Page 94 - JSOM Fall 2022

Operational Consideration for

Definitive Airway Management in the Austere Setting
A Case Report

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Jean-Baptiste Morvan, MD *; Jean Cotte, MD ; Marc Danguy des Deserts, MD ;
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Tamara Worlton, MD ; William Menini ; Olivier Cathelinaud, MD ; Pierre Pasquier, MD 7
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ABSTRACT
In modern and asymmetric conflicts, traumatic airway ob­ anesthetist). In its standard format, SLM is stored in eight
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struction caused by penetrating injury to the face and neck sealed containers with a total volume of 4m and a weight
anatomy is the second leading cause of preventable mortal­ ranging between 650 kg and 1 ton. The SLM capacity is in­
ity. Definitive airway management in the emergency setting tended to stabilize one or two severe combat casualties with
is most commonly accomplished by endotracheal intubation. the primary role of resuscitation and damage control surgery.
When this fails or is not possible, a surgical airway, usually cri­ In our recent experience, the SLM has been called upon to
cothyrotomy, is indicated. The clinical choice for establishing care for many more casualties that originally intended. In such
a definitive airway in the austere setting is impacted by oper­ situations, triage had to be performed, and adaptation of per­
ational factors such as a mass casualty incident or availability sonnel and equipment were required.
and type of casualty evacuation. This is a case report of a pa­
tient with severe cervicofacial injuries with imminent airway
compromise in the setting of a mass casualty incident, without Case Presentation
possibility of sedation and mechanical ventilation during his In 2016, SLM was deployed to provide surgical support of
evacuation. The authors seek to highlight the considerations allied forces with no forward surgical capabilities available.
and lessons learned for emergency cricothyrotomy. The host nation military command asked the coalition forces,
including the SLM, to provide forward surgical teams as in­
Keywords: Tactical Combat Casualty Care; cricothyrotomy; air- termediate medical treatment facilities between the front line
way; mass casualties; medical evacuation and the geographically distant local hospitals. Casualties were
immediately transported by host nation ambulance to the
SLM, approximately at 15 minutes from the frontline. The
SLM received combat casualties with no notification. Some
Introduction
arrived with only tenuous peripheral intravenous access and
In modern and asymmetric conflicts, traumatic airway obstruc­ hemostatic dressings. The ambulance staff were not able to
tion caused by penetrating injury to the face and neck is still perform tube thoracostomy or definitive airway management.
the second leading cause of preventable mortality. Definitive Additionally, they did not apply tourniquets. The SLM per­
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airway management in the resource­rich emergency setting is formed triage, emergency lifesaving surgical intervention, and
most commonly accomplished by endotracheal intubation. ensured rapid medical evacuation to host nation facilities. The
However, when this fails or is not feasible, a surgical airway, host nation facilities, which routinely dealt with war injuries,
usually cricothyrotomy, is indicated. This is a case report of a were at least a 2­hour drive from the front line. Helicopter
unique situation where endotracheal intubation was not indi­ evacuation was possible in thirty minutes. Ambulances and
cated and immediate surgical airway was needed in an austere helicopters were equipped with oxygen and staffed by a nurse
setting. and, more rarely, by a local physician. The ability to transfer
a mechanically ventilated or sedated patient was determined
Military operations of the French Armed Forces in the most by the SLM anesthesiologist­intensivist depending on tactical
austere combat settings may require the deployment of the considerations and the patient’s condition.
Surgical Life­Saving Module (SLM). SLM is a rapidly deploy­
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able (operational in 45 minutes) and highly mobile forward During a mass casualty incident (40 casualties in 2 hours, 60
surgical asset. The SLM team consists of a general trauma sur­ total casualties), the SLM received a 28­year­old Allied soldier,
geon (visceral or thoracic surgeon), a head and neck trauma wounded by an improvised explosive device on the frontline.
surgeon (oral and maxillofacial surgeon, otolaryngologist He presented with a compromised airway, due to active hem­
or neurosurgeon), an anesthesiologist­intensivist, and two orrhage precipitated by a large (15­cm) foreign body in the left
specialized nurses (one operating room nurse and one nurse mandibular angle (Figure 1).
*Correspondence to jbmorvan@hotmail.com
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1 LCL Jean-Baptiste Morvan and COL Olivier Cathelinaud are physicians in the Department of Otorhinolaryngology and Head and Neck Sur­
gery, Sainte Anne Military Training Hospital, Toulon, France. LCL Jean Cotte is a physician and CWO William Menini is affiliated with the
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Intensive Care Unit, Sainte Anne Training Military Hospital, Toulon, France. LCL Marc Danguy des Deserts is affiliated with the Intensive Care
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Unit, Clermont Tonnerre Training Military Hospital, Brest, France. CDR Tamara Worlton is a physician in the Department of Surgery, Uni­
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formed Services University of the Health Sciences, Bethesda, MD. COL Pierre Pasquier is a physician in the Intensive Care Unit, Percy Military
Training Hospital, Clamart, France and is affiliated with the Ecole du Val de Grâce, French Military Medical Academy, Paris, France.
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