BACKGROUND

Intubation and mechanical ventilation are challenging skills in the austere environment and appropriate consideration must be taken when placing a patient on a mechanical ventilator. Ventilator management is resource intensive and demanding which might not make it appropriate for all tactical situations. If a patient is maintaining their airway and has appropriate oxygenation and ventilation, they should not be intubated by prehospital providers for transport from point of injury (POI) to the first battlefield role of care.

Intubation and providing mechanical ventilation are not without risk. The benefits should outweigh the attributable cost and risk of managing the mechanically ventilated patient, especially within the austere/ battlefield setting. Pathology associated with failure to oxygenate and failure to ventilate will most often require definitive airway interventions and appropriate mechanical ventilator support. At times, it may only serve as a temporizing measure while seeking definitive critical care. Initiation of mechanical ventilation must be guided by clinical suspicion of underlying pathophysiology and clear criteria. A definitive airway is required for effective mechanical ventilation and these patients require sedation – both mechanical ventilation and sedation may make a hypotensive patient more hypotensive and could result in hemodynamic instability. Thoughtful consideration for the requirement of mechanical ventilation must occur. See the JTS Airway Management of Traumatic Injuries and Analgesia and Sedation Management during Prolonged Field Care CPG. In patients with hemorrhagic shock requiring intubation and mechanical ventilation, remember the general principle of “resuscitation before intubation.” Utilize airway adjuncts if the patient’s airway can be maintained adequately during initial resuscitation efforts with blood products. In an under-resuscitated patient, cardiac arrest can occur when induction and paralytic medications are given during rapid sequence intubation.

The intent of this CPG is to provide the non-critical care trained medical personnel with guidance on basic ventilator management. Expanded information on definitions, ventilator terms and modes can be found in Appendix A and B. In the prolonged care setting, telemedicine consultation should be used if possible. Additional JTS CPGs with ventilatory support considerations are Acute Respiratory Failure and Wartime Thoracic Injury.

In patients with hemorrhagic shock requiring intubation and mechanical ventilation, remember the general principle of “resuscitation before intubation.” Utilize airway adjuncts if the patient’s airway can be maintained adequately during initial resuscitation efforts with blood products.