Page 147 - JSOM Fall 2020

(Reference Analgesia and Sedation Management in PFC CPG 3. Number and percentage of patients who had definitive air-
12
for details and drug doses. ) way (endotracheal tube, cricothyroidotomy, tracheostomy)
with ETCO documented at the same role of care where the
2
Be cautious with sedation, advanced airway placement and procedure is done.
positive pressure ventilation in patients who are hypotensive
or under-resuscitated. Blood pressure can fall rapidly during DATA SOURCES
airway management due to a variety of mechanisms. • Patient Record
• Department of Defense Trauma Registry (DoDTR)
In all cases, monitor BP closely (every 1–2 minutes during the
procedure, every 3–5 minutes for 15 minutes post-procedure). SYSTEM REPORTING AND FREQUENCY
A BP drop may be brief (if due to vagal effects of epiglot- The above constitutes the minimum criteria for PI monitor-
tis stimulation during ETT placement) or sustained (due to ing of this CPG. System reporting will be performed annually;
positive pressure ventilation, increased intrathoracic pressure additional PI monitoring and system reporting may be per-
and decreased venous return to the heart). Loss of sympathetic formed as needed.
drive secondary to pain and sedation medications, and/or con-
tinued hypovolemia can also result in hypotension. Continue The system review and data analysis will be performed by the
resuscitation with blood products (trauma patients) or crys- Joint Trauma System (JTS) Director, JTS Program Manager,
talloid (non-trauma patients) if a hypotensive patient requires and the JTS PI Branch.
immediate airway interventions. Be prepared to support blood
pressure with vasopressors (e.g. epinephrine bolus or drip) if RESPONSIBILITIES
trained or under direct telemedicine guidance. It is the trauma team leader’s responsibility to ensure famil-
iarity, appropriate compliance and PI monitoring at the local
Neuromuscular blockade (succinylcholine, rocuronium, ve- level with this CPG.
curonium, etc.) is NOT recommended for use by the average
practitioner of PFC. Though these are standard medications to References
use in rapid sequence intubation and ventilator management, 1. Eastridge BJ, Mabry RL, Sequin P, et al. Death on the battlefield
their potential lethality in inexperienced hands does not jus- (2001-2011): implications for the future of combat casualty care.
tify routine recommended use. If trained and/or under direct J Trauma Acute Care Surg. 2012;73(6 suppl 5):S431–S437.
supervision of telemedicine support, the use of neuromuscular 2. Hudson I, Blackburn MB, Mannsalinas EA, et al. Analysis of
casualties that underwent airway management before reaching
blockade may be considered, subject to local medical direction role 2 facilities in the Afghanistan conflict 2008-2014. Mil Med.
and protocols. 2020;185(suppl 1):10–18.
3. Blackburn MB, April MD, Brown DJ, et al. Prehospital airway
procedures performed in trauma patients by ground forces in
Performance Improvement (PI) Monitoring Afghanistan. J Trauma Acute Care Surg. 2018;85(1S suppl 2):
S154–S160.
POPULATION OF INTEREST 4. Mabry RL. An analysis of battlefield cricothyrotomy in Iraq and
1. All patients who received ETT/cricothyroidotomy/supra- Afghanistan. J Spec Oper Med. 2012;12:17–23.
glottic airway/NPA 5. Adams BD, Cuniowski PA, Muck A, De Lorenzo RA. Registry
2. All patients with compromised airway (initial GCS < 8 or of Emergency Airways arriving at Combat Hospitals (REACH). J
abbreviated injury scale (AIS) head and neck ≥ 3, or AIS Trauma. 2008;64(6):1548–1554.
face ≥ 3). 6. Acosta P, Santisbon E, Varon J. The use of positive end-expira-
tory pressure in mechanical ventilation. Critical Care Clin. 2007;
23(2):251–261.
INTENT (EXPECTED OUTCOMES) 7. Loos PE, Glassman E, Doerr D, et al. Documentation in pro-
1. All injured patients who present with obtundation (GCS longed field care. J Spec Oper Med. 2018;18(1):126–132.
< 8), apnea, respiratory distress or insufficiency, airway ob- 8. Ball J, Keenan S. Prolonged Field Care Working Group position
struction, or impending airway loss will have a secure and paper: prolonged field care capabilities. J Spec Oper Med. 2015;
definitive airway established expeditiously upon arrival to 15(3):76–77.
a Role 2 or Role 3 if not done prehospital. 9. Mabry RL, Kharod CU, Bennett BL. Awake cricothyrotomy: a
2. SpO is maintained ≥ 90%. novel approach to the surgical airway in the tactical setting. Wil-
derness Environ Med. 2017;28(2S):S61–S68.
2
3. Patients with a definitive airway (endotracheal tube, crico- 10. Gillett B, Saloum D, Aghera A, Marshall JP. Skill proficiency is
thyroidotomy, tracheostomy) have ETCO monitoring to predicted by intubation frequency of emergency medicine attend-
2
confirm airway placement. ing physicians. West J Emerg Med. 2019;20(4):601–609.
11. Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the con-
PERFORMANCE/ADHERENCE METRICS firmation of endotracheal tube intubation: a systematic review
and meta-analysis. Ann Emerg Med. 2018;72(6):627–636.
1. Number and percentage of patients in the population of 12. Pamplin J, Fisher A, Penny A, et al. Analgesia and sedation man-
interest who had a secure and definitive airway (endotra- agement during prolonged field care. J Spec Oper Med. 2017;17
cheal tube, cricothyroidotomy, tracheostomy) established (1):106–120.
or verified, or documentation of appropriate intervention.
2. Number and percentage of patients in the population of
interest with SpO < 90%, < 80%, < 70%, < 60%.
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