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medications shape the best management techniques. Considerations oxygen saturation can be measured using a pulse oximeter which
include: limited availability of supplemental oxygen; medications for provides a measurement of hemoglobin saturation and, by inference,
induction/rapid sequence intubation, paralysis, and post-intubation the effectiveness of measures to oxygenate a patient. Ventilation can
management; and limitations in available equipment. Another reality be monitored with end-tidal carbon dioxide. The use of these tools
is limitations in sustainment training options, especially for advanced together in a PCC environment provides estimates of oxygen trans-
airway techniques. Due to these challenges, some common recom- port to the cells, tissue metabolism, and adequacy of ventilation.
mendations that may be considered “rescue” techniques in standard ■ Providers in the PCC environment can adopt, implement, moni-
hospital airway management may be recommended earlier or in a tor, and sustain respiration using concepts of manipulating minute
non-standard fashion to establish and control an airway in a PCC ventilation (respiratory rate multiplied by tidal volume). Put sim-
environment. Patients who require advanced airway placement tend ply, it is the number of times a patient is breathing each minute
to undergo more interventions, be more critically injured, and ulti- multiplied by the amount of air breathed in with each breath.
mately have a higher proportion of deaths. The ability to rapidly and ■ Support of adequate minute ventilation can be performed in an es-
consistently manage an airway when indicated, or spend time on other calating algorithm with rescue breathing, bag valve mask assisted
resuscitative needs when airway management is not indicated, may ventilation, and mechanical ventilation. Each of these methods may
contribute to improved outcomes (see Table 3). 7,8 require escalation of airway management skills and respiratory
skills. Manipulation of any of the variables of minute ventilation
Respiration and Ventilation – CAPT Mike Tripp, will alter gas exchange. Therefore, medical providers in the PCC
LCDR Nic Rohrhoff, Don Adams environment at all levels will need to be competent with the moni-
toring devices appropriate to their level of training. At a minimum,
Background all providers with specific medical training should be competent to
Respiration is the process of gas exchange at the cellular level. Oxygen use and interpret the previous paragraph’s monitoring devices.
is conducted into the lung and taken up by the blood via hemoglo- ■ The causes of respiratory failure can overlap and become confus-
bin to be transported throughout the body. In the peripheral tissues, ing. When in doubt and whenever possible, initiate a Telemedicine
carbon dioxide is exchanged for oxygen, which is transported by the Consultation for further guidance and input.
blood to the lungs, where it is exhaled. This process is essential to
cellular and organism survival. Dysfunction of this process is a feature Circulation And Resuscitation – Justin Rapp, 18D;
of multiple-injury patterns that can lead to increased morbidity and Dr Andrew Fisher
mortality (see Table 4).
Background
Additional Considerations PCC presents a unique challenge for implementing damage control re-
■ When in a PCC environment, simple monitoring technologies are suscitation (DCR) as defined by the JTS guideline. PCC goes beyond
able to be used by most providers in each of the provider categories DCR and should bridge the gap between the prevention of death,
to ensure adequate gas exchange and oxygen delivery. Peripheral the preservation of life, and definitive care. The goals are a return to

TABLE 3 PCC Role-based Guidelines for Airway Management
PCC Role-based Guidelines for Airway Management
TCCC - TCCC - TCCC - TCCC - *All Personnel – Complete Basic TCCC Management Plan for Airway then:
ASM CLS CMC CPP Assess for airway problem; use patient positioning per TCCC guidelines to maintain open airway.
• Re-assess airway interventions performed in TCCC.
• Positive end-expiratory pressure (PEEP) valves should be used anytime you are using a bag valve mask.
• Use nasal pharyngeal airway (NPA).
• Ensure all interventions noted above are completed by TCCC ASM and CLS personnel.
• Conduct inventory of all resources.
• Document all pertinent information on PCC Flowsheet (attached).
• Additional interventions include:
Role 1a:
• Re-asses airway before, after and during any patient movement.
• Airway adjuncts with an inflatable cuff such as ET or cricothyrotomy tube or inflatable laryngeal mask airways
(LMA) should be assessed for proper inflation levels to ensure that they are not under or over inflated.
• Inflate the cuff with a 10mL syringe and then releasing your thumb from the plunger to let the plunger equalize.
Role 1b:
• Re-assess airway before, after and during any patient movement.
• Airway adjuncts with an inflatable cuff such as ET or cricothyrotomy tube or inflatable laryngeal mask airways
(LMA) should be assessed for proper inflation levels to ensure that they are not under or over inflated.
• Inflate the cuff with a 10mL syringe and then releasing your thumb from the plunger to let the plunger equalize.
Role 1c:
• Airway adjuncts with an inflatable cuff such as ET or cricothyrotomy tube or inflatable LMA should be assessed
for proper inflation levels to ensure that they are not under or over inflated.
• Mechanical suction device and yankauer suction for suctioning out the oropharynx.
• Airway adjuncts should be assessed for efficacy by checking the patient’s work of breathing, ETCO and pulse
2
oximetry levels.
• Mouth care should be performed per the attached nursing care checklist in appendix.
• Ensure above interventions are completed by TCCC ASM, CLS and CMC personnel.
• Conduct inventory of all resources.
• Document all pertinent information on PCC Flowsheet (attached).
• Additional interventions include:
Role 1a:
• Re-assess all prior MARCH interventions.
Role 1b:
• Re-assess cuff pressures per above.
• Continued assessment of patient’s work of breathing, ETCO and pulse oximetry levels.
2
Role 1c:
• Inflate and periodically check cuff pressures with a cuff manometer to a goal of 20mmHg.
• Use heat moisture exchanger to keep contaminants out and endogenous heat and moisture in the lungs.
• Inline suction catheter for suctioning airway adjunct as indicated.
*Link to Airway Management in Prolonged Field Care, 01 May 2020 9

Prolonged Casualty Care Guidelines | 21