Page 47 - JSOM Winter 2024

Airway Management in Tactical Combat Casualty Care

TCCC Change 24-1

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Travis Shaw, NRP ; Justin Grisham, DO ; Joseph Kotora, DO, MPH ; Ryan Knight, MD ;
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Jared Sleeman, NRP ; Kelby Durnin, NRP ; Harold Montgomery, ATP *; Travis Deaton, MD 8
ABSTRACT
Tactical Combat Casualty Care (TCCC) has been designated for that phase of care has been shifted to the Committee on
by the U.S. Department of Defense as the military standard for Enroute Combat Casualty Care.
battlefield trauma care. The TCCC Guidelines are a set of evi-
dence-based, best-practice recommendations for combat med- Keywords: Tactical Combat Casualty Care; TCCC; airway;
ical personnel to use in caring for casualties on the battlefield nasopharyngeal airway; extraglottic airway
prior to their arrival at a medical treatment facility.
In 2024, the Committee on TCCC approved a change to the Changes and Trends in Airway Management TCCC
recommended management of the airway in TCCC. This
change to the TCCC Guidelines does the following: The original TCCC Guidelines recognized that airway ob-
struction was not a major cause of death in combat casualties
• Continues the recommendation for use of the “Sit-Up and unless there was direct trauma to the face or neck. While en-
Lean-Forward” positioning to keep the airway clear in ca- dotracheal intubation was considered the “Gold Standard” for
sualties with direct maxillofacial trauma when the casual- airway control in civilian settings, it was deemed unsuitable
ties are conscious and able to do so. for combat situations due to the skill and frequency of train-
• Recommends the removal of the extraglottic airway as an ing required, as well as the complexity of managing trauma
airway adjunct. airways with blood and distorted anatomy. Instead, TCCC
• Recommends that casualties who are unconscious but do initially recommended airway positioning, nasopharyngeal
not have a traumatic airway obstruction be placed in the airways, and cricothyrotomy for Tactical Field Care, reserv-
recovery position with the chin tilted away from the chest. ing advanced options like endotracheal intubation for Tactical
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There is no longer a recommendation to use the “jaw thrust.” Evacuation (TACEVAC). In 2003, based on experiences in Af-
• Recommends the removal of the Control-Cric as the pre- ghanistan, the guidelines were updated to allow conscious ca-
ferred cricothyroidotomy device. sualties to assume positions that best protected their airways,
• Recommends continuous capnography monitoring for ca- such as sitting up and leaning forward. In 2012, the TCCC
sualties who have a cricothyroidotomy performed, in order guidelines evolved to recommend the use of any supraglottic
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to provide initial and ongoing assurance that the cricothy- airway (SGA) during TACEVAC, and in 2015, the Cric-Key
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rotomy tube is positioned correctly. was introduced as the preferred cricothyrotomy tool, though
• Adds an oxygenation and ventilatory support note at the this recommendation was later rescinded in 2021. By 2017,
end of the respiratory/breathing section of Tactical Field the I-gel became the preferred extraglottic airway (EGA) due
Care. to its ease of use, expanding its recommendation to include
• Adds a recommendation in the Respirations/Breathing Tactical Field Care, which was also rescinded in 2021.
section that in the case of impaired ventilation and uncor-
rectable hypoxia with an oxygen saturation less than 90%, Mabry and colleagues’ 2010 review of 232 potentially pre-
a properly sized nasopharyngeal airway should be consid- ventable deaths identified 18 fatalities (1.8%) due to airway
ered when performing bag valve mask ventilations. obstruction, all of which involved penetrating trauma to the
• Adds a recommendation in the Respirations/Breathing sec- face or neck, with cricothyrotomies attempted but unsuccessful
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tion that states that in the case of impaired ventilation and in five cases. Eastridge and colleagues’ 2012 analysis of 4,596
uncorrectable hypoxia with an oxygen saturation less than U.S. combat deaths from 2001 to 2011 found that 87.3% of
90%, the casualty should be ventilated with a 1,000-mL fatalities occurred before reaching medical treatment, with air-
resuscitator bag valve mask. way compromise being the second leading cause of preventable
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• Removes recommendations for airway management in the death, accounting for 8% of potentially survivable injuries.
Tactical Evacuation Care phase of care, as responsibility Both of these studies noted that many airway fatalities involved
*Correspondence to travis.a.shaw@gmail.com or harold.r.montgomery2.civ@health.mil
1 CMSgt Travis Shaw is a Pararescueman (PJ) in the United States Air Force and member of the Committee on Tactical Combat Casualty Care
(CoTCCC). Dr. Justin Grisham is an Emergency Medical physician and has served in the United States Army as a flight surgeon on a Forward
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Resuscitative Surgical Team. CAPT Joe Kotora is a Emergency Physician in the United States Navy and member of the Committee on Tactical
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Combat Casualty Care (CoTCCC). COL Ryan Knight is an Emergency Physician in the United States Army and member of the Committee on
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Tactical Combat Casualty Care (CoTCCC). MSgt Jared Sleeman is an Independent Medical Duty Technician (IDMT) in the United States Air
Force. TSgt Durnin is an Independent Medical Duty Technician (IDMT) in the United States Air Force. Harold Montgomery is a retired Special
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Operations medic and the program manager/vice chair for the Committee on Tactical Combat Casualty Care. CAPT Travis Deaton is an Emer-
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gency Physician in the United States Navy and the chair of the Committee on Tactical Combat Casualty Care.
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