Page 108 - JSOM Summer 2022

Management of Acute Lung Injuries

and Acute Respiratory Distress Syndrome in the
Tactical and Prolonged Field Care Setting

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Gordon F. Bagley, SO-ATP, DiMM, NREMT-P ; Christian Ciochirca, MD *

ABSTRACT
The authors examine two acute lung injuries (ALI) that can to assist his breathing but cannot get a reading on your pulse
occur in the tactical setting – positive pressure pulmonary ox. You attempt to listen for lung sounds but the vehicle en-
edema and inhalation injury – as well as acute respiratory dis- gine makes this impossible. You do note equal and bilateral
tress syndrome (ARDS), all of which can quickly progress in rise and fall of the chest and his situation does not deteriorate
a prolonged field care (PFC) environment. These conditions further during the rest of the drive. Upon return to base (RTB)
present complex problems to emergency department (ED) you bring him to the camp clinic for further assessment. He is
and intensive care unit (ICU) teams worldwide, requiring inti- positive for a mild traumatic brain injury (mTBI) after a mili-
mate knowledge of their distinct disease pathophysiology and tary acute concussion evaluation (MACE) exam, has an SpO
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advanced critical care equipment. These challenges are com- of 92%, respiratory rate (RR) of 25, and continues to com-
pounded in the world of the Special Operations Forces (SOF) plain of shortness of breath. He does not wish to lie down and
medic who often operates as the sole provider in environments is clearly uncomfortable. He also states he has been battling a
with both limited resources and prolonged evacuation times. chest cold for the past week but did not want to be pulled from
It is the hope of the authors that by breaking down these com- the mission and therefore he did not tell anyone. Upon exam-
plex critical care topics and providing concrete guidance and ination you note crackles in both lung fields and the patient
treatment recommendations that we can ultimately improve coughs up frothy sputum for the first time which you note is
the care SOF medics provide overseas in an austere opera- tinged with blood. At that moment your team leader walks
tional environment. in and informs you that a weather front has moved in much
sooner than expected and air medevac assets will be unable
Keywords: acute lung injury; ARDS; Special Operations medi- to reach you for up to 48 hours. Ground casualty evacuation
cine; tactical medicine; prolonged field care; positive pressure (CASEVAC) is considered too dangerous due to enemy activity
pulmonary edema; blast lung; inhalation injury and the lack of air support. As the sole medical provider on
camp, it is your responsibility to manage this patient for the
next two days using what supplies you have.
Case Study Introduction
This scenario represents the difficult position that SOF medics
You find yourself as the medic for a SOF team occupying a can find themselves in overseas, shifting in a matter of hours
rural COP in the Eastern Mountains of Afghanistan during between, combat, tactical medicine, and the critical care med-
the winter. Your team and partner force are conducting a night icine of prolonged field care (PFC). Here the casualty received
raid on a compound that is a 2-hour drive away. During clear- a minor to moderate blast injury with no penetrating trauma
ing operations, one of your team members is injured by an in the tactical setting. Under other circumstances, this casu-
improvised explosive device (IED) blast. The blast occurs in alty may have undergone observation and a TBI protocol, and
the far room of the objective building. Your teammate was in made a full return to duty without showing any of the signs
a hallway 20 ft in front of the open door to the room when the or symptoms that were evident by the end of the scenario. So
IED detonated. He was knocked backed 2–3 ft, feels dazed, what happened? The casualty experienced a combination of
and can hear ringing but claims no loss of consciousness. He two acute lung injuries (ALIs), exacerbated by environmental
has several minor cuts and scrapes and is coughing from the factors and a preexisting condition, which are now leading
smoke that quickly flooded the hallway, but has no penetrat- the patient down the road towards acute respiratory distress
ing wounds. Additionally, another teammate ran into the hall- syndrome (ARDS). The first ALI was caused by the explosive
way, pulled him to his feet and the two exited the building pressure wave of the IED in the confined space of the house,
running approximately 100 m to where you were located at a leading to positive pressure pulmonary edema or blast lung
blocking position (BP). After assessment, you categorize him injury (BLI). Compounding this was the inhalation injury your
as minimal but keep him at the BP for continued observation teammate received as he moved through the hallway filled
before evacuating him with the force. During the movement with smoke. Outside, he sprinted through the freezing cold of
back to base he begins to complain of shortness of breath and the Afghan winter night to your position, adding stress to his
continues to cough. You help him into a seated tripod position already damaged lungs, and then remained outside with you in
*Correspondence to christian.ciochirca@gmx.at
1 SFC Gordon F. Bagley is a registered emergency medical technician and is affiliated with the US Army Special Operations Command in Fort
Bragg, NC. LTC Christian Ciochirca is a physician affiliated with the AUT Armed Forces. He was the deputy medical director of the Joint Armed
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Forces and works now as a consultant in anaesthesia and intensive care at the Klinik Hietzing in Vienna, Austria.

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