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.

• 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.

Historical review of modern military conflicts suggests that airway compromise accounts or 1-2 % of total combat fatalities. This study examines the specific intervention of pre-hospital cricothyrotomy (PC) in the military setting using the largest studies of civilian medics performing PC as historical controls.

The majority of patients who underwent PC died (66%). The largest group of survivors had gunshot wounds to the face and/or neck (38%) followed by explosion related injury to the face, neck and head (33%). Military medics have a 33% failure rate when performing this procedure compared to 15% for physicians and physician assistants. Minor complications occurred in 21% of cases. The survival rate and complication rates are similar to previous civilian studies of medics performing PC.  However, the failure rate for military medics is three to five times higher than comparable civilian studies.

The CricKey is a novel surgical cricothyroidotomy device combining the functions of a tracheal hook, stylet, dilator, and bougie incorporated with a Melker airway cannula. This study compares surgical cricothyroidotomy with standard open surgical versus CricKey technique.

Participants included US Army combat medics credentialed at the emergency medical technician–basic level.  After a brief anatomy review and demonstration, 15 military medics with minimal training performed in random order standard open surgical cricothyroidotomy and CricKey surgical cricothyroidotomy on cadavers.  Compared with the standard open surgical cricothyroidotomy technique, military medics demonstrated faster insertion with the CricKey. First-pass success was not significantly different between the techniques.

Advanced Trauma Life Support guidelines and combat casualty care doctrine recommend the use of needle thoracentesis (needle thoracostomy) for the emergency treatment of tension pneumothorax.  Emergency situations require a reproducible, simple, and effective normal response for treatment of life-threatening pneumothorax. This study evaluated chest wall thickness in a forward-deployed tri-service population using a retrospective analysis of multidetector CT (MDCT)-assisted autopsies performed on combat casualties at the Armed Forces Institute of Pathology. 

If needle thoracentesis is attempted with an angiocatheter or needle of insufficient length, the procedure will fail. Recommended procedures for needle thoracentesis to relieve tension pneumothorax should be adapted to reflect use of an angiocatheter or needle of sufficient length.  A 3.25 inch angiocatheter would have reached the pleural space in 99% of the cases in this series.