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ABSTRACT: Optimal fluid resuscitation on the battlefield 2017;17(3):146–147
in the absence of blood products remains unclear. Contem- (Interview) We Cannot Afford to Lose the Lessons We Have
porary Combat medics are generally limited to hydroxyethyl Learned: COL (Ret) Rob Lutz’s Reflections on a 20-Year SOF
starch or crystalloid solutions, both of which present signifi- Medical Career Pennardt A
cant drawbacks. Obtaining US Food and Drug Administration
(FDA)-approved freeze-dried plasma (FDP) is a top casualty Keywords: interviews; Tactical Combat Casualty Care
care research priority for the US Military. Interest in this agent
reflects a desire to simultaneously expand intravascular vol- 2017;17(4):19–28
ume and address coagulopathy. The history of FDP dates to Extraglottic Airways in Tactical Combat Casualty Care:
the Second World War, when American expeditionary forces TCCC Guidelines Change 17-01 28 August 2017 Otten EJ,
used this agent frequently. Also fielded was 25% albumin, Montgomery HR, Butler FK
an agent that lacks coagulation factors but offers impressive ABSTRACT: Extraglottic airway (EGA) devices have been
volume expansion with minimal weight to carry and requires used by both physicians and prehospital providers for several
no reconstitution in the field. The current potential value of decades. The original TCCC Guidelines published in 1996 in-
25% albumin is largely overlooked. Although FDP presents cluded a recommendation to use the laryngeal mask airway
an attractive future option for battlefield prehospital fluid re- (LMA) as an option to assist in securing the airway in Tactical
suscitation once FDA approved, this article argues that in the Evacuation (TACEVAC) phase of care. Since then, a variety of
interim, 25% albumin, augmented with fibrinogen concen- EGAs have been used in both combat casualty care and civil-
trate and tranexamic acid to mitigate hemodilution effects on ian trauma care. In 2012, the Committee on TCCC (CoTCCC)
coagulation capacity, offers an effective volume resuscitation and the Defense Health Board (DHB) reaffirmed support for
alternative that could save lives on the battlefield immediately. the use of supraglottic airway (SGA) devices in the TACEVAC
Keywords: albumin; fluid resuscitation; Hextend ; colloid; phase of TCCC, but did not recommend a specific SGA based
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Tactical Combat Casualty Care; prolonged field care on the evidence available at that point in time. This paper will
use the more inclusive term “extraglottic airway” instead of
2017;17(2):89–95 the term “supragottic airway” used in the DHB memo. Cur-
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Manikin Human-Patient Simulator Training Horn GT, Bowl- rent evidence suggests that the i-gel (Intersurgical Complete
ing F, Lowe DE, Parimore JG, Stagliano DR, Studer NM Respiratory Systems; http://www.intersurgical.com/info/igel)
EGA performs as well or better than the other EGAs available
ABSTRACT: Background: Human-patient simulators (HPSs) and has other advantages in ease of training, size and weight,
may help enhance medical education. Manikin HPS devices cost, safety, and simplicity of use. The gel-filled cuff in the i-gel
respond to common field medical interventions, such as cri- both eliminates the need for cuff pressure monitoring during
cothyroidotomy, and have realistic feedback features, such as flight and reduces the risk of pressure-induced neuropraxia to
respirations and pulses. This study surveys Special Operations cranial nerves in the oropharynx and hypopharynx as a com-
Medics for evaluations of HPS features. Methods: Of 518 sub- plication of EGA use. The i-gel thus makes the medic’s tasks
jects, 376 completed testing and surveys with valid responses. simpler and frees him or her from the requirement to carry a
A total of 102 variables were divided into three categories-gen- cuff manometer as part of the medical kit. This latest change
eral characteristics, procedures, and injuries-and assessed on a to the TCCC Guidelines as described below does the following
five-point Likert scale. The Student t test was used to analyze things: (1) adds extraglottic airways (EGAs) as an option for
data together and as separate groups against each other and airway management in Tactical Field Care; (2) recommends
against an aggregated mean. Results: Features that received the i-gel as the preferred EGA in TCCC because its gel-filled
high scores (i.e., higher than 4.5/5) corresponded closely with cuff makes it simpler to use than EGAs with air-filled cuffs
pillars of the Tactical Combat Casualty Care (TCCC) curric- and also eliminates the need for monitoring of cuff pressure;
ulum, basic life support, and realism. Discussion: US Army (3) notes that should an EGA with an air-filled cuff be used,
Special Operations Command and US Special Operations the pressure in the cuff must be monitored, especially during
Command Medics have overall high confidence in manikin and after changes in altitude during casualty transport; (4) em-
HPS devices and specifically in those that align with TCCC phasizes COL Bob Mabry’s often-made point that extraglottic
training and lifesaving procedures. The skills most valued airways will not be tolerated by a casualty unless he or she is
coincide with difficult-to-practice measures, such as cricothy- deeply unconscious and notes that an NPA is a better option
roidotomy and wound packing. Features such as prerecorded if there is doubt about whether or not the casualty will toler-
sounds, sex, automated movements, skin color, defibrillation, ate an EGA; (5) adds the use of suction as an adjunct to air-
bowel sounds, and electrocardiogram are rated lower. These way management when available and appropriate (i.e., when
evaluations may guide future development or procurement of needed to remove blood and vomitus); (6) clarifies the word-
manikin HPS devices. ing regarding cervical spine stabilization to emphasize that it is
Keywords: human-patient simulator; manikin; Tactical Com- not needed for casualties who have sustained only penetrating
bat Casualty Care; training trauma (without blunt force trauma); (7) reinforces that sur-
gical cricothyroidotomies should not be performed simply be-
2017;17(2):174–187 cause a casualty is unconscious; (8) provides a reminder that,
(Classical Conference) TacMed Updates: K9 Tactical Emer- for casualties with facial trauma or facial burns with suspected
inhalation injury, neither NPAs nor EGAs may be adequate
gency Casualty Care Direct Threat Care Guidelines Palmer for airway management, and a surgical cricothyroidotomy
LE, Yee A
may be required; (9) adds that pulse oximetry monitoring is a
Keywords: canines; K9s; Operational K9s; Tactical Emergency useful adjunct to assess airway patency and that capnography
Casualty Care should also be used in the TACEVAC phase of care; and (10)

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