglottic airways will not be tolerated by a casualty who the chest when NDC is performed (this may be difficult
is not deeply unconscious. If an unconscious casualty without to appreciate in high­noise environments), or
direct airway trauma needs an airway intervention, but does – Hemoglobin oxygen saturation increases to 90% or
not tolerate an extraglottic airway, consider the use of a naso­ greater (note that this may take several minutes and may
pharyngeal airway. not happen at altitude), or

142 | JSOM Volume 18, Edition 3 / Fall 2018