Managing Patients in the Austere Environment Utilizing the M.A.R.C.H Algorithm: A - Airway Management & Control

In our last post, we presented the importance of a systematic approach to managing Massive Hemorrhages when treating Life Threat injuries while applying Life Saving Interventions during Care Under Fire or Direct Threat Care.  As we continue the patient treatment and management cascade of victims in the austere environment we continue to break down the life-saving interventions utilizing the M.A.R.C.H. algorithm in managing patients with traumatic injuries. A. or Airway Management needs to be recognized immediately only after controlling massive bleeds.  Again, looking at the Lethal Triad of Trauma, the three components that make up the triad are Hypothermia, Acidosis, and Presenting Coagulopathy.  Our job as providers is to mitigate this triad by applying Damage Control measures as soon as possible thus, It starts with the first trained hands applied to a patient at the point of wounding that starts the cascade of success through Damage Control in Surgery.  By recognizing and applying the appropriate life-saving interventions to your wounded patient provides for the best outcomes for survival moving through the trauma system.  Whether you are a level one provider in the military or a pre-hospital provider, your ability to critical think and manage your patient greatly reduces the effects of the triad of death.   

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A compromised Airway is the third most common cause of death both in combat and in American Active Shooter Hostile Events. If the Airway compromise goes unrecognized and is not mitigated immediately after you deal with any massive hemorrhage, then your patient's chances of survival diminish greatly every minute as well as survival through the Damage Control cascade and long-term deficits.  

 As a provider in a tactical environment, we first must understand what phase of care we are in and critically think through the situation we are encountering.  The tactical commander decisions regarding the mission directly affect how and when we will treat the victim's injuries.  We know the best medical treatment during direct threat operations is placing effective fire on target or shutting down the active shooter.  Second is getting covered or getting your victim covered, then rendering treatment driven by the tactical situation. During Care Under Fire most airway management strategies are deferred to the Tactical Field Care phase of the operation.  However, if the opportunity presents itself we can manage a victims airway with position. Chin lift, jaw thrust, recovery position and NPA are best during the Care Under Fire phase.

During the Tactical Field Care phase through the Tactical Evacuation phase of a mission, the victim's airway can be managed with more sophisticated airway adjuncts.  I do not advocate any one particular device, but I do recommend having a couple devices that are simple, effective and multi-purposeful.  Real estate and weight are to be considered when choosing your tools. Also having the ability to needle or surgically criq a patient is important and a skill that needs to be part of the provider's tactical medical toolbox.  

Supporting our student's missions in the austere environment, VAMS provides students education and training with many different types of airway adjuncts.  Each manufacturer has their special features and application techniques, so understanding specific adjuncts you utilize in the field is very important and must be practiced regularly both in low light and no light situations.  All skills are perishable and should be rehearsed statically as well as dynamically in training evolutions.

In conclusion, as you extricate your victims from the point of wounding to the casualty collection point and out to the transport, the airway needs to be reassessed just like you would a tourniquet.  Ensure your adjuncts are secure and provide a stable airway. This ensures the best outcome for your patients and their management through the cascade to definitive care and recovery from their injuries.  

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By recognizing the Method of Injury, recognizing massive hemorrhage, and understanding the pros, and cons of your equipment and medical supplies will enhance your ability as a responder to saves lives. Combining all three methods of bleeding control may be required to stop a hemorrhage. Critical thinking and being aggressive with your life-saving treatment interventions as well as exciting the extrication of your patient to the appropriate treatment facility is all part of damage control providing for the best survival outcomes for your patient.