Page 147 - 2020 JSOM Winter

d. Perform initial assessment for hemorrhagic shock (al- 5. Respiration/Breathing
tered mental status in the absence of brain injury and/ a. Assess for tension pneumothorax and treat, as necessary.
or weak or absent radial pulse) and consider immediate • Suspect a tension pneumothorax and treat when
initiation of shock resuscitation efforts. a casualty has significant torso trauma or primary
4. Airway Management blast injury and one or more of the following:
a. Conscious casualty with no airway problem identified: – Severe or progressive respiratory distress
• No airway intervention required – Severe or progressive tachypnea
b. Unconscious casualty without airway obstruction: – Absent or markedly decreased breath sounds on
• Place casualty in the recovery position one side of the chest
• Chin lift or jaw thrust maneuver or – Hemoglobin oxygen saturation <90% on pulse
• Nasopharyngeal airway or shock oximetry
• Extraglottic airway – Traumatic cardiac arrest without obviously fatal
c. Casualty with airway obstruction or impending airway wounds
obstruction: ■ If not treated promptly, tension pneumotho-
• Allow a conscious casualty to assume any position rax may progress from respiratory distress to
that best protects the airway, to include sitting up shock and traumatic cardiac arrest.
and/or leaning forward. • Initial treatment of suspected tension pneumothorax:
• Use a chin lift or jaw thrust maneuver – If the casualty has a chest seal in place, burp or
• Use suction if available and appropriate remove the chest seal.
• Nasopharyngeal airway or – Establish pulse oximetry monitoring.
• Extraglottic airway (if the casualty is unconscious) – Place the casualty in the supine or recovery po-
• Place an unconscious casualty in the recovery sition unless he or she is conscious and needs to
position sit up to help keep the airway clear as a result of
d. If the previous measures are unsuccessful, perform a sur- maxillofacial trauma.
gical cricothyroidotomy using one of the following: – Decompress the chest on the side of the injury
• Cric-Key technique (preferred option). with a 14-gauge or a 10-gauge, 3.25-inch needle/
• Bougie-aided open surgical technique using a flanged catheter unit.
and cuffed airway cannula of <10mm outer diame- ■ Either the fifth intercostal space (ICS) in the
ter, 6–7mm internal diameter, and 5–8cm of intratra- anterior axillary line (AAL) or the second ICS
cheal length. in the mid-clavicular line (MCL) may be used
• Standard open surgical technique using a flanged for needle decompression (NDC) If the ante-
and cuffed airway cannula of <10mm outer diame- rior (MCL) site is used, do not insert the needle
ter, 6–7mm internal diameter, and 5–8cm of intratra- medial to the nipple line.
cheal length (least desirable option). ■ The needle/catheter unit should be inserted at
• Use lidocaine if the casualty is conscious. an angle perpendicular to the chest wall and
e. Cervical spine stabilization is not necessary for casual- just over the top of the lower rib at the inser-
ties who have sustained only penetrating trauma. tion site. Insert the needle/catheter unit all the
f. Monitor the hemoglobin oxygen saturation in casualties way to the hub and hold it in place for 5–10
to help assess airway patency. seconds to allow decompression to occur.
g. Always remember that the casualty’s airway status may ■ After the NDC has been performed, remove
change over time and requires frequent reassessment. the needle and leave the catheter in place.
– If a casualty has significant torso trauma or pri-
Airway Notes: mary blast injury and is in traumatic cardiac arrest
• The i-Gel is the preferred extraglottic airway because (no pulse, no respirations, no response to painful
its gel-filled cuff makes it simpler to use and avoids the stimuli, no other signs of life), decompress both
need for cuff inflation and monitoring. If an extraglottic sides of the chest before discontinuing treatment.
airway with an air-filled cuff is used, the cuff pressure • The NDC should be considered successful if:
must be monitored to avoid overpressurization, espe- – Respiratory distress improves, or
cially during TACEVAC on an aircraft with the accom- – There is an obvious hissing sound as air escapes
panying pressure changes. from the chest when NDC is performed (this may
• Extraglottic airways will not be tolerated by a casualty be difficult to appreciate in high-noise environ-
who is not deeply unconscious. If an unconscious casu- ments), or
alty without direct airway trauma needs an airway in- – Hemoglobin oxygen saturation increases to 90%
tervention but does not tolerate an extraglottic airway, or greater (note that this may take several minutes
consider the use of a nasopharyngeal airway. and may not happen at altitude), or
• For casualties with trauma to the face and mouth, or – A casualty with no vital signs has return of con-
facial burns with suspected inhalation injury, nasopha- sciousness and/or radial pulse.
ryngeal airways and extraglottic airways may not suf- • If the initial NDC fails to improve the casual-
fice and a surgical cricothyroidotomy may be required. ty’s signs/symptoms from the suspected tension
• Surgical cricothyroidotomies should not be performed pneumothorax:
on unconscious casualties who have no direct airway – Perform a second NDC on the same side of the
trauma unless use of a nasopharyngeal airway and/or an chest at whichever of the two recommended sites
extraglottic airway have been unsuccessful in opening was not previously used. Use a new needle/cathe-
the airway. ter unit for the second attempt.

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