TRAININGGROUNDS
How to manage an airway on the battlefield CRAWL TRAININGGROUNDS
What is Airway? A Compromised airway is one of the three leading cause of preventable death on the battlefield Airway management techniques are used to prevent airway obstruction and ensure and open pathway of air to the lungs IF UNTREATED, BLOCKAGE IS LIFE-THREATENING AND MAY REQUIRE IMMEDIATE ATTENTION TO PREVENT DEATH *Note A trauma assessment must be completed before treating a casualty with breathing problems. Also, you must be in a situation in which you and the casualty are not under hostile fire. 2
Mechanisms of Injury Typically caused by Airway Obstructions, due to: Trauma Edema (swelling) Excess secretions Foreign bodies Broken Teeth Vomitus Tongue *the most common cause in an unconscious patient 3
Airway Anatomy and How it Works? The Airway is the canal through which air passes to and from the lungs. The airway consists of: nose mouth throat larynx trachea 4
Types of Airway Managment Basic Airway (Does not require equipment) Head-Tilt/Chin-Lift Jaw Thrust Trauma Chin Lift Advanced Airway (Requires equipment) Nasopharyngeal Airway (NPA) Supraglottic Airway Tracheal Intubation Crycothyroidotomy (Cric-Key) 5
Airway : A Phased Approach 1) Assess Responsiveness 2) Position the Casualty 3) Open the Airway a. Head-Tilt/Chin-Lift b. Jaw Thrust Technique 4) Check for Breathing 5) Determine Appropriate Action a. Insert NPA b. Ventilation / Rescue Breathing c. Advanced Airway 6
Assess Responsiveness A. Establish whether the casualty is conscious Ask are you okay? Gently shake if necessary B. Determine the casualty s level of conciousness using the AVPU scale AVPU Responsiveness Assessment: ALERT VERBAL (responds to verbal stimuli) PAIN (Responds to painful stimuli) UNRESPONSIVE (does not respond to any stimuli) C. *Casualties with an altered mental status should be disarmed immediately 1. Assess Responsiveness 2. Position the Casualty 3. Open the Airway a. Head-Tilt/Chin-Lift b. Jaw Thrust Technique 4. Check for Breathing 5. Determine Appropriate Action a. Insert NPA b. Ventilation c. Advanced Airway 7
Position the Casualty: On His/Her Back Positioning a Unresponsive Casualty on Back: (1) Placing a casualty flat on their back is the best position to work on maintaining an airway. (2) Take care if the casualty is lying on his chest (prone position); you will need to cautiously roll the casualty as a unit so that his body does not twist (which may further complicate a back, neck, or spinal injury). (3) To position the unresponsive patient so that he is lying on his back and on a firm surface: (a) Kneel beside the casualty with your knees near his shoulders and check for responsiveness (leave space to roll his body) (b) Call for help/assistance if possible (c) Straighten the casualty's legs (d) Take the casualties arm that is nearest to you and move it so that it is straight and above his head. Repeat the procedure for the other arm. (e) Place one hand behind his head and neck for support. With your other hand, grasp the casualty under his far arm. C,D,E 8 NOTE: Do not leave an unconscious casualty on his back. If you must leave the casualty, place the casualty in the recovery position to help keep his airway open.
Open the Airway: Process Flow Unconscious Casualty without airway obstruction 1. Chin lift or jaw thrust maneuver 2. Nasopharyngeal airway Place casualty in recovery position (on his/her side) Lateral Recovery Position Conscious Casualty with airway obstruction or impending airway obstruction: 1. Chin lift or jaw thrust maneuver 2. Nasopharyngeal airway Allow casualty to assume any position that best protects the airway, to include sitting up. If unconscious, place casualty in recovery position (on his/her side) 1. Assess Responsiveness 2. Position the Casualty 3. Open the Airway a. Head-Tilt/Chin-Lift b. Jaw Thrust Technique 4. Check for Breathing 5. Determine Appropriate Action a. Insert NPA b. Ventilation c. Advanced Airway 9
Open the Airway: Recovery Position How to Put Casualty in the Recovery Position Start with the victim lying on the back and with the legs straight out: a) Kneel on one side of the victim, facing the victim. b) Move the arm closest to you so it is perpendicular to the body, with the elbow flexed (perpendicular). c) Move the farthest arm across the body so that the hand is resting across the torso. d) Bend the leg farthest from you so the knee is elevated. e) Reach inside (preferably the outside of the knee, grasping clothing) the knee to pull the thigh toward you. f) Use the other arm to pull the shoulder that is farthest from you. g) Roll the body toward you. Leave the upper leg in a flexed position to stabilize the body. Lateral Recovery Position 10
Open the Airway: Head-Tilt/Chin-Lift NOTE: Even if the casualty is still breathing, the head-tilt/chin-lift will help to keep the airway open and help the casualty to breathe easier. a. Kneel at the level of the casualty s shoulders. b. Place one of your hands on the casualty s forehead and apply firm, backward pressure with the palm of your hand to tilt the head back. c. Place the fingertips of your other hand under the tip of the bony part of the casualty s lower jaw and bring the chin forward. See figure 5-1. 1. Assess Responsiveness 2. Position the Casualty 3. Open the Airway a. Head-Tilt/Chin-Lift b. Jaw Thrust Technique 4. Check for Breathing 5. Determine Appropriate Action d. Lift the chin forward until the upper and lower teeth are almost brought together. The mouth should not be closed as this could interfere with breathing if the nasal passages are blocked or damaged. If needed, the thumb may be used to depress the casualty's lower lip slightly to keep his mouth open. a. Insert NPA b. Ventilation c. Advanced Airway CAUTION: Do not use the thumb to lift the lower jaw. CAUTION: Do not press deeply into the soft tissue under the chin with the fingers as this could close the casualty s airway. CAUTION: Do not completely close the casualty s mouth. e. If you see something in the casualty's mouth (such as foreign material, loose teeth, dentures, facial bone, or vomitus) that could block his airway, use your fingers to remove the material as quickly as possible 11
Open the Airway: Jaw Thrust Technique Jaw Thrust Technique: (1) The jaw thrust is the safest/first approach to opening the airway of a casualty who has a suspected neck injury because in most cases it can be accomplished without extending the neck. (2) The jaw thrust may be accomplished by the rescuer grasping the angles of the casualty s lower jaw and lifting with both hands, one on each side, displacing the jaw forward and up (Figure 5). (3) The rescuer s elbows should rest on the surface on which the casualty is lying. If the lips close, the lower lip can be retracted with the thumb. 1. Assess Responsiveness 2. Position the Casualty 3. Open the Airway a. Head-Tilt/Chin-Lift b. Jaw Thrust Technique 4. Check for Breathing 5. Determine Appropriate Action a. Insert NPA b. Ventilation c. Advanced Airway 12
Check for Breathing While maintaining the open airway position (head-tilt/chinlift), place your ear over the casualty s mouth and nose and look toward the chest and abdomen. 1. Assess Responsiveness 2. Position the Casualty 3. Open the Airway a. Head-Tilt/Chin-Lift b. Jaw Thrust Technique 4. Check for Breathing 5. Determine Appropriate Action a. Insert NPA Check for signs of breathing while maintaining an open airway (head-tilt/chin-lift). b. Ventilation c. Advanced Airway a. Look to see if the casualty's chest rises and falls. b. Listen for air escaping during exhalation. 13 c. Feel for the flow of air on the side of your face.
Determine Appropriate Action: Airway Protocol Reposition Airway manually (jaw-thrust if c-spine injury) Sweep & Suction as needed Heimlich Maneuver if indicated. NO Trauma Assessment Airway Assessment Airway Established? YES Conscious with Adequate Respirations (RR>8 or <30) YES Indications include: Airway Obstructions Apnea Excess work of breathing Decreased LOC (GCS<8) Hypoxia (SpO2 <90%) Shock 1. Assess Responsiveness 2. Position the Casualty 3. Open the Airway a. Head-Tilt/Chin-Lift b. Jaw Thrust Technique 4. Check for Breathing 5. Determine Appropriate Action NO a. Insert NPA Consider & Initiate Immediate Evacuation as required b. Ventilation Monitor: Re-check airway every 5 min Sweep & Suction as needed Supplemental O2 if possible Assist ventilation w/bvm as needed Restart Protocol if problems arise Evac - Priority YES Is SpO2 >90% c. Advanced Airway NO 14 Ranger Medic Handbook 2007 Edition 75 th Ranger Regiment, US Army Special Operations Command See next Slide
Monitor: Re-check airway every 5 min Sweep & Suction as needed Supplemental O2 if possible Assist ventilation w/bvm as needed Restart Protocol if problems arise Evac - Priority YES Determine Appropriate Action: Airway Protocol Is SpO2 >90% NO Insert Nasopharyngeal Airway (NPA) Supplemental O2 if possible Assist ventilations with BVM as required. Ensure Tidal Volume of 500-600cc Previous slide DO NOT use nasopharyngeal airway if basal skull fracture is suspected 1. Assess Responsiveness 2. Position the Casualty 3. Open the Airway a. Head-Tilt/Chin-Lift b. Jaw Thrust Technique Thoracic Trauma NO YES Establish More Definitive Airway as Required IAW Procedures 1. Crycothyroidotomy 2. Supraglottic Airway Device 3. Orotrachealintubation Refer to Thoracic Trauma Consider Immediate Cricothyroidotomy as dictated by: 1. Maxillofacial Trauma 2. Tactical Situation 3. Any other Failed Intubation 4. Check for Breathing 5. Determine Appropriate Action a. Insert NPA b. Ventilation c. Advanced Airway Definitive Airway Established? NO Re-Assess Intervention Provided Consider other causes of Hypoxia YES 15 Ranger Medic Handbook 2007 Edition 75 th Ranger Regiment, US Army Special Operations Command Assist Ventilation w/ BVM as Needed Monitor Airway Continuously Sweep & Suction as required Restart Protocol if respiratory problems arise
How to use the nasopharyngeal airway (NPA) *Note: NPAs should not be used on casualties with suspected head trauma or a suspected skull fracture 1. Lubricate the NPA 1 Use a water-soluble lubricant prior to insertion 2. Insert the NPA With the bevel toward the septum (center of nose), advance the NPA gently, straight in, following the floor of the nose If resistence is felt do not force If you are experiencing problems, try the other nostril 3. Ensure correct Placement 2 3 The flange should rest on the victim s nostril. 16
Ventilation of a Casualty 1. The patient s chest should be exposed and you should look for symmetrical movement of the chest wall 2. Ensure adequate ventilation with Bag Valve Mask (BVM), 10 to 12 breaths per minute for adults. Two-rescuer Bagging (*Preferred) 17 The rescuer at the head uses the thumb and first finger of each hand to provide a complete seal around the edges of the mask. Use the remaining fingers to lift the mandible and extend the neck while observing chest rise. The other rescuer slowly squeezes the bag (over 2 seconds) until he observes chest rise. One-rescuer Bagging The rescuer circles the top edges of the mask with her index and first finger and lifts the jaw with the remaining fingers. The bag is squeezed while the rescuer observes chest rise. Mask seal is key to the successful use of the bag mask.
Advanced Airway If the previous measures (including the use of an NPA and assisted ventilation) are unsuccessful, perform a surgical cricothyroidotomy using one of the following devices: Cric-Key (Control-Cric TM ) *preferred option Bougie-aided open surgical technique using a flanged and cuffed airway cannula of less than10 mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intra-tracheal length Standard open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6-7 mm internal diameter, and 5-8 cm of intra-tracheal length (Least desirable option) 1. Assess Responsiveness 2. Position the Casualty 3. Open the Airway a. Head-Tilt/Chin-Lift b. Jaw Thrust Technique 4. Check for Breathing 5. Determine Appropriate Action a. Insert NPA b. Ventilation c. Advanced Airway 18 *Note: Use lidocaine if the casualty is conscious.
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