1. Improving Far Forward Medicine
Improving Far Forward Medicine
38 hours until CASEVAC?!? Now what!?!
Prolonged Field Care
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@PFCwgMedicine
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Prepared
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Why We Started This
-Fills gaps in current protocol and references
-Reach out and get a question answered by the community
-Download resources to any mobile device eReader
-Join the working group and let your voice be heard
-Your chance to contribute to your own training and
education before it becomes mandatory from above
-In partnership with SOF Medics and Docs in 40 countries
-Access to Training resources and Recommendations
Get the Info You Need Now!
PFC Videos on our YouTube Channel
10 Essential Capabilities - you must have
Tourniquet Conversion Paper - Answers nagging questions
Analgesia and sedation Paper - Easy, long term sedation
Airway Recommendation Paper – Best practices
PEEP Valve - Are you using them?
Long-Term Patient Care Flowsheet – Easy to trend vitals
Fresh Whole Blood Trans. FAQs – Answered

2. So You Saved the day With a Cric!
What’s Next?
Best Practice Airway Care
Adapted from:
Scott Weingart’s EMCrit Podcast #84 “Post Intubation Package”
Bob Mabry and Rich Levitan’s Tactical Airway
PFC WG Airway Recommendations
PFCWG Sedation and Analgesia Recommendations
NAP4 Study

3. Special Operations/Tactical /PFC Airway Algorithm
If in doubt, Cricothyroidotomy
This was meant for Medics who are not able to maintain proficiency on Direct Endotracheal Intubation defined by
initial training and evaluation
Recommending medics watch 50 video intubations!
Mannequin should be used for stress inoculation training
6-8 live intubations per quarter
Cuffed Cricothyroidotomy tube can remain in place up to 72 hours
You won’t have to fight the gag reflex with narcotics and paralytics

4. Near
Death?
Immediate SC No No No No
Tolerates
SGA? No

5. Airway Recommendations: Why not intubation!
Post ET intubation pain and sedation drips requiring a lot of meds
Having a tube in the back of your throat is extremely uncomfortable
CN IX constantly sending signal to CN X to gag (Pharyngeal Reflex Arc)
Initial training not uniform or evaluated live
Veterinary models not similar to human anatomy
Skills maintenance not likely with:
Deployments and other training requirements
1-4 week MPT rotation every 4 years
Large volume of medics
Limited access to low volume community hospital
No civilian cert accrediting medics to intubate on the streets

6. Indications for the Cric
If a patient has massive facial trauma and is conscious you will need to take control of the airway
Take it early
If you sedate one of these guys you will need to take their airway. Don’t wait until it is emergent
Do you plan on them sleeping sitting up bleeding from their face?
If they are bleeding enough from their facial trauma they may develop hypovolemia and accompanying anxiety and agitation
They will be come fatigued at some point and will lose the ability to protect their own airway
If a patient has sustained burns of the upper airway they will likely develop edema and lose their airway
Do the cric early before it is an emergency
If a patient has chest wall injury and cannot maintain O2 sats even while sleeping they will need positive pressure ventilations
Will they tolerate bagging with BVM and facemask?
Any other disease process that limits their ability to maintain saturation or protect their own airway
Cerebral or meningeal diseases
If a patient had any of the processes described earlier you will need to take control of the airway
Awake cricotyroidotomy?

7. Click for NAP4 Study Resus.me comments
“In appropriate circumstances (prophylactic cricothyroidotomy) has numerous advantages, not least the potential to secure and check the ‘rescue airway’ in a calm and unhurried manner, without hypoxia, before an emergency arises”
Quantitative wave-form ETCO2 should be the standard of care for EVERY ED and ICU intubation
Needle cricothyrotomy seems to fail more often than surgical cricothyrotomy
Awake intubation was not used when it was indicated
Junior resident anesthesiologists were often responding to the ED and ICU
There was a failure to plan for failure
Obesity figured into a large percentage of the airway disasters
Airway operators were not prepared or just did not properly progress to surgical airway

8. The Awake Cricothyroidotomy Checklist
Most military SOF medics are extremely comfortable and practiced at this skill
Patient can remain sitting up breathing on their own during the procedure
Pretreat with 8mg zofran
Give 1-2mg IV of Versed to take the edge off and cause amnesia
Give pain control dose of Ketamine 0.1mg/kg IV slow push over 2 mins
Adequately clean area with povidine iodine and allow it to dry
Inject wheal of 2% lidocane over Cricothyroid Membrane and clean area where you will incise
Advance the needle while aspirating
When you see bubbles you are in the Trachea
Squirt 3mls into the trachea causing them to cough and distribute the lidocaine
Make your vertical incision like normal
Make horizontal stabbing incision ensuring the hole is wide enough for the tube to easily pass
Secure with cric hook or bougie
Insert the tube and inflate the cuff
Confirm and reconfirm Placement like you would with ET intubation
Failures by inexperienced operators usually end up under the skin but outside the airway

9. Confirm and Reconfirm Placement
Qualitative Single Use Color Changing Capnometer
Can give false positives, wait 6 breaths
ETD Bulb
Can detect if tube is sub cutaneous and not in the airway
Quantitative Numeric Capnometer
Better, Waveform capnography best
Stethoscope if environment permits

10. Check Depth of Tube
If you used a full size ET tube and buried it to the hilt you may need to pull it back until you can see or feel it in the lower airway in the neck
3cm should be good enough
Use stethoscope to ensure tube is not in right main-stem bronchus
Tube placement is routinely checked with X-Ray in hospitals
Ultrasound can be used as well

11. Secure in Place
Suture with a Box suture sandal wrapping and taping to the tube
Further secure with commercial device or tied IV tubing
Check under this device every 8 hours for signs of pressure necrosis

12. Sedation and Analgesia
From SOCOM PFC WG Analgesia/Sedation Comments(February, 2014)
"Any procedure that involves sedation should also include monitoring the patient, ideally with end tidal CO2 (with a waveform), and at a minimum, have oxygen saturation (pulse ox) monitoring."
Many of the drugs available to 18Ds can cause nausea. Pre-treat with 8mg Zofran (Pill Pack?!)
If ketamine is given in analgesia doses it should not be done as a drip. Do boluses over at least 2 mins. You can give a Ketamine sedation drip for transport or procedure as follows:
Add 750mg of to a 250mg bag of normal Saline (some providers add up to 25mg of versed also.) The initial drip rate is kg bodyweight/2=cc/hr. For example a 100 kg patient would be started at 50cc/hr drip rate. At this rate, you can calculate the bag lasting about 5 hours. In practice, it is observed that the majority of the time, the drip rate could be cut in half after 20-30min, and the bag may last 8-9hrs.
(For reference, the initial doses are ketamine: 1.5mg/kg/hr, and versed:0.05mg/kg/hr).
If any other questions see the SOCOM PFC WG Analgesia/Sedation Comments(February, 2014) at

13. Lung Protective Strategy
This may mean a BVM with a PEEP valve for us
SAVent (which has no PEEP) should only be used when absolutely necessary for a couple hours at most
Initial transport when all personnel are required to drive
High threat/ High security needed
Should get back to BVM with PEEP valve ASAP
If older Impact 752 vent available see Rule of 5s Checklist
If you have a real vent available be sure to watch:
Scott Weingart’s Dominating the Vent

14. Raise Head of Bed Fowlers Position Ideal
30-45degrees
This natural position will improve lung function
May prevent micro aspiration from stomach contents around the cuff
Help ICP in head injured patients
More comfortable if patient is aware

15. Keep out Debris and Humidify the Air
ICU ventilators have humidification built in
So do humans
Our option to replicate it:
Heat Moisture exchanger ($5.00)
Retains patient’s own moisture
Blocks out sand and debris from helicopter rotor wash if no vent available

16. Place and Use Inline Suction Every Hour
Suction the mouth when you suction the tube
If not using in-line Ballard suction use best sterile technique possible

17. If Quantitative End Tidal CO2 isn’t Hooked up yet DO IT!
If transporting or transferring this will immediately alert you to a problem
$1300-$2500
SPO2 Pulse Oxs may take minutes to let you know, especially if the patient is on 100% O2

18. Check ET Tube Cuff Pressure
Too low and you risk micro-aspiration and VAP
That’s bad
Too high and the patient has the potential for tracheal ischemia
Also bad
The ideal pressure is between cm H20, hard to guessimate.
Use a cufflator or cuff safe ($ $300.00)
If replacing air in cuff with Saline be sure to get ALL the air out
Small amount of air mixed with water may be more dangerous than air alone
Water is not compressible and forces expanding air pressure to be focused on one area

19. NG OG Tube
Can be done procedurally prior to tubing if the situation permits
Use Ketamine and suck out stomach contents if patient is known to have large amount of stomach contents
Complete after the cric if it was done emergently

20. Have a Plan for alarms or vital signs out of normal range
Each member of the team who is not “medically” trained should know what constitutes an emergency and when to seek help.
Rising or Absent ETCO2
Falling or Absent Pulse Ox
Change respiratory rate
Change in Heart Rate
Change in Blood Pressure
Change in Glucose
Change in Lactate

21. Begin Pulmonary Hygeine or Chest Physical Therapy Once Tubed
Consists of:
Adequate analgesia will facilitate everything else
Initial clorahixadine swab of mouth
Rotating patient positioning periodically (6-8hrs)
Flushing (2cc saline) and Suctioning of tube causing a cough
Flushing and suctioning mouth
Oral care such as Brushing teeth, applying chap stick
Percussing injured side to loosen blood and mucus
If attempting to squeegee a tube out with foley cath balloon keep the procedure sterile

22. The Post Cric Checklist
Confirm and reconfirm placement
Check Depth of tube
Secure the Tube Well
Achieve Adequate Analgesia and Sedation
Confirm Lung Protective Strategy/BVM with PEEP
Raise the Head of the Bed to °
Protect Tube inlet and Humidify the Air
Place In-Line Suction and suction the mouth
Double check that Quantitative ETCO2 capnometry is in place
Check Cuff Pressure
Place an NG Tube and Prevent Aspiration past the Cuff of the ETT
Get a Blood Gas if possible
Put a BVM at the Bedside ± PEEP Valve
Have a Plan for Vent Alarms and changing vitals
Pulmonary Hygiene

23. Improving Far Forward Medicine
Improving Far Forward Medicine
38 hours until CASEVAC?!? Now what!?!
Prolonged Field Care
Downloadable Resources Subscribe Now
Instant Updates
@PFCwgMedicine
Get
Prepared
@FOAMedPFC
Why We Started This
-Fills gaps in current protocol and references
-Reach out and get a question answered by the community
-Download resources to any mobile device eReader
-Join the working group and let your voice be heard
-Your chance to contribute to your own training and
education before it becomes mandatory from above
-In partnership with SOF Medics and Docs in 40 countries
-Access to Training resources and Recommendations
Get the Info You Need Now!
PFC Videos on our YouTube Channel
10 Essential Capabilities - you must have
Tourniquet Conversion Paper - Answers nagging questions
Analgesia and sedation Paper - Easy, long term sedation
Airway Recommendation Paper – Best practices
PEEP Valve - Are you using them?
Long-Term Patient Care Flowsheet – Easy to trend vitals
Fresh Whole Blood Trans. FAQs – Answered