Page 146 - JSOM Fall 2020

of BVM ventilation may lead to poor patient cooperation, ab- Easy bilateral rise and fall of the chest + misting of the
normal tidal volumes, gastric insufflation (and resultant regur- tube + no signs of gastric insufflation. (Reassess fre-
gitation/aspiration), or other complications. quently and have another medic double check if unsure.)
• Better: Minimum plus portable capnometer. Ultrasound
The decision to perform a cricothyroidotomy is one that if trained/available to guide and/or verify placement
is sometimes difficult. When possible, in urgent but not emer- • Best: Continuous ETCO /waveform capnography
2
gency situations, a telemedicine call should be considered to
help with medical decision making. Verification of correct tube placement must be performed ev-
ery time as incorrect tube placement may be fatal. The REACH
An important adjunct to passing an endotracheal tube, either via study showed that right mainstem and hypopharynx place-
5
the cricothyroid membrane or the oropharynx, is the use of a ment are the most common locations of incorrect placement
gum elastic bougie (sometimes also referred to as an Eschmann of ETT. Esophageal intubation is also common. Subcutaneous
stylet or simply bougie). This device is simple, rugged and placement of cricothyroidotomy tube may occur. Use capnog-
should be used to guide tube placement. The bougie is placed in raphy to verify correct tube placement as tube misplacement
the trachea before the endotracheal tube and may be used first can be fatal. Auscultate, if possible, to verify bilateral breath
to confirm proper positioning by either tactile discrimination sounds. If ultrasound is available, this can be used to further
(feeling the tube bump against the tracheal rings on introduc- verify placement in the correct position. 11
tion), or by encountering a hard stop when abutted against the
carina. An endotracheal tube is then introduced over the bougie IV/IO ACCESS
into the trachea. Last, the bougie is removed. A bougie may • Minimum: If (IV)/intraosseous (IO) attempts fail or
also be used to change tubes in the case of a tube malfunction. when unavailable: medication may be given intramuscu-
This may be accomplished by placing a bougie in a tube that is larly or intranasally for immediate sedation to facilitate
currently positioned, remove the tube over the bougie (ensuring surgical cricothyroidotomy. Continue attempts at IV/IO
the bougie remains in the proper position within the airway lu- access after airway has been controlled
men), and replacing a new tube over that bougie. Remove the • Better: 1–2 patent IV/IO
bougie, leaving the new tube in place. Confirmation procedures • Best: 2–3× patent IV/IO with additional IO device on
discussed below must be repeated once the new tube is in place. standby

Consistent with TCCC guidelines, the routine use of orotra- Though an important consideration to administer medications
cheal intubation is not recommended as the minimum stan- and fluids, do not delay an emergent airway to obtain IV/IO
dard in PFC. This procedure requires considerable skill and access in the instance you are the sole provider.
sustainment and requires appropriate sedation for both
10
rapid sequence intubation and post-intubation management. If Ultrasound may be used to help identify small or deep veins.
a provider is appropriately trained, current and practiced in Ultrasound-guided IV access may be attempted if trained.
the procedure, and has the required support equipment and Other sites to consider for superficial IV attempts include the
medications, then orotracheal intubation may be considered. external jugular and saphenous veins. If appropriately trained,
Although preferred when possible, training in orotracheal in- consider central venous access or venous cutdown.
tubation is not required to obtain a definitive airway in the
PFC operational setting. Consider basic measures first before DRUGS
proceeding to either type of invasive airway. Additional details Airway Placement
on orotracheal intubation are included in the JTS Airway CPG. • Minimum: Local anesthetic for cricothyroidotomy (su-
perficial skin anesthesia plus 1–2 mL injected through
Airway management in the tactical setting requires a dif- the cricothyroid membrane); or placement without med-
ferent conceptual approach than airway management in the ications in unconscious patient.
hospital, or even the civilian prehospital environment. Differ- **Note: most sedating agents can be given IM if IV/IO
ences in epidemiology, injury patterns, equipment and envi- has not been established
ronment must be considered if airway management is to be • Better: Any IV/IO sedating agent (opioid, benzodiaze-
optimized. First, most military casualties requiring a prehos- pine: reference the Analgesia and Sedation Management
pital airway have trauma to the head, face or neck. Surgical for PFC CPG for procedural doses of such agents). 12
airway is often the final common pathway due to bleeding or • Best: Procedural dose ketamine (1–2mg/kg IV push) for
distorted anatomy. In comparison, most airways in the civilian ETT or cricothyroidotomy placement + local anesthetic
prehospital environment are placed in elderly people for car- (lidocaine) for cricothyroidotomy placement
diac arrest. When reliable suction and oxygen delivery are not
available, or personnel are not experienced in rapid sequence Prolonged Sedation
intubation using neuromuscular blockade, a definitive airway (post-airway placement)
will often mean a surgical airway. • Minimum (without IV access): Ketamine (sedation dose),
3–4mg/kg IM
Proper Tube Placement • Better: IV/IO pushes of ketamine, opioid, and/or mid-
azolam (alone or in combination as per the individu-
• Minimum: Visualization of the tube passing through al’s scope of practice, experience, and availability of
the vocal cords (in the case of endotracheal intubation); medications)
auscultation of epigastric region (should be silent) and • Best: Ketamine IV/IO Drip. Hydromorphone or alter-
bilateral lung sounds (should be present). Colorimetric nate opioid IV/IO push for breakthrough pain and mid-
capnography + endotracheal detection device (EDD).
azolam IV/IO push as needed for sedation

144 | JSOM Volume 20, Edition 3 / Fall 2020