Page 140 - JSOM Fall 2020

This brings a commitment of resources to ventilate and sedate Field providers have the option to deliver analgesia and seda-
the patient, complicates patient transport, and with limited re- tion in metered boluses or via a continuous infusion. Bolus
sources, risks agitation, self-ex tubation, and psychologic harm administration requires less training and equipment. These are
when ventilator batteries and sedating medications run out. 9 given at regular intervals with observation for effect and re-
peat dosing as needed. Infusions can be beneficial when man-
First-pass success of prehospital intubation has been noted aging multiple casualties as there are fewer opportunities for
as 69% for medics and 87% for physicians, with proficiency cross contamination and needle stick injuries, with the poten-
met when performing more than 18 intubations annually, and tial of using less medication in a resource poor environment.
expert status at more than 304 per year. In initial training, For Pararescue, the addition of continuous infusions would be
healthcare personnel required a minimum of 57 intubations another competency requirement above their baseline training
to be considered competent, but despite this level of training, on bolus administration. For our PJs we will continue using
almost 20% of the individuals still required assistance from boluses as the primary sedative and analgesic administration
proficient providers. 10,11 PJs, like most medics, rarely perform technique with the option for continuous infusion for those
intubations on live patients after initial training. Advocacy for trained and comfortable with the technique.
mandatory clinical rotations rich in airway management op-
portunities is critical. Wound Care
The severely burned patient must contend with loss of the
Not all patients with airway burn injury ultimately require skin’s natural abilities to regulate temperature, prevent mois-
intubation, and unnecessary intubation may compromise the ture loss, defend against opportunistic infections and pro-
clinical outcome of burned patients due to complications of vide an elastic covering. 19,20 A key component of burn care
aspiration and ventilator associated pneumonia, tracheobron- consists of evaluating for circumferential eschar which could
chitis, tracheoesophageal fistula, and bronchopulmonary dys- lead to compartment syndrome or compromised ventilation.
plasia. 12,17 Although the patient who was intubated vomited Escharotomy is a crucial skill for the management of severe
during the attempt, we obtained follow-up and he did not burns and does not require significant equipment to perform.
develop an aspiration pneumonia. Due to reflexive actions In training, drills incorporate drawing incision lines and mak-
of the upper airway, frequently, most inhalational burn inju- ing escharotomy incisions on cadavers under surgical direc-
ries should not require intubation due to a lack of vocal cord tion. While escharotomy can be a bloody procedure when
edema. In the hospital setting patients with soot in the oral electrocautery is not used, the PJs were able to maintain he-
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cavity, facial burns, or body burns should undergo fiberoptic mostasis using hemostatic gauze dressing with direct pressure.
laryngoscopy to view laryngeal edema, after which the visu-
alization of edema is the primary driver for intubation. This When topical antibiotics such as silver sulfadiazine or mafenide
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practice is impractical in field conditions. acetate are unavailable, dry sterile dressings should be applied
after initial debridement. Ideally, wounds would be debrided
Therefore, our policy is to monitor patients closely if they have twice daily and topical agents reapplied afterward. The wound
signs of airway injury, have all gear at the bedside prepared, should be inspected at each debridement for any degeneration
and intervene for stridor or respiratory distress. This practice such as darkening or malodor, which may indicate wound sep-
is based on the difficulty of prehospital intubation by para- sis. If there are signs of sepsis, parenteral antibiotics should be
medics, the fact that not all burned airways require intubation, initiated followed by expedited evacuation to a surgeon ca-
the potential for complications from successful and failed in- pable of burn excision. During this mission, dry sterile dress-
tubations, and the ability to conserve resources if the patient ings were used without application of topical antibiotics due
does not require intubation. Resources include manpower, to limitations of gear space with priority given to resuscita-
expertise, supplemental oxygen, and medications. This policy tion fluids during pack-out. The use of dry sterile dressings
was recommended specifically for PJs by Roger Yurt, MD (for- changed every 24 hours is a simple, logisti cally feasible, and
mer director of the NYP/Cornell burn unit). accepted treatment (personal communications over time by
R.S. with senior ICU physician at the US Army Burn Center
On this mission, thermal injury and fluid resuscitation resulted and staff at NY Presbyterian/Cornell FDNY Burn Unit).
in progressive, symptomatic airway edema requiring intuba-
tion and cricothyroidotomy. In the PFC setting of inhalation Lessons Learned
injury, clear airway compromise (stridor and respiratory dis-
tress) should be present before proceeding with emergent in- PJs and SOF medics must be comfortable with rapid sequence
tubation or surgical airway. This recommendation is based on intubation (RSI) and the use of paralytics. To meet this goal,
risk-benefit analysis for Special Operations paramedics, and the Special Operations medical community should mandate
not for well-supplied resuscitation or surgical teams with air- clinical rotations in anesthesia or emergency medicine, which
way experts. allow intubation and ventilator management. Provide clinical
rotations in anesthesia or emergency medicine with focus on
Analgesia and Sedation RSI and intubation skills.
In 2018 a consensus statement was issued promoting the use of
ketamine as a stand-alone analgesic and adjunct to opioids. Mission planning for 72 hours and the basic concepts of PFC
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Ketamine has been shown to act as antiallodynic and antihy- drove pack-out for long-term patient management. Beyond
peralgesic, producing pain relief in burn patients. Fentanyl (a planning for stabilizing the patients and the critical care gear,
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µ-opioid receptor agonist) is a mainstay for acute pain man- we have considered additional PFC needs (personal protective
agement in burn ICUs; however, there is an increased medi- equipment, contractor bags, patient hygiene supplies, etc.).
cation requirement for burn patients beyond standard dosing From a supply standpoint, obtaining large volumes (>50L) of
and these patients often develop tolerance. 16–18 RL for fluid resuscitation presented a logistical challenge and

138 | JSOM Volume 20, Edition 3 / Fall 2020