airway management in the combat casualty
TRANSCRIPT
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Airway Management in the
Combat CasualtyCPT Allen Proulx, MPAS, PA-C
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References
Tactical combat Casualty Care, Butler, Hagmann,
Butler, Association of Militray Surgeons of U.S., 1996
Emergency Medicine: A Comprehensive StudyGuide, Tintinalli, 6th ed, Mcgraw-Hill, 2004.
USMC FMSS.
C.M. Bensons Anatomy Drawings (CD).
University of New Mexico.McKinley County EMS.
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Overview
Discuss why we would secure an airway in the
combat casualty
Discuss and analyze some options in
establishing an airway in the combat casualtyReview the use of the Combitube
Review the steps in performing a
cricothyroidotomy
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Scenario
You are supporting a unit operating in
western Afghanistan when a soldier is
brought in s/p his vehicle hitting a landmine.
The vehicle exploded. The casualty isunconscious and unresponsive and has 2nd
degree burns to the face and neck. You
perform your CBA initial assessment and
note no other injuries.
What do you do?
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Secure the Airway
What questions need to be answered when
we plan for airway management?
What is effective?
What is easy and quick to use?
Consider yourself inexperienced
What requires minimal equipment?
What is my back-up?
The Nasopharyngeal Airway, Combitube and
Cricothyroidotomy are excellent choices!
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Options
Endotracheal intubation in the hands ofan inexperienced provider, with acontrolled setting has about a 42%
success rate.The Combitube has a 95% success ratein the field.
Cricothyroidotomy has a 90% successrate in inexperienced physicians and a98% success rate with flight nurses.
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Nasopharyngeal Airway (NPA)
1% of all combatfatalities can besalvaged by ensuringthe airway is patent
throughout evacuation.All unconscious/alteredmental statuscasualties should havetheir airway secured
with a NPA.Oropharyngeal airwayis a poor choice formilitary.
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Elbow deflector
Suction catheter
Small syringe:
20 ml distal cuff
Large (blue) syringe:
100 ml large balloon
Ringmarks
Distalcuff
Oropha-
ryngealballon
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Pharyngeallumen No. 1
Esophago-
tracheal
lumen No. 2
Esophageal - tracheal
COMBITUBE
Oropharyngeal
balloon
Distal
cuff
Perforations
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Specially useful:
Difficult intubationBlind intubation
Difficult circumstances(space, illumination)
Combitube
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Emergency intubation
Bleeding and vomitingImmediate decompression
of esophagus and stomach
Note:The casualty must beunconscious and have no gagreflex
Indications for
Combitube
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Merits of COMBITUBE
Low price, all-in-one device
Non invasive
No preparations necessaryRapid and easy intubation
Immediate fixation
PREVENTION OF ASPIRATION
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Complications
Aspiration
Ensure there is no gag reflex
Esophageal perforation
Direct trauma to the larynx
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The Basic Procedure
Open
mouth,
pressaway
tongue
Head:
Neutral
position
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The Basic Procedure
Flat
insertionalong
tongue
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The Basic Procedure
Emergency:
No. 2: 10 mlEmergency:No. 1: 85 ml
(or more)
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The Basic Procedure
Esophageal
position
Self-fixation
Behindhard palate
Active
decom-pression
Ventilation
via longer
blue tube
No. 1
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The Basic Procedure
Ventilation
via shorterclear
tube
No. 2
Tracheal
position
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Laryngoscope May be Used
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Cricothyroidotomy
DEFINITION -
An emergency surgical procedure where
an incision is made through the skin and
cricothyroid membrane which allows forthe placement of an endotracheal tube into
the trachea when airway control is not
possible by other methods.
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Indications
Trauma to the head or neck which
would preclude the use of an ambu-
bag, oropharyngeal airway,
nasopharyngeal airway, orcombitube/endotracheal tube insertion
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Merits of the
CricothyroidotomyProvides a definitive airway for
ventilating the patient
Can be performed quickly and has few
complications associated with the
procedure
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Contraindications
Massive trauma to the larynx or cricoid
cartilage:
Damage to the affected structures will
make it impossible to perform theprocedure properly
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Complications
Hemorrhage
Esophageal perforation
Tracheoesophageal fistulaSubcutaneous air
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Basic Anatomy
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Basic Anatomy
Anterior view of the
larynx to show the
median cricothyroid
ligament.1. Thyroid lamina.
2. Arch of cricoid
cartilage.
3. Mediancricothyroid
ligament (cut here)
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Required Equipment forEmergency
Cricothyroidotomy
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Quicktrach
http://www.life-assist.com/airway/at99_7.jpg -
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Quicktrach
http://www.life-assist.com/airway/at99_5.jpg -
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Nu-Trake
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Required Equipment
#10 or 15 Scalpel
Endotracheal Tube
Size 6 and Larger
10 cc Syringe
Stethoscope
Curved Kelly
Hemostat, Straight
will work
Ambu-bagSterile Dressing
Vaseline / Petroleum
GauzeBetadine or Alcohol
Wipes
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Required Equipment
(continued)
Sterile or Clean Gloves
Suture Material
Suction DeviceSuture Scissors
Tape
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Performing the
cricothyroidotomyDetermine that the patient requires anemergency cricothyroidotomy.
Assemble required equipment, quickly.
Use pre-established kits
Do it. Dont hesitate
Position the patients head/neck
The patient is placed in a supine or semi-recumbant position
The neck is placed in a neutral position
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Performing the
cricothyroidotomyPalpate the thyroid
and cricoid cartilage
for orientation
A - Cricoid Cartilage
B - Cricothyroid
Membrane
C - Incision Site
D - Thyroid Cartilage
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Performing the
cricothyroidotomy
Locate the cricothyroid membrane
Stabilize the thyroid cartilage using yournon-dominant hand
This is not as easy as it sounds!
Make a vertical vs horizontal incisionthrough the skin approximately 2-5 cm (1inch+) long over the cricothyroid membrane
Visualize the cricothyroid membrane
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Performing the
cricothyroidotomyMake a transverse
incision into the
cricothyroid
membrane DO NOT make the
incision more than
1/2 inch deep or you
may perforate the
esophagus
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Performing the
cricothyroidotomy
Insert the Curved Kelly Hemostat into
the incision and blunt dissect the
incision (turn the Curved KellyHemostat or scalpel handle 90 degrees
to open up the incision)
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Performing the
cricothyroidotomy
Insert the endotracheal tube (adult
6mm or Ped smaller? whatever will
fit), into the incision, directing thetube distally down the trachea
P f i h
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Performing the
cricothyroidotomy
Ventilate the patient with two breaths
Check for proper placement of the
endotracheal tube with these first two
ventilations by:
Observing the chest rise and fall with each
ventilation
Auscultate for bilateral breath soundsPulse Oximiter would be an excellent
assessment tool!!
P f i th
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Performing the
cricothyroidotomyBilaterally Absent Breath Sounds - theendotracheal tube is not within the tracheaand has probably been placed within theesophagus or subcutaneous tissue.
Remove the tube and attempt to reinsert into thetrachea
Right main-stem placement is common.
Breath Sounds in the Right Lung Field - theendotracheal tube has been placed too fardown the bronchial tree and is in the rightmainstem bronchus. Pull back the tube 1/4 to 1/2 inch or until bilateral
breath sounds have been established
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Performing the
cricothyroidotomyAuscultate over the epigastrium for gastric
sounds
Placement of the endotracheal tube into the
esophagus will produce gurgling sounds in theepigastric area with ventilations
Inflate the endotracheal tubes cuff with 10
ccs of air
Inflation of the cuff serves two purposes:
Holds the endotracheal tube in place
Acts as a barrier and prevents fluids from entering
the lungs
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Performing the
cricothyroidotomyApply petroleum gauzedressing to insertionsite
Apply a dry, sterile
dressing to theinsertion site
Tape around the tubethen completely aroundthe neck.
Sutures not needed.This is a temporaryairway!!
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Performing the
cricothyroidotomyContinue to ventilate the patient (1
breath every 5 seconds) and suction as
necessary.
Loving Gentle Squeeze 2 in, 3 out.
Continue to monitor the patient for
changes
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Performing the
cricothyroidotomy
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Questions??