Page 96 - JSOM Fall 2022

preventable death on the battlefield, behind compressible hem­ the use of local anesthesia due to the theoretical risk of obscur­
orrhage and tension pneumothorax. 1,5–7 SLM was designed to ing the anatomic landmarks. However, this case report high­
address these three leading causes of battlefield mortality with lights the pitfalls of this approach. A critical appraisal of the
3
a small surgical team as close to the frontline as possible. The evidence on this subject should form the basis of a new version
SLM has a smaller footprint than the French role 2 or 3 and of those guidelines.
can be deployed for small­scale military operations with fewer
personnel involved, such as the Special Operations Forces. 8–10
The SLM is comparable to the US surgical resuscitation teams Conclusion
(SRTs) and forward surgical teams (FSTs). 11,12 Trauma surgical Definitive airway technique in the austere setting can be im­
support is flexible and rapidly mobile. pacted by imminent incoming casualties and the capability of
further medical evacuation. Emergency cricothyrotomy should
Airway management is critical to conduct damage control be a comfortable capability of forward surgical teams such
strategies. Definitive airway management in the emergency as French SLM. This case report illustrates these challenges
setting is most commonly accomplished by endotracheal intu­ and highlights lessons learned such as the use of local anesthe­
bation. When endotracheal intubation fails or is not possible sia and higher dose of ketamine for patient comfort. Further
because of traumatic injury to the face, neck, or upper airway, expert consensus on how and when to perform an emergent
a surgical airway, usually cricothyrotomy, is indicated. 13,14 cricothyrotomy in the austere setting is still needed.
In certain situations, the medical intervention of choice is a
definitive airway with tracheal intubation. However, rapid Author Contributions
sequence intubation (RSI) is not practical in all situations JBM, JC, and PP conceived the study concept. JBM and WM
for one individual to acutely manage, such as with multiple coordinated and collected the data, and JC and OC analyzed
15
trauma patients, or if RSI medications are not available. In the data. JC, MDD, TW, and PP revised the manuscript. JBM
the case of anatomical superficial neck landmark identifica­ wrote the first draft, and all authors read and approved the
tion failure, the otolaryngologist used a vertical, midline skin final manuscript.
incision to optimize visualization and palpation of the crico­
16
thyroid membrane and surrounding anatomy. Since location Disclosure
of the cricothyroid membrane could be particularly compro­ The authors have indicated they have no financial relation­
mised in case of cervical injuries or burns, the help of at least ships relevant to this article to disclose.
one other person is necessary to maintain adequate head and
body position. 4,17 As in our case, the patient with maxillofacial Disclaimer
trauma presents serious challenges. The first challenge is to The opinions or assertions contained herein are the private
18
secure the airway for sufficient and effective breathing and/ ones of the authors and are not to be construed as official or
or ventilation. When planning to secure the airway, the physi­ reflecting the views of the Department of Defense, the Uni­
cian has to consider the nature of the trauma and its effect on formed Services University of the Health Sciences, or any other
the airway, possible trauma of the cervical spine, and the risk agency of the US Government.
of regurgitation and significant bleeding that may cause cir­
culatory deterioration and aspiration. The time available for References
deciding on and then performing the cricothyrotomy is often 1. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield
short because the patient’s condition can deteriorate quickly. (2001­2011): implications for the future of combat casualty care.
J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431–437.
In the combat setting, awake cricothyrotomy represents an 2. Pasquier P, de Rudnicki S, Donat N, et al. [Epidemiology of war
alternative of choice to orotracheal intubation and ensures a injuries, about two conflicts: Iraq and Afghanistan]. Ann Fr Anesth
Reanim. 2011;30(11):819–827. doi:10.1016/j.annfar.2011.05.018
fast and efficient definitive airway. However being simple to 3. Malgras B, Aoun O, Pauleau G, et al. Deployment of the Sur­
execute, even in austere settings, it requires a regular refresher gical Life­saving Module (SLM) in 2017: Lessons learned
19
training for both use of material and procedures. Awareness in setting up and training operational surgical units. Injury.
of this technique allows clinicians to save precious time es­ 2019;50(5):1133–1137.
tablishing a definitive airway, especially in mass casualty in­ 4. Langvad S, Hyldmo PK, Nakstad AR, et al. Emergency cricothy­
cidents. It allows spontaneous ventilation and facilitates the rotomy: a systematic review. Scand J Trauma Resusc Emerg Med.
2013;21:43.
evacuation of an injured person in case of transport without 5. Bellamy RF, Maningas PA, Vayer JS. Epidemiology of trauma:
ventilation capability. Orotracheal intubation would have military experience. Ann Emerg Med. 1986;15(12):1384–1388.
been possible and preferable in other tactical circumstances. 18 6. Mabry RL, Edens JW, Pearse L, et al. Fatal airway injuries during
Operation Enduring Freedom and Operation Iraqi Freedom. Pre-
Use of local anesthesia and ketamine significantly reduces the hosp Emerg Care. 2010;14(2):272–277.
risks associated with traditional RSI (hypotension during in­ 7. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating
duction and loss of respiratory effort with full neuromuscular preventable death on the battlefield. Arch Surg. 2011;146(12):
1350–1358.
blockade). A dosage more consistent with the Tactical Combat 8. Malgras B, Barbier O, Petit L, et al. Surgical challenges in a new
Casualties Care (TCCC) guidelines near 200mg intramuscu­ theater of modern warfare: the French role 2 in Gao, Mali. In-
lar (IM) ketamine or even the newer guideline of 300mg IM jury. 2016;47(1):99–103.
ketamine would have allowed the patient to maintain their 9. Barbier O, Pasquier P, Racle M, et al. Dynamic Insights on surgi­
airway. Local anesthesia could have spared the patient the cal activity in a new modern warfare: the French Role 2 in Bangui,
14
additional discomfort and should be used if operational sit­ Central African Republic. Mil Med. 2017;182(3):e1756–e1761.
uations allow. The ease of this procedure would have been 10. Luft A, Pasquier P, Soucanye de Landevoisin E, et al. The damage
control resuscitation and surgical team: the new French paradigm
improved without compromising the transport of the patient. for management of combat casualties. Mil Med. Published online
The French military guidelines currently do not recommend November 26, 2020:usaa322.

92 | JSOM Volume 22, Edition 3 / Fall 2022