Page 14 - 2022 Spring JSOM

c. Casualty with airway obstruction or impending airway – If the casualty has a chest seal in place, burp or
obstruction: remove the chest seal.
• Allow a conscious casualty to assume any position – Establish pulse oximetry monitoring.
that best protects the airway, to include sitting up – Place the casualty in the supine or recovery po-
and/or leaning forward. sition unless he or she is conscious and needs to
• Use a chin lift or jaw thrust maneuver sit up to help keep the airway clear as a result of
• Use suction if available and appropriate maxillofacial trauma.
• Nasopharyngeal airway or – Decompress the chest on the side of the injury
• Extraglottic airway (if the casualty is unconscious) with a 14-gauge or a 10-gauge, 3.25-inch needle/
• Place an unconscious casualty in the recovery position catheter unit.
d. If the previous measures are unsuccessful, perform a sur- • Either the 5th intercostal space (ICS) in the anterior
gical cricothyroidotomy using one of the following: axillary line (AAL) or the 2nd ICS in the mid-clavic-
• Bougie-aided open surgical technique using a flanged ular line (MCL) may be used for needle decompres-
and cuffed airway cannula of less than 10 mm outer sion (NDC.) If the anterior (MCL) site is used, do not
diameter, 6–7 mm internal diameter, and 5–8 cm of insert the needle medial to the nipple line.
intratracheal length. • The needle/catheter unit should be inserted at an an-
• Standard open surgical technique using a flanged gle perpendicular to the chest wall and just over the
and cuffed airway cannula of less than 10mm outer top of the lower rib at the insertion site. Insert the
diameter, 6–7 mm internal diameter, and 5–8 cm of needle/catheter unit all the way to the hub and hold
intra-tracheal length. it in place for 5–10 seconds to allow decompression
• Use lidocaine if the casualty is conscious. to occur.
e. Cervical spine stabilization is not necessary for casual- • After the NDC has been performed, remove the nee-
ties who have sustained only penetrating trauma. dle and leave the catheter in place.
f. Monitor the hemoglobin oxygen saturation in casualties – If a casualty has significant torso trauma or pri-
to help assess airway patency. mary blast injury and is in traumatic cardiac arrest
g. Always remember that the casualty’s airway status may (no pulse, no respirations, no response to painful
change over time and requires frequent reassessment. stimuli, no other signs of life), decompress both
Airway Notes: sides of the chest before discontinuing treatment.
• If an extraglottic airway with an air-filled cuff is used, • The NDC should be considered successful if:
the cuff pressure must be monitored to avoid overpres- – Respiratory distress improves, or
surization, especially during TACEVAC on an aircraft – There is an obvious hissing sound as air escapes
with the accompanying 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 casualty’s signs/
fice and a surgical cricothyroidotomy may be required. symptoms from the suspected tension pneumothorax:
• Surgical cricothyroidotomies should not be performed – Perform a second NDC on the same side of the
on unconscious casualties who have no direct airway chest at whichever of the two recommended sites
trauma unless use of a nasopharyngeal airway and/or an was not previously used. Use a new needle/cathe-
extraglottic airway have been unsuccessful in opening ter unit for the second attempt.
the airway. – Consider, based on the mechanism of injury and
5. Respiration/Breathing physical findings whether decompression of the
a. Assess for tension pneumothorax and treat, as necessary. opposite side of the chest may be needed.
• Suspect a tension pneumothorax and treat when – Continue to re-assess!
a casualty has significant torso trauma or primary • If the initial NDC was successful, but symptoms later
blast injury and one or more of the following: recur:
– Severe or progressive respiratory distress – Perform another NDC at the same site that was
– Severe or progressive tachypnea used previously. Use a new needle/catheter unit
– Absent or markedly decreased breath sounds on for the repeat NDC
one side of the chest – Continue to re-assess!
– Hemoglobin oxygen saturation < 90% on pulse • If the second NDC is also not successful: continue on
oximetry to the Circulation section of the TCCC Guidelines.
– Shock b. All open and/or sucking chest wounds should be treated
– Traumatic cardiac arrest without obviously fatal by immediately applying a vented chest seal to cover the
wounds defect. If a vented chest seal is not available, use a non-
◆ If not treated promptly, tension pneumotho- vented chest seal. Monitor the casualty for the potential
rax may progress from respiratory distress to development of a subsequent tension pneumothorax. If
shock and traumatic cardiac arrest. the casualty develops increasing hypoxia, respiratory
• Initial treatment of suspected tension pneumothorax: distress, or hypotension and a tension pneumothorax is

12 | JSOM Volume 22, Edition 1 / Sping 2022