Advanced Airway Management

C168W002

DEPARTMENT OF COMBAT MEDIC TRAINING

Advanced Airway Management

Terminal Learning ObjectiveTerminal Learning Objective

Given a combat casualty with airway compromise,

Maintain a casualty's airway,

IAW Prehospital Trauma Life Support

The Respiratory System - ReviewThe Respiratory System - Review

The Respiratory System - ReviewThe Respiratory System - Review

AirwayAirway

Remember:Interventions to the airway are best

deferred to the tactical field care phase

and only after life threatening bleeding has been

addressed.

Essential Airway SkillsEssential Airway Skills

Patient Positioning

Patient PositioningPatient Positioning

Essential Airway SkillsEssential Airway Skills

A conscious casualty, able to follow commands and sit up are much easier to care for.

What would happen if the casualty in the previous picture was forced to lie on his back?

What additional treatment would be required due to his position?

Manual Maneuvers Manual Maneuvers

Used on unconscious casualties

when the tactical situation allows

Head-tilt, chin-lift

Jaw-thrust

SuctioningSuctioning

Traditional mechanical suction is preferred,

but rarely available in combat. Medics often improvise by simply using a large syringe

and tubing.

Various commercial manual suction

devices are available.

SuctioningSuctioning

Indications

Mucus, vomitus or blood in the airway.

Complications of suctioning can be avoided by sticking to the 15 sec rule.

Prolonged suctioning will produce hypoxemia.

Cardiac dysrhythmias from arterial hypoxemia.

Vagus nerve stimulation may lead to profound bradycardia and hypotension.

Nasopharyngeal Airway AdjunctNasopharyngeal Airway Adjunct

Why are OPAs NOT the first choice in a combat environment?

OPAs are more likely to dislodge during transport.

Most combat casualties either sustain immediate profound wounds or deteriorate into

unconsciousness. As the casualty “deteriorates” their gag reflex will still be intact. An OPA will

stimulate the gag reflex cause a variety of undesirable reactions.

Nasopharyngeal Airway AdjunctNasopharyngeal Airway Adjunct

Nasopharyngeal Airway AdjunctNasopharyngeal Airway Adjunct

An NPA will illicit a pain response in altered casualties.

When an NPA is used,

consider placing the casualty in the recovery position to prevent the aspiration of blood

mucus or vomitus.

Check on your Learning…Check on your Learning…

Q: During what level of care is the airway managed?

Q: Why is a NPA preferred over an OPA in a combat environment?

T A: During Tactical Field Care ext

A: Does not trigger gag reflex, can remain in if casualty regains consciousness. t

Check on your Learning…Check on your Learning…

Q: How do you avoid hypoxemia when suctioning?

Q: What nerve is being stimulated if suctioning is too aggressive?

A: Limit suctioning to 15 seconds

T A: Vagus Nerve ext

Intermediate Airway ReviewIntermediate Airway Review

Combitube and King LT

Their ability lies between basic airway adjuncts (OPA, NPA) and

endotracheal intubation (ETT)

or surgical cricothyroidotom

yKing LT

37 French

4 to 5 1/2 feet tall

41 French

>5 feet

Yellow (Sz 3) = 4 - 5 Ft.

Red (Sz) 4 = 5 - 6 Ft.

Purple (Sz) 5 = >6 Ft.

Intermediate Airway ReviewIntermediate Airway Review

IndicationsUnconscious Trauma Patient

w/o gag reflex

Adult Patients in Respiratory arrest or breathing at a rate less

than 10 BPM

Adult Patients in Medical cardiac Arrest

Near Drowning

Electrocution

Drug Over Dose

ContraindicationsIntact Gag Reflex

Adults shorter than 4 feet tall

Known Esophageal Disease

Patients who have ingested a Caustic Substance-(Acid or

Lye)

Inhalation Burns

Intermediate Airway ReviewIntermediate Airway Review

Combitube Insertion

Combitube in Trachea Combitube in Esophagus

Intermediate Airway ReviewIntermediate Airway Review

King LT Insertion

Advanced Airway ManagementAdvanced Airway Management

Endotracheal intubation (Gold Standard) Placement of an ETT into the trachea.

Orotracheal and NasotrachealOrotracheal and Nasotracheal

Neither intubation through the mouth or nose are preferred in the combat environment.

Orotracheal Intubation Nasotracheal Intubation

Why Not?Why Not?

One study says: In an urban environment, critically injured

trauma casualties with ETT had no better outcomes than those

with an OPA.

Another study says: It is a hard skill.

(Even in good light with a paralyzed casualty)

The view through the NVGs says: Not very tactical.

Airway ManagementAirway Management

This casualty’s airway be

managed with an Emergency

Cricothyroidotomy

Breaking Down the WordBreaking Down the Word

Crico - thyroid - otomy

Emergency CricothyroidotomyEmergency Cricothyroidotomy

If the casualty is conscious or altered, the procedure can still be performed under local anesthesia using

lidocaine.

It isolates the airway.

Decreased risk of gastric insufflation and aspiration.

No need to maintain a mask to face seal.

Requires little to no special equipment.

Emergency CricothyroidotomyEmergency Cricothyroidotomy

Special Note:The tube used to secure the airway must be a

minimum of 6 mm in diameter to allow for spontaneous breathing and adequate oxygenation

in adults

Emergency CricothyroidotomyEmergency Cricothyroidotomy

IndicationsInability to ventilate a combat casualty in any

other way due to:

Severe maxillofacial traumaAirway obstruction

Structural deformities of the airway

Inhalation burns/edemaUnconscious casualty unable

to protect his airway

Emergency CricothyroidotomyEmergency Cricothyroidotomy

Complication or disadvantages of the emergency cricothyroidotomy

Invasive procedure causing bleeding at insertion/incision site and blood aspiration.

Misplacement of the tube

Esophageal laceration or intubation

Hematoma

Vocal cord injury or paralysis, hoarseness

Emergency CricothyroidotomyEmergency Cricothyroidotomy

Equipment

Find Your Cricothyroid MembraneFind Your Cricothyroid Membrane

Check on your Learning…Check on your Learning…

Q: Should an emergency cricothyroidotomy be performed on a conscious casualty with inhalation burns/edema?

Q: Why would an emergency cricothyroidotomy be preferred over an intermediate airway?

T A: Yes, using a local anesthetic

T A: If the casualty is conscious or altered the Cric can still be performed under local anesthesia.

Intermediate airways require a unconscious casualty with no gag reflex. ext

SummarySummary

What is the easiest way to maintain an open airway on a conscious casualty?

Allow the casualty to position himself.

SummarySummary

Q: Which adjunct is preferred in a combat setting and why?

A: NPA

They are better tolerated by casualties.

Can be used in a greater number of casualties.

Less likely to become dislodged, causing an

obstruction.

SummarySummary

Q: What are the contraindications for the Combitube and King LT?

A: Intact gag reflex

Height does not fall within the ranges of the device.

Known esophageal disease

Caustic substance (acid or lye) ingestion

Inhalation burns (these devices do not protect the trachea)

SummarySummary

Q: What are the disadvantages of Orotracheal and Nasotracheal intubation?

1. In an urban environment, critically injured trauma casualties with an ETT had no better outcome than those transported with a BVM and OPA.

1. First-time intubationists trained on mannequins, noted an initial success rate of only 42% in the ideal confines of the OR with paralyzed casualties.

3. Orotracheal intubation requires additional equipment and the use of a white light on the end of a laryngoscope which may tactically compromise the medic and the unit.

SummarySummary

The advanced airway of choice in combat conditions is:

Emergency Cricothyroidotomy

(Surgical Cric)

Questions?