Positioning of the patient to help clear airway obstruction should be considered first, when possible.  The simple option of placing the patient in a sitting position, placing the patient in the lateral “recovery” position, or head tilt-chin lift/jaw thrust maneuver may be enough to ensure adequate respirations.  Simple adjuncts such as a nasal or oropharyngeal airway (in an unconscious patient) may be utilized in addition to proper positioning to help ensure a clear airway.

For those patients requiring active airway assistance, the first step should be inserting an NPA to open the airway.  BVM ventilation is the next step in the algorithm and though it appears to be relatively simple, the procedure requires preparation, training and skill to perform correctly.  A spontaneously breathing patient may prove challenging, but properly delivered, synchronous breaths may be the only requirement to assist a patient’s respirations.  Care should be taken to ensure proper volume and rate of bag-delivered breath.  One hand should provide moderate pressure to the bag for no more than 50% of the volume of an adult bag or just enough to see the chest begin to rise at a rate of 12-16 breaths per minute (one breath every 4-5 seconds) initially.  It is important to avoid hyperventilation through large or rapid breaths, particularly with traumatic brain injury (TBI) casualties, therefore ETCO2 monitoring is indicated for all patients requiring assisted ventilation and all patients with altered mental status (including both TBI casualties and sedated patients). BVM is an important airway management skill (see Appendix C: Bag-Valve-Mask Technique for a detailed description).  It is highly recommended that all PFC training on airway skills cover BVM skills and techniques.

OP and SGA insertion can present a considerable noxious stimulus and may not be tolerated by conscious or even some semiconscious patients.  Additionally, the dyssynchronous use of BVM ventilation may lead to poor patient cooperation, abnormal tidal volumes, gastric insufflation (and resultant regurgitation/aspiration), or other complications.

The decision to perform a cricothyroidotomy is one that is sometimes difficult.  When possible, in urgent but not emergency situations, a telemedicine call should be considered to help with medical decision making.

An important adjunct to passing an endotracheal tube, either via the cricothyroid membrane or the oropharynx, is the use of a gum elastic bougie (sometimes also referred to as an Eschmann Stylet or, simply bougie).  This device is simple, rugged and should be used to guide tube placement.  The bougie is placed in the trachea before the endotracheal tube and may be used first to confirm proper positioning by either tactile discrimination (feeling the tube bump against the tracheal rings on introduction), or by encountering a hard stop when abutted against the carina.  An endotracheal tube is then introduced over the bougie into the trachea.  Lastly, the bougie is removed.  A bougie may also be used to change tubes in the case of a tube malfunction.  This may be accomplished by placing a bougie in a tube that is currently positioned, remove the tube over the bougie (ensuring the bougie remains in the proper position within the airway lumen), and replacing a new tube over that bougie.  Remove the bougie, leaving the new tube in place.  Confirmation procedures discussed below must be repeated once the new tube is in place.

Consistent with TCCC guidelines, the routine use of orotracheal intubation is not recommended as the minimum standard in PFC.  This procedure requires considerable skill and sustainment;10 and requires appropriate sedation for both rapid sequence intubation and post-intubation management.  If a provider is appropriately trained, current and practiced in the procedure, and has the required support equipment and medications, then orotracheal intubation may be considered.  Although preferred when possible, training in orotracheal intubation is not required to obtain a definitive airway in the PFC operational setting. Consider basic measures first before proceeding to either type of invasive airway.  Additional details on orotracheal intubation are included in the JTS Airway CPG.

Airway management in the tactical setting requires a different conceptual approach than airway management in the hospital, or even the civilian prehospital environment.  Differences in epidemiology, injury patterns, equipment and environment must be considered if airway management is to be optimized.  First, most military casualties requiring a prehospital airway have trauma to the head, face or neck.  Surgical airway is often the final common pathway due to bleeding or distorted anatomy.  In comparison, most airways in the civilian prehospital environment are placed in elderly people for cardiac arrest.  When reliable suction and oxygen delivery are not available, or personnel are not experienced in rapid sequence intubation using neuromuscular blockade, a definitive airway will often mean a surgical airway.

Proper  Tube  Placement

Verification of correct tube placement must be performed every time as incorrect tube placement may be fatal.  The REACH study5 showed that right mainstem and hypopharynx placement are the most common locations of incorrect placement of ETT.  Esophageal intubation is also common.  Subcutaneous placement of cricothyroidotomy tube may occur.  Use capnography to verify correct tube placement as tube misplacement can be fatal.  Auscultate, if possible, to verify bilateral breath sounds. If ultrasound is available, this can be used to further verify placement in the correct position.11 

IV/IO  Access

Though an important consideration to administer medications and fluids, do not delay an emergent airway to obtain IV/IO access in the instance you are the sole provider.

Ultrasound may be used to help identify small or deep veins.  Ultrasound guided IV access may be attempted if trained.  Other sites to consider for superficial IV attempts include the external jugular and saphenous veins.  If appropriately trained, consider central venous access or venous cutdown.

Drugs

Airway  Placement

Prolonged  Sedation

(post-airway placement)

(Reference Analgesia and Sedation Management in PFC CPG  for details and drug doses).12

Be cautious with sedation, advanced airway placement and positive pressure ventilation in patients who are hypotensive or under-resuscitated.  Blood pressure can fall rapidly during airway management due to a variety of mechanisms.

In all cases, monitor BP closely (every 1-2 minutes during the procedure, every 3-5 minutes for 15 minutes post-procedure).  A BP drop may be brief (if due to vagal effects of epiglottis stimulation during ETT placement) or sustained (due to positive pressure ventilation, increased intrathoracic pressure and decreased venous return to the heart).  Loss of sympathetic drive secondary to pain and sedation medications, and/or continued hypovolemia can also result in hypotension.  Continue resuscitation with blood products (trauma patients) or crystalloid (non-trauma patients) if a hypotensive patient requires immediate airway interventions.  Be prepared to support blood pressure with vasopressors (e.g. epinephrine bolus or drip) if trained or under direct telemedicine guidance.

Neuromuscular blockade (succinylcholine, rocuronium, vecuronium, etc.) is NOT recommended for use by the average practitioner of PFC.  Though these are standard medications to use in rapid sequence intubation and ventilator management, their potential lethality in inexperienced hands does not justify routine recommended use.  If trained and/or under direct supervision of telemedicine support, the use of neuromuscular blockade may be considered, subject to local medical direction and protocols.