Guidelines and Key Points

Triage casualties as required.

Casualties with an altered mental status should immediately have weapons cleared and secured, communications secured, and sensitive mission items redistributed.

#### Triage Casualties Key Points

Possible causes of altered mental status are Traumatic Brain Injury (TBI), shock, hypoxia, and pain medications. The casualty may resist being disarmed. It may be useful to say “Let Smith hold your weapon for you while I check you out,” to help them better accept your taking their weapon.

### Airway Management

1. Conscious casualty with no airway problem identified:

- No airway intervention required

2. Unconscious casualty without airway obstruction:

- Chin lift or jaw thrust maneuver or
- Nasopharyngeal airway or
- Extraglottic airway
- Place casualty in the recovery position

3. Casualty with airway obstruction or impending airway obstruction:

- Allow a conscious casualty to assume any position that best protects the airway, to include sitting up
- Use a chin lift or jaw thrust maneuver
- Use suction if available and appropriate
- Nasopharyngeal airway or
- Extraglottic airway (if the casualty is unconscious)
- Place an unconscious casualty in the recovery position.

4. If the previous measures are unsuccessful, perform a surgical cricothyroidotomy using one of the following:

- Cric-Key technique (Preferred option)
- Bougie-aided open surgical technique, using a flanged and cuffed airway cannula of less than 10 mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intratracheal length
- Standard open surgical technique using a flanged and cuffed airway cannula of less than 10 mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intra-tracheal length (Least desirable option)
- Use lidocaine if the casualty is conscious.

5. Cervical spine stabilization is not necessary for casualties who have sustained only penetrating trauma.

6. Monitor the hemoglobin oxygen saturation in casualties to help assess airway patency.

7. Always remember that the casualty’s airway status may change over time and requires frequent reassessment.

#### Airway Management Key Points

- The recovery position helps to protect against vomiting and aspiration. Again, note that C-spine stabilization is not required in penetrating head and neck trauma.

- Casualties with severe facial injuries can often protect their own airway by sitting up and leaning forward. Let them do it if they can. You may have to do a surgical airway with the casualty in the sitting position.

- The i-gel is the preferred extraglottic airway because its gel-filled cuff makes it simpler to use and avoids the need for cuff inflation and monitoring. If an extraglottic airway with an air-filled cuff is used, the cuff pressure must be monitored to avoid overpressurization, especially during TACEVAC on an aircraft with the accompanying pressure changes.

- Extraglottic airways will not be tolerated by a casualty who is not deeply unconscious. If an unconscious casualty without direct airway trauma needs an airway intervention, but does not tolerate an extraglottic airway, consider the use of a nasopharyngeal airway.

- For casualties with trauma to the face and mouth, or facial burns with suspected inhalation injury, nasopharyngeal airways and extraglottic airways may not suffice and a surgical cricothyroidotomy may be required.

- Surgical cricothyroidotomies should not be performed on unconscious casualties who have no direct airway trauma unless use of a nasopharyngeal airway and/or an extraglottic airway have been unsuccessful in opening the airway.

Cricothyroidotomy is hard to do. Combat medics have often failed to get it right on the battlefield, with a 33% failure rate. This is the most technically difficult procedure we ask medics, corpsmen, and PJs to do.

The Cric-Key is the preferred surgical airway technique. Under test conditions, medics were faster and more successful using the Cric-Key technique compared to the open surgical technique.

To prepare, combat medics should perform a cricothyroidotomy at least five times during training on an anatomically realistic model.