Introduction
It is well documented since the Vietnam conflict, and more recently in Iraq and Afghanistan military conflicts, that airway obstruction caused by trauma is the second leading cause of preventable death for combat fatalities. Consequently, the Committee on Tactical Combat Casualty Care (CoTCCC) conducts periodic airway management updates since the first published tactical combat casualty care (TCCC) trauma guidelines by Butler et al 1996. These periodic reviews are based on the need for combat medical providers to be proficient in managing battlefield airway injuries. The CoTCCC reviewed the airway management guidelines with updates in 2017 and 2021. More recently, the CoTCCC published a 2024 update that was a comprehensive, multiyear review of the strength of evidence for airway management procedures including: 1) positioning of patient, 2) nasopharyngeal airway, 3) supraglottic airways, 4) tracheal intubation and 5) surgical cricothyroidotomy. Our intent with this initial announcement is to inform the reader about the CoTCCC airway management update, indicate what has changed, and to reveal the current TCCC recommendations – See Table 1. The previous TCCC 2021 version of the airway management recommendations can be viewed in Table 2. The TCCC guideline 2024 updates include three updates to Airway Management, Respiration/Breathing, and Traumatic Brain Injury sections. These updates have been recently published by Deaton et al 2024, and they also are located on the CoTCCC Deployed Medicine website. (Note: this Department of Defense website now requires you to create an account with a username and password before you can access the tactical combat casualty care content to ensure that your access meets the Defense Information Systems Agency cybersecurity requirements).
|
Tactical Field Care Airway Management
|
|
RED text indicates new text in this year’s update to the TCCC Guidelines;
BLUE text indicates text that did not change but was relocated within the guidelines.
a. Assess for unobstructed airway.
b. If there is a traumatic airway obstruction or impending traumatic obstruction, prepare for possible direct airway intervention.
c. Allow a conscious casualty to assume any position that best protects the airway, to include sitting up and/or leaning forward.
d. Place an unconscious casualty in the recovery position: head tilted back, chin away from chest.
e. Use suction if available and appropriate.
f. If the previous measures are unsuccessful, and the casualty’s airway obstruction (e.g., facial fractures, direct airway injury, blood, deformations or burns) is unmanageable, perform a surgical cricothyroidotomy using one of the following:
• Bougie-aided open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6–7mm internal diameter, and 5–8cm of intratracheal length.
• Standard open surgical technique using a flanged and cuffed airway cannula of less than 10mm outer diameter, 6–7mm internal diameter, and 5–8cm of intra-tracheal length.
• Verify placement with continuous end-tidal CO2 (EtCO2) capnography.
• Use lidocaine if the casualty is conscious.
g. Frequently reassess SpO2, EtCO2, and airway patency, as airway status may change over time.
h. Cervical spine stabilization is not necessary for casualties who have sustained only penetrating trauma.
|
Table 1. Tactical Combat Casualty Care Airway Management Guidelines Update 2024
The 2024 summary of changes for airway management in the Tactical Field Care (TFC) phase of casualty management are the following:
- Simplifies the airway management sequence in Tactical Field Care.
- Better defines the recovery position with head tilted back and chin away from chest.
- Eliminates nasopharyngeal, and extraglottic airways during TFC.
- Provides more specific indications for surgical cricothyroidotomy.
- Establishes need for frequent reassessment of SpO2, EtCO2, and airway patency.
|
Tactical Field Care Airway Management (older version)
|
|
a. Conscious casualty with no airway problem identified:
1. No airway intervention required
b. Unconscious casualty without airway obstruction:
1. Place casualty in the recovery position
2. Chin lift or jaw thrust maneuver or
3. Nasopharyngeal airway or
4. Extraglottic airway
c. Casualty with airway obstruction or impending airway obstruction:
1. Allow a conscious casualty to assume any position that best protects the airway, to
include sitting up and/or leaning forward.
2. Use a chin lift or jaw thrust maneuver
3. Use suction if available and appropriate
4. Nasopharyngeal airway or
5. Extraglottic airway (if the casualty is unconscious)
6. Place an unconscious casualty in the recovery position
d. If the previous measures are unsuccessful, perform a surgical cricothyroidotomy using one of the following:
1. 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.
2. 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.
3. Use lidocaine if the casualty is conscious.
e. Cervical spine stabilization is not necessary for casualties who have sustained only
penetrating trauma.
f. Monitor the hemoglobin oxygen saturation in casualties to help assess airway
patency.
g. Always remember that the casualty’s airway status may change over time and
requires frequent reassessment.
Airway Notes:
• If an extraglottic airway with an air-filled cuff is used, the cuff pressure must be monitored to avoid over pressurization, especially during tactical evacuation 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.
|
Table 2. Tactical Combat Casualty Care Airway Management Guidelines 2021
Implication for the Wilderness Provider
For the reader who is not aware of the Tactical Combat Casualty Care guidelines and the three phases of medical care, a good overview or refresher can be found in a Wilderness Medicine Magazine article. There are many changes to the 2024 update of the TCCC airway management guidelines following this article’s comprehensive review of the literature. A subsequent Wilderness Magazine article (Part 2) will present the rationale and evidence for these airway management changes, and if all of these new airway management recommendations can be transitioned to the wilderness medical provider.
In the current 2024 TCCC guidelines, there are no changes to the basic management plan for Care Under Fire (in the wilderness/austere setting this would be analogous to any threat/hostile environment, e.g., avalanche, rock slide, wild animal attack, severe weather, etc.), where the airway management is generally best deferred until the Tactical Field Care phase or non-threat/hostile environment.
In the Tactical Field Care phase, (in the wilderness/austere setting this is when you are in a non-threat/hostile setting), the updated airway management guidelines are listed in Table 1. One obvious change from the TCCC guidelines in 2021 (Table 2) is that there is no mention of inserting a nasopharyngeal airway. The CoTCCC decided to place it in the Respiration/Breathing section of the TCCC guidelines where it now states the following:
If the casualty has impaired ventilation and uncorrectable hypoxia with decreasing oxygen saturation below 90%, consider insertion of a properly sized nasopharyngeal airway, and ventilate using a 1000mL resuscitator bag valve mask.
The basic management plan for Tactical Evacuation Care (in the wilderness this is care during ground or air evacuation), there is no 2024 update and airway management section and it still states the following:
Endotracheal intubation may be considered in lieu of cricothyroidotomy if trained.
Due to the CoTCCC airway update, a position statement was released recently by the Committee on Tactical Emergency Casualty Care (C-TECC), a civilian tactical medical society, about the continuing use of supraglottic airways. We recommend wilderness medical providers to review both CoTCCC and C-TECC airway management recommendations. In the wilderness setting, there is currently no justification to change from using SGAs in medical protocols when used with the appropriate training.
Final Thoughts
An airway procedure performed in any austere setting illustrates the need to appreciate “principles versus preferences” of medical care, an adage that was frequently described by the late Norman McSwain, MD. For example, with regard to surgical cricothyrotomy, the principle is the requirement to open the airway through the cricothyroid membrane to oxygenate, ventilate, and protect the airway. The preference is how the principle is realized with a cricothyrotomy procedure and tools of choice. Even though there are many cricothyrotomy procedures and devices, not all are practical for use in the austere environment. In Part 2 of this article, we will provide the rationale for the CoTCCC airway guideline changes in 2024, elaborate on differences between the battlefield versus wilderness airway management, and how best to transition these procedures and devices to your wilderness medicine toolkit. Finally, we will suggest a minimum set of airway devices for your wilderness basic, advanced, and expeditionary medical kits.