Page 143 - JSOM Fall 2020

Airway Management in Prolonged Field Care

Collin Dye; Sean Keenan; Brandon Carius; Paul Loos; Michael Remley; Brandon Mendes;
Jacob L. Arnold; Ian May; Douglas Powell; Joshua M. Tobin; Jamie Riesberg; Stacy Shackelford

Purpose
This Role 1, prolonged field care (PFC) clinical practice guide- • Massive facial trauma
line (CPG) is intended to be used after Tactical Combat Casu- • Burns to the face or inhalation injury with hoarseness
alty Care (TCCC) Guidelines, when evacuation to higher level or stridor
of care is not immediately possible. A provider must first and • Massive neck trauma
foremost be an expert in TCCC, the Department of Defense • Expanding neck mass/hematoma
standard of care for first responders. The intent of this PFC • Acute pharyngeal infection (retropharyngeal abscess,
CPG is to provide evidence and experience-based solutions peritonsillar abscess, epiglottitis)
to those who manage airways in an austere environment. An • Foreign body aspiration
emphasis is placed on utilizing the tools and adjuncts most • Anaphylaxis (airway swelling)
familiar to a Role 1 provider. The PFC capability of airway
is addressed to reflect the reality of managing an airway in INSUFFICIENT OXYGENATION OR VENTILATION
a Role 1 resource-constrained environment. A separate Joint These indications may be apparent on initial evaluation or may
Trauma System CPG will address mechanical ventilation. This emerge during the course of patient management. If the need
PFC CPG also introduces an acronym to assist providers and to establish an airway develops more gradually, additional
their teams in preparing for advanced procedures, to include elective airway techniques can be employed. Interventions such
airway management. as prolonged manual bag or mechanical ventilation require
an airway intervention to ensure best overall management.
Examples include:
Background
• Chest wall and pulmonary trauma (blunt or penetrat-
Airway compromise is the second leading cause of poten- ing) such as flail segments, pulmonary contusions (from
1
tially survivable death on the battlefield after hemorrhage. blast, blunt or crush mechanism)
Complete airway occlusion can cause death from suffocation • Burns with greater than 40% body surface area
within minutes. Austere environments present significant chal- • Traumatic brain injury with decreased level of con-
lenges with airway management. Limited provider experience sciousness (GCS ≤ 8)
and skill, equipment, resources, and medications shape the • Traumatic brain injury with suspected herniation requir-
best management techniques. Considerations include: limited ing hyperventilation (target ETCO between 30 and 35)
availability of supplemental oxygen; medications for induc- • Procedural sedation or surgical procedure
2
tion/rapid sequence intubation, paralysis, and post-intubation • Respiratory failure from disease, infection, or injury:
management; and limitations in available equipment. An- o Chemical or toxic inhalation injuries
other reality currently is limitations in sustainment training o Acute respiratory distress syndrome (ARDS) from in-
options, especially for advanced airway techniques. Due to fection, massive resuscitation, drug-induced or other
these challenges, some common recommendations that may causes
be considered “rescue” techniques in standard hospital air- o Primary lung infection (pneumonia)
way management may be recommended earlier or in a non- o Massive pulmonary embolism
standard fashion to establish and control an airway in a PFC o TRALI (transfusion-related acute lung injury) or
environment. Patients who require advanced airway place- TACO (transfusion associated circulatory overload)
ment tend to undergo more interventions, be more critically due to massive transfusion
injured, and ultimately have a higher proportion of deaths.
The ability to rapidly and consistently manage an airway Machine, Suction, Monitor, Airway, Intravenous
when indicated, or spend time on other resuscitative needs Access, Drugs
when airway management is not indicated, may contribute to
improved outcomes. 2,3 Checklists are commonly used in medical practice. In prepara-
tion for an advanced procedure (including securing an airway)
using an acronym or other checklist approach will prove in-
Indications for Airway Management valuable. One such acronym, originally developed as a simple
DISRUPTED FACE OR NECK ANATOMY pre-operative anesthesia checklist, is presented.
If managing an isolated injury that disrupts face or neck anat-
omy, healthy adults may only need a mechanical airway placed The MSMAID acronym (Machine, Suction, Monitor, Airway,
and may not require assisted ventilation if they are not heavily Intravenous access, Drugs) organizes an approach to prepa-
sedated. Examples of conditions requiring early airway man- ration for airway management and may also prove useful in
agement include: preparation for other procedures.

141