Page 48 - JSOM Winter 2024

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concurrent trauma to large vascular structures, and neither backward and lack of escape for fluids from air passages. Use
study reported deaths from intrinsic airway obstruction or as- of the lateral recumbent, or rescue, position for unconscious
piration. Sebesta’s review in Iraq noted that 10% of deaths at combat casualties is recommended to reduce the likelihood of
a combat support hospital (CSH) were due to airway issues, vomiting and aspiration. 12
6
though no details were provided. Schauer and colleagues’ 2020 Level of Evidence: Level C (Limited Data, C-LD)
study focused on prehospital airway interventions and found
that 89% involved endotracheal intubation, likely performed Why is there a modification to the recovery position?
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in controlled environments like TACEVAC. While Schauer and
colleagues’ study did not address deaths from airway obstruc- CoTCCC guidelines now recommend that when the patient
tion in the absence of airway trauma, it raises questions about is in the recovery position that the head be tilted back or, in
whether casualties who were unconscious due to TBI or hem- other words, the chin be placed away from the chest. Head and
orrhagic shock and who did not receive airway interventions chin placement contribute significantly to the care regimen of
could have been saved with proper airway management, such the airway-vulnerable patient. Regardless of the unconscious
as nasopharyngeal airway (NPA) or EGA placement. patient’s body positioning, the airway will be significantly
impacted if the head is in a flexed (chin down) position. In
Airway management techniques used by combat medics, Corps- an evaluation of 80 lightly anesthetized patients placed in a
men, and PJs in Afghanistan and Iraq differed from civilian head flexed position, all patients regardless of body position-
13
practices, where endotracheal intubation (ETI) is commonly ing had an obstructed airway. The greatest improvement in
employed in out-of-hospital cardiac arrest (OHCA) and other airway patency was observed in the head extended (chin away
scenarios. In the military setting, ETI is more challenging due to from chest) position, as there were no observed completely ob-
complex trauma, such as maxillofacial injuries, and the limited structed airways. Regardless of body position (supine, lateral,
training medics have compared to civilian paramedics. Studies or prone), the head flexion (chin down) position demonstrated
like the REACH analysis found that advanced airways were the most pronounced airway obstructions. The mid-position
8
used in 4.2% of combat casualties, with 86% of these involv- showed improvements compared to the flexed position, and
ing ETI, while only a small percentage used supraglottic air- the extended position had the most patent airway observa-
ways (7.5%) and cricothyrotomies (5.8%). A further analysis tions. Boidin observed similar characteristics by noting an air-
in 2011 highlighted the prevalence of advanced airway place- way can be obstructed by merely flexing the neck even with a
ments by enlisted medics at the point of injury, with esopha- properly sized NPA in place. 14
geal-tracheal airways being the most commonly used, but with
a high mortality rate (85%) among these patients. Schauer There is conflicting evidence as to whether a left or right-side
9
and colleagues’ 2018 study of prehospital airway interventions recovery position is more beneficial. Additionally, there is con-
in the Department of Defense Trauma Registry identified that flicting evidence on whether the recovery position increases
ETIs were the predominant intervention, followed by cricothy- cardiac output when compared with supine. 15–18
rotomies, though many patients had multiple airway devices Level of Evidence: Level C (Limited Data, C-LD)
placed during care. The data underscore the challenges and
unique considerations of airway management in combat set- What considerations should be made when placing
tings, which differ significantly from civilian protocols. 10
a casualty with suspected spinal injuries in the
recovery position?
Airway Management in TCCC Comprehensive Review
Notable considerations of placing a semi- or unconscious
The airway and breathing guideline review took a bottom-up patient in the lateral position include cervical spine or pelvic
approach, challenging all dogmatic assumptions with robust fracture injuries and general treatment awareness. In a 2015
evidence analysis. The preponderance of airway technique literature review of log-rolled trauma patients and artificially
and equipment reviews are performed in civilian emergency injured and rolled cadavers, the authors identified no clinical
medical services (EMS), and the primary mechanism of airway studies demonstrating that rotating trauma patients from the
injury is OHCA. Comparing OHCA and battlefield trauma supine position to a lateral position conclusively affects mor-
airway management is complex, and careful considerations tality or causes neurological deterioration. However, in the
are essential when determining applicability of civilian stud- cadaver studies, there were statistically significant displace-
ies. The Committee on TCCC (CoTCCC) developed and ments caused by rolling, but the resulting injuries related to
answered the following questions, which guided the recom- the displacements were unknown. Effective medical provider
19
mended changes to the guidelines. judgement is paramount in situations involving possible spinal
injury, and patient rolling benefits must be weighed against
Why is patient positioning critical in airway possible spinal or pelvic fracture injuries. Providers need to
management and what are the benefits of placing a conduct thorough and frequent checks of their patient in the
casualty in the recovery position as opposed to the recovery position, as patient status indicators may be less ap-
supine position? parent. In a study examining these cues in a basic life sup-
port (BLS) scenario, providers identified breathing cessation a
Patient placement in the supine position with no artificial ad- mean 14.5 seconds later (32 vs. 17.5 s) in a recovery position
juncts presents multiple challenges for the airway-challenged. patient than in a supine head tilt chin lift patient. 20
As early as 1871, the prone position was identified as supe-
rior to supine to alleviate the patient’s “drunken stupor with Pelvic fracture, significant limb injury and hemo/pneumotho-
vomited matter in the pharynx,” among other advantages. In rax conditions may be exacerbated or preclude placing a pa-
1903, the supine position in drowning patients was strongly tient in a recovery position. Additionally, interventions such as
contraindicated, owing to the tendency of the tongue to fall intraosseous insertion, chest tube placement, and tourniquet

46 | JSOM Volume 24, Edition 4 / Winter 2024