Page 31 - JSOM Summer 2020

with a surgical airway as opposed to an orotracheal airway ophthalmologist at the Role 3; however, given the nature of
may be the safest option. It is important to have equipment for the ARSC teams, communication is not always feasible. In-
a surgical airway ready in the event orotracheal intubation is juries to the globe should be covered with an occlusive shield
unsuccessful. Always confirm airway placement with Etco . and parental antibiotics and antiemetics should be adminis-
36
2
See the guidelines “JTS Airway Management of Traumatic in- tered. These patients frequently experience severe nausea; oral
juries CPG.” 37 medications should be avoided. It is imperative to avoid pres-
sure to the globe, ensure nothing is directly touching the in-
jured globe, and no intraocular medications are administered.
Neck Injuries
See the “JTS Ocular Injuries and Vision-Threatening Condi-
Hard indications for surgical neck exploration in the ARSC tions in Prolonged Field Care CPG.” Lateral canthotomy
41
environment are no different than at the Role 2 or Role 3 and and cantholysis should be performed if there is concern for
include “hard signs” of vascular injury with active hemor- retrobulbar hematoma or increased intraorbital pressure. In
rhage or expanding or pulsatile hematoma. However, because the rare circumstance that telemedicine support is available, it
of the lack of imaging, lack of resources, and the inherent chal- should be heavily used. Establish telemedicine consultation as
lenge of these injuries, casualties without hard signs should soon as possible. AD.VI.S.OR, the Advanced Virtual Support
be transferred to a higher level of care as long as they have for Operational Forces system, offers 24/7/365, on-demand,
an acceptable airway for transport (this could be their native real-time telemedicine consultations (https://prolongedfieldcare
airway or a definitive airway). In some cases, exploration is .org/telemed-resources-for-us-mil).
indicated when airway injury is suspected on the basis of sub-
cutaneous emphysema or air bubbling through the wound ; Torso Trauma
38
however, many cases of tracheal injury can be temporarily
managed with endotracheal intubation with the cuff inflated Approximately 13% of combat casualty patients presented
below the level of injury. Be ready to immediately perform a with injury patterns at risk of noncompressible torso hemor-
surgical airway in these patients, because a relatively stable rhage (NCTH), and this was identified as a cause of death in
patient may have significant airway disruption. Proximal and 50% to 70% of patients assessed to have potentially survivable
distal vascular control is difficult for injuries approaching the injuries in Operation Enduring Freedom (OEF) and Operation
base of the neck or skull base. In this environment, most pene- Iraqi Freedom (OIF). 35,42–44 Truncal injury was characterized as
trating wounds to the neck without immediate life-threatening 36% thoracic and 64% abdominopelvic. It is in this patient
35
hemorrhage should be transferred to a higher level of care for population that forward-positioned surgeons have the greatest
additional diagnostic workup and subsequent formal surgical potential to directly influence survival. 45–48 The ability to per-
exploration. Although penetration of the platysma alone is not form extended focused assessment with sonography for trauma
an indication for neck exploration in the austere environment (E-FAST) for identification of intrathoracic injury and intra -
in the current trauma system, multiple factors must be taken abdominal hemorrhage is required because X-ray and com-
into consideration (e.g., transport time, capabilities at sending puted tomography (CT) scan may be unavailable. Ultrasound
and receiving facilities, the trauma system) because the level of has its limitations and has higher false-positive and -negative
injury may be difficult to ascertain without imaging. Maintain rates in penetrating trauma. In one study looking at combat
a low threshold to secure the patient’s airway before transfer. trauma, FAST only had a sensitivity of 12% for intraabdom-
In addition, communication to the higher level of care should inal injury requiring laparotomy, which underscores the use
49
be established to discuss the plan for these casualties. of training to improve diagnostic sensitivity, as well as the
challenges of these teams that do not have any additional di-
agnostic imaging. Diagnostic peritoneal lavage and diagnostic
Traumatic Brain Injury
peritoneal aspiration (DPL/DPA) can be used to augment di-
Non-neurosurgeons should be cautious when performing agnostic capability when FAST results are equivocal, although
craniotomy or craniectomy in the austere setting; this is no DPL/DPA are only limited to evaluation of the peritoneal cav-
different from a surgeon at a Role 2. However, in this far- ity. ARSC teams have to optimize requirement for ultrasound
forward environment, medical management and craniectomy capability and providers must have the appropriate ultrasound
have even more challenges. Lack of appropriate training and training. Ultrasound is limited for identification of pelvic or
experience may make operative therapy more dangerous than retroperitoneal hemorrhage; therefore, a high index of suspi-
medical management alone. In the austere setting, every at- cion should be maintained when the injury mechanism indi-
tempt should be made to maximize medical management (e.g., cates potential retroperitoneal bleeding.
Etco monitoring, hypertonic saline, bed positioning, airway
2
management, sedation, paralysis, keeping the head elevated Although not proven with prospective outcome data, REBOA
and midline). Discuss the patient with and transfer to a neu- has shown potential in the austere environment as a bridge to
rosurgeon as soon as clinically possible. If transport is not prompt surgical intervention, obtain rapid proximal vascular
39
possible, the provider should attempt to seek the guidance of hemorrhage control, reduce blood transfusion requirements,
a neurosurgeon in real time. In the absence of proper imaging, improve exposure by reducing hemorrhage, facilitate rapid
burr holes or needle drainage of suspected epidural hemato- normalization of hemodynamics, and as a force multiplier
50
mas are discouraged. See the “JTS Emergency Cranial Pro- during MASCAL scenarios. 51,52 Early femoral arterial access
cedures by Non-neurosurgeons in Deployed Setting CPG.” 40 (18 gauge A-line, 4Fr or 5Fr micropuncture) and monitoring
can help identify patients who will die of hemorrhage earlier.
Placing arterial access is strongly encouraged and does not re-
Ophthalmology
quire placement of a REBOA but improves monitoring. This
Trained ophthalmologists are never available in this envi- can be upsized to the 7Fr femoral sheath for balloon occlusion
ronment and every attempt should be made to contact an should the patient deteriorate. The sheath may be left in situ

Austere Resuscitative and Surgical Care Guidelines | 29