J R Army Med Corps 2000; 146: 215-227 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

BATLS

Battlefield Advanced Trauma Life Support (BATLS)

logistic capabilities (JSP 110). In these CHAPTER 3 TRIAGE circumstances the aim of the medical services must be to give care to the greatest Aim benefit of the largest number - that is ‘to do 0301. On successfully completing this most for the most’. topic you will have a sound understanding 0308. The term mass casualties is of how to prioritise casualties for treatment reserved for a situation when medical and evacuation, so that the survival of the resources are overwhelmed.When resources maximum number is ensured. are adequate, the incident is said to be ‘compensated’. In a military setting, an Introduction ‘uncompensated’ situation may exist 0302. The management of a single temporarily or over a prolonged period. It seriously injured casualty in peacetime may be appropriate for the local military or civilian practice is frequently commander to introduce mass casualty problematic. On the battlefield, problems triage without a formal declaration having are compounded by: environment, difficult been made by a higher authority. terrain and tactical constraints. The 0309. The triage system in an situation is even more difficult when faced uncompensated situation thus becomes; with large numbers of casualties. • P1 - Immediate Treatment. Those needing 0303. If a system for prioritisation of care emergency life-saving treatment. of the injured is not in place, many Procedures should not be time salvageable casualties may die consuming and concern only those with a unnecessarily.Triage (from the French verb high chance of good quality survival. trier, to sieve or to sort), has evolved Examples are remedial airway through military conflicts dating from the obstruction, accessible haemorrhage and Napoleonic Wars to recent civilian disasters. emergency amputations. http://militaryhealth.bmj.com/

Definition • P2 - Delayed Treatment. Those needing 0304. The process of triage is complex. The major surgery (after initial sustaining preferred definition is: treatment such as intravenous fluids, Sorting casualties and the assignment of antibiotics and splinting), or medical treatment and evacuation priorities to treatment, but where conditions permit wounded at each role of medical care. delay without endangering life. Examples are open fractures of long bones, large Triage Priorities joint dislocations and burns covering 15- 0305. There are four triage priorities: 30% BSA. • Priority One (P1). Those needing on September 28, 2021 by guest. Protected copyright. immediate life-saving resuscitation and/or • P3 - Minimal Treatment. Those with surgery. relatively minor injuries who can • Priority Two (P2). Those needing early effectively take care of themselves or be resuscitation and/or surgery, but some helped by untrained personnel. Examples delay is acceptable. are minor lacerations and uncomplicated • Priority Three (P3). Those who require fractures. treatment but where a longer delay is acceptable. • P1 Hold - Expectant Treatment. Those • Dead. with serious multiple injuries needing 0306. This is the P (Priority) System, of extensive treatment or with a poor chance triage.Triage must be repeated at every link of survival. These casualties receive of the evacuation chain and the priority appropriate supportive treatment adjusted to reflect deterioration or compatible with resources, for example, improvement in the casualty’s clinical analgesia. Examples are severe head and condition. spinal injuries, extensive burns and large doses of radiation. Mass Casualties 0310. The T (Treatment) System of 0307. A mass casualty situation triage, is an alternative to the P System and overwhelms the available medical and is routinely used by the RN, the RAF, BATLS Chapters 3 & 4 216 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

NATO allies, the International Committee the airway, breathing and circulation (see of the Red Cross, civilian ambulance Table 3.1). services and in civilian disaster 0314. Triage is only a ‘snapshot’ of how programmes. the casualty is at the time of assessment. In 0311. The relationship between the two order to identify changes in the casualty’s systems is as follows; condition, the triage sieve must be repeated • P1 is equivalent to T1 at each link of the evacuation chain. It is • P2 is equivalent to T2 important initially not to try to predict how • P3 is equivalent to T3 a casualty may deteriorate, this will lead to • P1 Hold is equivalent to T4 over-triage (a higher than necessary triage • Dead is still Dead. category) and can overwhelm the system with P1 and P2 casualties. Triage for Treatment 0312 A simple, safe, rapid and Triage for Evacuation reproducible system is required that can be 0315. Limited time and personnel applied by any Serviceman with appropriate resources may prohibit a more detailed medical training. Physiological systems that triage assessment other than that given by look at the consequences of injury (a change the triage sieve. When possible, the Triage in the vital signs: Respiratory Rate, Pulse Rate Sort can be used to refine triage sieve and Capillary Refill Time [CRT] are more decisions. Triage sort uses the respiratory reliable than anatomical systems (which rate, systolic blood pressure and Glasgow require extensive clinical knowledge and a Coma Scale, to numerically score the need to undress the casualty). casualty from 0 to 12 and give an indication 0313. A widely accepted physiological of priority for evacuation and/or the need method of triage for treatment is the Triage for further intervention. This score has a Sieve. This involves an assessment of the proven direct relationship to outcome from casualty’s mobility, then an assessment of severe injury. Table 3.1 The triage sieve Table 3.2 Triage sort coded values You must Tr iage all casualties before treatment; assess Physiological variable Measured value Score priority, write on forehead, move to next casualty. Respiratory rate 10-30 4 >30 3 Remember 6-9 2 DON’T PAUSE TO TREAT or 1-5 1 00 Start You will have failed in your task. Systolic blood pressure >90 4 here 89-76 3 75-50 2

<49 1 http://militaryhealth.bmj.com/ Walking? 1 Ye s P3 00 Glasgow Coma Scale 15-13 4 12-9 3 NO 8-6 2 5-4 1 30 Airway opening BREATHING? procedures Still NO Dead 0316. Priorities are assigned as follows: • P1 (T1) 1-103 Ye s • P2 (T2) 11 • P3 (T3) 12 • P1 Hold (T4) 1-33 on September 28, 2021 by guest. Protected copyright. Ye s Starts to Breath P1 (A) • Dead 0 0317. The coded values for the Triage Breathing Sort are given in Table 3.2. After coding Rate Under 10 or over 30/min each of the three parameters, add them P1 (B) together to give a score ranging from 0 10-30/min (dead) to 12 (physiologically normal). 0318. Evacuation will be delayed when the number of casualties outstrips available transport. In this situation, the greater time Over 120/min CRT>2 secs P1 (C) Pulse spent with the casualty will allow additional Rate anatomical assessment of injuries. Where and CRT2 the priority determined by physiology does Under 120/min CRT<2 secs not match the anatomical severity of P2 injuries, the priority can be upgraded. Example: A soldier loses his left leg in a landmine incident. Immediate first aid is Now TREAT the injured effective in stopping haemorrhage. He is 1 It must also be realised that some in this group, despite being ambulatory, may have injuries of sufficient 3. The overlap in scores allows for the seriously injured to be magnitude to cause a clinical deterioration requiring a change in priority. 2 Is unreliable in the cold or placed in either category, depending on number of casualties dark. and resources available for evacuation. 217 BATLS Chapters 3 & 4 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

transported to the RAP. He cannot walk, his Application at Role One and respiratory rate is 22 and his pulse is Role Two 110/minute. He is triaged P2 for treatment 0322. For the regimental medical officer (Triage Sieve). He then receives intravenous (RMO) and the dressing station medical fluids and analgesia. His systolic BP is 115 officer, casualties are likely to be graded for mmHg, his respiratory rate is 20, he is fully treatment and/or evacuation as follows: alert, with a GCS of 15. He scores 12 on his • P1 Triage Sort, which is P3 for evacuation. Airway: Obstruction including that Clearly, he requires early surgical treatment due to maxillofacial injury. and the RMO upgrades his priority to P2 Airway burns with the for evacuation to the field hospital. potential for obstruction. 0319. To help understand priority Breathing: Tension pneumothorax - open allocations for evacuation, it is appropriate chest wound - flail to consider the standard casualty evacuation chest/pulmonary contusion. chain which is usually through the logistical Respiratory rate <10>30. Lines of Support. These lines of support Triage Sort Score 1-10. relate to the Combat Services Support Circulation: Major haemorrhage - external (CSS) provided at levels of operational or internal - compressible or deployment, that is, First Line at unit level, non compressible. CRT >2S. Second Line at brigade or divisional level, Pulse rate >120/mm. Massive Third Line between the divisional rear muscle injuries. Multiple boundary and point of entry, and Fourth fractures and/or multiple Line at the base4. These should not be wounds. Burns between 15 confused with Roles of Medical Support and 30% Body Surface Area which is the term used throughout NATO (BSA). to define the levels of medical capability5. • P2 Lesser visceral injuries. • Role 1 Treatment to restore and stabilise Vascular injuries not having vital functions. (Regimental Aid features of P1. Cerebral Post/Medical Section(s)). injuries that are deteriorating • Role 2 Resuscitation and stabilising (See table 8.2). Burns of less treatment - may include stabilising than 15% BSA involving face, (Damage Control) surgery eyelids, hands, perineum and (Dressing Station). across joints (see paragraph • Role 3 Hospitalisation and life-saving 1222). Large joint surgery, definitive surgery (Field dislocations.

Hospital). • P3 Lesser fractures and http://militaryhealth.bmj.com/ • Role 4 Time consuming specialist and dislocations. Lesser soft tissue long term treatment (NHS injuries ultimately requiring Hospital). surgery. Maxillofacial injuries 0320. It should be assumed that early with no airway problems. surgery takes place at the field hospital, with Eye injuries. Other burns less subsequent care taking place back in the than 15% BSA. United Kingdom, within the National 0323. Expectant (P1 Hold [T4]) cases Health Service. There will be occasions would include, for example, burns of greater when surgery, through a field surgical team than 30% BSA, gunshot wounds to the

being attached, is available forward of field brain and other injuries with a poor on September 28, 2021 by guest. Protected copyright. hospitals. This will be the norm in prognosis. airborne and airmobile operations and 0324. Medical cases are categorised in when FIRST 6 teams are attached to Close exactly the same way in relation to their Support Squadrons of Medical Regiments. need for resuscitation and timely Sepcialist teams, such as burns teams and intervention by a physician. Psychiatric head and neck teams, can be allocated to cases invariably tend to fit into the P3 selected field hospitals: this will influence bracket, with the particular caveat they the disposal and transfer of candidate should be treated as far forward as possible; casualties. this approach will result in the maximum 0321. United Kingdom military number being rendered fit and returned to operations are increasingly Joint Service in duty. The further rearward a psychiatric nature, for example, surgical support at case is evacuated, the less likely this is to Role Three may be found from the RN happen. in the form of a Primary Casualty Receiving Ship (PCRS). An intermediate Application at Role Three hospital may be set up, at a convenient 0325. The critical decision at the field location on either the tactical or strategic hospital is whether the casualty needs LOCs. resuscitation and surgery now, or whether 4. See Army Doctrinal Publication Vol 3 Logistics (Army Code 71566). 5. For example, there will be Role 1 and Role 2 medical units at Third Line. 6. Forward Immediate Resuscitation and Surgery Teams. BATLS Chapters 3 & 4 218 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

he can withstand further delay. The consists of the larynx, trachea and lungs. An identification of casualties requiring expert open airway allows air (containing oxygen) treatment by specialist teams must also be to enter the lungs, oxygenate the blood, considered. which is then carried to the tissues. A 0326. At this level, in the presence of reduction in oxygen levels in the blood or mass casualties, the P1 Hold (T4) category tissues, is termed hypoxia. Tissue hypoxia will represent: causes cell damage and, if prolonged, can • Cases whose survival is uncertain. lead to organ failure and death. Some • Cases who require prolonged surgery, organs are more sensitive to hypoxia than who must wait until time and facilities are others. For example, cerebral hypoxia even available. for a short period of time will cause agitation, • Major burns cases who are kept for 48 then a decreased level of consciousness and hours prior to transfer to a specialist eventually, irreversible or fatal brain damage. burns team. 0403. Carbon dioxide is produced by 0327. When there are many casualties, cellular metabolism and carried in the the expedient of the greatest good of the blood to the lungs; it is then exhaled. If greatest number must prevail. there is airway obstruction, there is a build up of carbon dioxide in the blood Summary (hypercarbia). This causes drowsiness. • Triage is the sorting of casualties into Supplementary oxygen must be orders of priority for treatment and administered to all seriously injured avacuation. The triage process is dynamic battle casualties as early as possible in and needs reassessment throughout the the evacuation chain. casualty evacuation chain. It will be coloured by doctrinal and organisational 0404. Obstruction to either the upper or factors which affect time between and lower airway can compromise ventilation of location of, medical echelons in the chain. the lungs and quickly result in cerebral Even when faced with large numbers of hypoxia. Management of the upper and lower casualties, the A B C routine must be airway is the first concern in any battlefield followed in order to identify life-threatening casualty. problems and indicate priorities. • The principles of management of the The airway must be opened, injured remain as primary survey, maintained and protected, with resuscitation, secondary survey and ventilatory support provided if necessary. definitive care, albeit that the last two may

be carried out at a more rearward Airway and Breathing http://militaryhealth.bmj.com/ echelon. The philosophy of treatment for 0405. Early preventable deaths from large numbers of casualties is: airway problems after injury are frequently • To evacuate rearwards all those who can due to: withstand the journey. • Failure to recognize the urgent need for • To address the medical resources towards intervention in casualties with a those who have the best chance of compromised airway. survival. • Limited experience in airway clearing This is achieved through effective and skills. efficient triage. • Faulty judgement in selecting the correct airway manoeuvre. CHAPTER 4 AIRWAY • Failure to secure the airway prior to on September 28, 2021 by guest. Protected copyright. MANAGEMENT evacuation. AND VENTILATION • Becoming distracted by less urgent problems.

Aim Awareness 0401. On successfully completing this topic 0406. Particular problems that will you will be able to: endanger the airway: • Recognize those conditions causing • Head injury with decreased level of consciousness (see paragraph 0822). airway and breathing difficulty in the • Other causes of decreased level of battlefield casualty. consciousness (poisoning, alcohol, low • Discuss the principles of airway and oxygen, carbon monoxide). ventilatory management. • Maxillofacial injuries: • Demonstrate basic and advanced • Mid face fractures can move methods of airway management. backwards and block the airway. • Mandible fractures can allow the Anatomy and Physiology of the tongue to fall backwards. Airway • Bleeding and secretions caused by 0402.The upper airway consists of the nose, these injuries can block the airway. mouth and pharynx. The lower airway • Injuries to the neck: 219 BATLS Chapters 3 & 4 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

• Direct trauma to the larynx and • When pedestrians have been hit by a supporting structures. vehicle. • Bleeding inside the neck • Where casualties have been thrown by compressing the hypopharynx or explosions. trachea. • In the unconscious casualty (especially • Burns to the face and neck: where there is blunt injury above the • Swelling of the upper and lower clavicle). airway due to direct burns or • In the conscious casualty complaining of inhaling hot smoke, gases or steam, neck pain or loss of sensation or motor will cause airway obstruction. function in one or both arms. (see 0407. Airway problems may be: paragraph 1002-1006). • Immediate (block the airway quickly) or, 0415. Moving a casualty with bony spinal • Delayed (come on after a time delay - injury risks damaging the spinal cord. minutes or hours) or, Ideally, these casualties should only be • Deteriorate with time; this is often insidious moved when the appropriate spinal because of its slow progression and is immobilization devices are in place. (see easily overlooked. paragraph 1007). 0408. An airway that has been cleared may obstruct again if the casualty’s level of In situations where there is danger to consciousness decreases, there is further the casualty or rescuer, rapid bleeding into the airway or there is extraction of the casualty using increasing swelling in or around the airway. improvised immobilisation or none at all, will be needed. Recognition Priority is CLEAR THE AIRWAY but stay safe. 0409. Talk to the casualty! Failure to respond implies an altered level of 0416. Penetrating missile neck wounds consciousness with the potential for airway that directly involve the bony cervical spine compromise. A positive appropriate reply in or spinal cord carry a 95% mortality. They a normal voice indicates that the airway is patent, breathing normal and brain can be ignored in terms of cervical spine perfusion adequate. Any inappropriate or protection; get on and manage the airway! A incomprehensible response may suggest combination of blunt and penetrating neck airway or breathing compromise, or both. injuries should be managed as for blunt 0410. Look to see if the casualty is injury. agitated, drowsy or cyanosed. The absence of cyanosis does not mean the casualty is Clearing the airway adequately oxygenated. 0417. In the casualty with suspected http://militaryhealth.bmj.com/ cervical spine injury, manual inline Remember that a casualty who refuses immobilization of the cervical spine and to lie down quietly may be trying to sit airway clearance are carried out together. In up in an attempt to keep his airway a casualty with an altered level of open and/or his breathing adequate. consciousness, the tongue falls backwards and obstructs the hypopharynx. This 0411. Listen for abnormal sounds. obstruction can be readily corrected by the Snoring, gurgling and gargling sounds are jaw-thrust or chin-lift manoeuvres. Blood and associated with partial obstruction of the debris can be cleared by suction and finger sweeps. pharynx. Hoarseness implies laryngeal on September 28, 2021 by guest. Protected copyright. injury.The abusive casualty may be hypoxic and should not be presumed to be merely insubordinate or intoxicated. Total obstruction equals total silence! 0412. Feel for air movement on expiration and check if the trachea is in the midline.

Management 0413. Management comprises: • Clearing the obstructed airway. Fig 4.1 Jaw-thrust Fig 4.2 Chin-lift • Maintaining the intact airway. 0418. Jaw-thrust. Grasp the angles of the • Protecting the airway at risk. mandible, one hand on each side and move 0414. Techniques for clearing, maintaining and protecting the airway need the mandible forward. The jaw-thrust is to be modified in the trauma casualty when used for the injured casualty because it does cervical spine injury is suspected or present. not destabilise a possible cervical spine Cervical spine injury is suspected: fracture and risk converting a fracture • In falls from a height. without spinal cord injury to one with spinal • In vehicle collisions. cord injury. This maneouvre will open 95% BATLS Chapters 3 & 4 220 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

of obstructed upper airways. The jaw-thrust continue with the jaw-thrust or chin-lift or is illustrated at Fig 4.1. try using an oropharyngeal airway or 0419. Chin-lift. Place the fingers of one nasopharyngeal airway. hand under the chin and gently lift it 0426. Oropharyngeal airway. The upwards to bring the chin anteriorly. To oropharyngeal airway (Guedel type) is open the mouth, use the thumb of the same inserted into the casualty’s mouth over the hand to depress the lower lip slightly. The tongue. It stops the tongue falling back and thumb may also be placed behind the lower provides a clear passage for air flow. The incisors and, simultaneously, the chin gently preferred method is to insert the airway lifted.This will open the upper airway in 70- concavity upwards until the tip reaches the 80% of casualties.The chin-lift is illustrated soft palate and then rotate it 180°, slipping at Fig 4.2. it into place over the tongue (see Fig 4.3).

Make sure you do not Make sure that the airway does not hyperextend the neck. push the tongue backwards as this will block rather than open the airway. 0420. Suction. Remove blood and secretions from the oropharynx with a rigid 0427. A casualty with a gag reflex may suction device (for example, a Yankauer reject the oral airway. If so, move on to the sucker). If there is bleeding at the external nasopharyngeal airway. nares clear this with suction. A casualty with 0428. Nasopharyngeal airway. A facial injuries may also have a cribriform nasopharyngeal airway can be used when plate fracture; this means that suction catheters should not be inserted through the nose as they could enter the skull and injure the brain. 0421. Finger sweeps. Finger sweeps into the back of the mouth and pharynx may be useful for dislodging foreign bodies, particularly if no suction device is available.

Make sure that your fingers do not inadvertently push foreign bodies further into the airway.

0422. Displacement of fractured maxilla or http://militaryhealth.bmj.com/ mandible. Where airway obstruction results from a fractured maxilla, insert the index or middle finger or both, through the mouth behind the hard palate and pull it forward to disimpact the displaced bone. When an anterior mandibular fracture allows the tongue to fall back into the hypopharynx you may have to pull the mandible forward manually. on September 28, 2021 by guest. Protected copyright. Maintaining the airway 0423. How to maintain the casualty’s Fig 4.4 Nasopharyngeal airway airway will depend on: • The casualty’s injuries. there is oral injury, a fractured mandible or • The casualty’s level of consciousness. massetter spasm. It is better tolerated than • The equipment available. the Guedel by the more responsive casualty 0424. Clearing the casualty’s airway may and is less likely to be dislodged during result in his level of consciousness evacuation (see Fig 4.4). A suspected improving and being able to maintain his fractured base of skull is not a own airway. contraindication for use of this airway if an 0425. If the casualty cannot maintain his oropharyngeal airway cannot be inserted. own airway you (or an assistant) need to 0429. Lubricate the airway and insert it through either nostril, straight backwards - not upwards - so that its tip enters the hypopharynx. A safety pin should be applied across the proximal end before insertion to prevent the tube disappearing into the casualty’s airway. If this happens it could compromise rather than maintain the Fig 4.3 Nasopharyngeal airway airway. A complication of inserting the 221 BATLS Chapters 3 & 4 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

nasopharyngeal airway is bleeding from the the lower airway. nose. Gentle insertion, good lubrication and • To protect the airway from: using an airway that passes easily into the • Obstruction due to swelling. nose will decrease the incidence of bleeding. • Aspiration of gastric contents or other fluid. (Note: A cuffed The oropharyngeal and endotracheal tube or cuffed nasopharyngeal devices MAINTAIN surgical airway maintains a clear the airway but do not protect it from passage and the cuff provides a seal). aspiration. • To allow accurate control of oxygenation and ventilation. 0430. A casualty whose airway has been • As part of head injury management by cleared and maintained by the techniques helping to control oxygen and carbon described above may need help with their dioxide levels in cerebral blood flow (see breathing if this is depressed due to injuries Chapter 8): or toxic agents. • In the management of some chest 0431. Ventilation is covered at paragraphs injuries. 0446-0451 and is practised in Skill Station 1. • In surgery and anasthesia. Protecting the airway at risk - advanced airway DEFINITIVE AIRWAY techniques This is a cuffed tube placed in the 0432. Advanced airway techniques include: • Surgical cricothyroidotomy. trachea by the surgical route or by • Surgical tracheostomy. endotracheal intubation. • Endotracheal intubation. 0433. Indications for performing advanced SURGICAL AIRWAY airway techniques are:- 0434. A surgical airway is used when: • Inability to clear or maintain an airway • A casualty needing a definitive airway for using simple manoeuvres and airways in, resuscitation or evacuation is too awake to for example: tolerate endotracheal intubation without • Injury around the face. the use of anaesthetic drugs. • Face and airway burns (causing • Trauma to the face and neck make swelling of the airway, see endotracheal intubation impossible. paragraphs 0406 and 1213). • A casualty with face and neck burns • An obstruction in the upper airway requires airway protection to pre-empt that cannot be removed and needs delayed obstruction but expert to be by-passed. anaesthetic help is unavailable to carry • Neck injury or swelling blocking out endotracheal intubation. http://militaryhealth.bmj.com/ Surgical cricothyroidotomy 9435. Surgical cricothyroidotomy places a tube into the trachea via the cricothyroid membrane (See fig 4.5). A small tracheostomy tube (5-7 mm) is suitable. This will be practised in skill station 2 and is illustrated in Fig 4.6. During the procedure, appropriate cervical spine

protection must be maintained when on September 28, 2021 by guest. Protected copyright. indicated. There are also commercially available cricothyroidotomy sets in use with some NATO armies. A cricothyroidotomy can be replaced by a formal tracheostomy (if needed) at a later time. Fig 4.5 Cricothyroid membrance Emergency tracheostomy 0436. A formal surgical tracheostomy takes longer and is more difficult, than a surgical cricothyroidotomy. Commercial sets are available for rapid tracheostomy using a Seldinger (guide wire) technique.

Endotracheal intubation 0437. This technique uses a laryngoscope to visualise the vocal cords. A cuffed endotracheal tube is placed through the vocal cords into the trachea. This skill is illustrated at Fig 4.7 [shown in Skill Station Fig 4.6 Insertion of tracheostomy tube 2] and will be practised in the Skill Station. BATLS Chapters 3 & 4 222 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

0438. At Role 1 and Role 2, in the • If in doubt about the position of the absence of anaesthetic skills and drugs, endotracheal tube, take it out and endotracheal intubation will only be oxygenate the casualty by another method. achieved in deeply unconscious casualties (GCS 4 or less). Attempting intubation in It is failure to oxygenate the casualty the semiconscious casualty will result in that kills, not inability to intubate. gagging on the laryngoscope and coughing on the endotracheal tube. In casualties with If you need to take over care of an raised intracranial pressure this will increase intubated casualty make sure the the pressure even further and worsen the endotracheal tube is in the correct place situation. If the casualty gags or coughs, stop and has not moved during evacuation and try another method of airway or transfer of the casualty. management. Note: This presents a dilemma with head Note: Other methods for maintaining the injuries in coma (GCS 8 or less). Ideally airways. Both the laryngeal mask airway and these casualties should be intubated and combitubes have been used in civilian ventilated to prevent cerebral hypoxia and practice to manage the trauma casualty’s hypercabia worsening. In many of them, airway.Their role in military trauma has still attempting to do this without the aid of to be evaluated. anaesthetic drugs worsens the situation by raising ICP. A surgical airway with Oxygenation and Assisted ventilation and oxygenation my be required. 0439. In casualties who are not deeply Ventilation unconscious, maintain the airway with simple Oxygenation techniques. If protection is necessary, insert a 0443. The primary goal in providing surgical cricothyroidotomy under local supplementary oxygen is to maximise the anaesthesia. delivery of oxygen to the cells. This is done 0440. Where anaesthetic skills and drugs by providing the highest possible oxygen are available or can be brought to the concentration to the lungs using high flow casualty by an Incident Response Team oxygen at 10-15 litres per minute, as soon as (IRT), endotracheal intubation can be oxygen is available. A disposable face mask achieved using: without a reservoir bag can deliver 35-60% • Rapid sequence induction of anaesthesia oxygen, depending on type of mask and with: oxygen flow. A face mask with an oxygen • Application of cricoid pressure (Sellick’s reservoir can be used to deliver up to 85% manoeuvre) and, oxygen. A correctly fitting bag-valve-mask • Maintenance of cervical spine system with a reservoir, can be used to http://militaryhealth.bmj.com/ immobilisation when indicated. deliver up to 100% oxygen to the lungs. 0441. Intermittent oxygenation during difficult intubation. Intubation of the Ventilation hypoventilating or apnoeic casualty may 0444. Spontaneous ventilation (self require several attempts and even then, may ventilation) means the same as breathing. not be successful. If oxygen is available, you Assisted (artificial) ventilation means the must avoid prolonged efforts to intubate casualty is receiving help with breathing. without intermittently oxygenating and The aim is to improve gaseous exchange in ventilating the casualty.You should practise the lungs and to breathe for the casualty if

taking a deep breath when starting an spontaneous ventilation has stopped or is on September 28, 2021 by guest. Protected copyright. attempt at intubation; if you have to take inadequate. Indications for assisted further breath before successfully ventilation include: intubating the casualty, abort the attempt. • Head injury. 0442. Correct placement of the • Chest injury. endotracheal tube is checked in Skill • Respiratory depression due to drugs Station 2. The main points are: (such as nerve agents and opiates). • See if the endotracheal tube has passed 0445. Assisted ventilation can be achieved between the vocal cords. Remember to by the following techniques: maintain immobilisation of the cervical • Mouth to mouth (or nose). spine when indicated. • Mouth to mask. • Listen on both sides in the mid-axillary • Bag-valve-mask. line for equal breath sounds. • Bag-valve-endotracheal tube or surgical • Listen over the stomach for gurgling airway. sounds during assisted ventilation for • Automatic ventilation (used by specialist evidence of oesophageal intubation. resuscitation teams in field hospitals for • Feel and listen for air movement at the prolonged casualty ventilation). proximal end of the tube if the casualty is 0446. Assisted ventilation is described in breathing spontaneously. Skill Station 1 and will be practiced there. • Monitor end-tidal carbon dioxide levels if 0447. Mouth to mouth (one man) equipment is available. technique. If a pocket mask with a one-way 223 BATLS Chapters 3 & 4 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

valve and oxygen inlet is not available, you spine immobilization as can best be can give assisted ventilation by removing managed but airway management takes the mask from the bag-valve-mask device precedence. and blowing into the connecting port. Note: Do not use the mouth to mask Unconscious casualties without a technique if there is a chemical agent vapour definitive airway must not be hazard either in the environment or on the transferred lying on their backs. casualty. 0448. Bag-valve-mask. This technique can The casualty at risk from airway blocking be performed one or two handed and is best during transfer. performed with an oral or nasal airway in place. 0453. Where the casualty’s airway is at 0449. Bag-valve-endotracheal tube/surgical risk from blocking during transfer, for airway. The technique you will use will example, airway burns: depend on the circumstances and equipment available. If a manual bag-valve- • Get specialist advice. endotracheal tube/surgical airway technique • Consider providing a surgical airway, or is used, the bag is squeezed to achieve endotracheal intubation if anaesthetic obvious chest movement at a rate of expertise is to hand. approximately 12-15 breaths per minute, Note: On balance, a surgical airway is the that is, one second squeeze - three to four method of choice. It may be difficult in the seconds release. An oxygen source and a extreme incising through burnt skin. Aim reservoir should be attached to the bag as not to go through burnt skin but, your soon as they are available. prime concern is to protect the airway during casualty transfer! Evacuation of Airway Compromised Casualties Summary 0450. Casualties who have lost their • Airway obstruction must be recognised normal protective airway reflexes are in and relieved quickly. danger of aspirating gastric contents, blood • Beware of cervical spine injury during and debris and developing airway airway management. obstruction; they become hypoxic. • Start with simple techniques such as jaw- Caring for and monitoring a casualty in thrust/chin-lift/oropharyngeal suction. the back of military vehicles or helicopters • Try Guedel or nasopharyngeal airways. can be difficult, especially in low light • Give high flow oxygen from a mask with a conditions. A balance has to be made reservoir. between: • Definitive airways protect against • The need to move the casualty. aspiration of gastric contents and blood. http://militaryhealth.bmj.com/ • The safety of the casualty during • Definitive airways include: evacuation. • Surgical cricothyroidotomy. • The resources available to move the • Endotracheal intubation. casualty. Note: Choice of definitive airway will • Distance for evacuation. depend on skills and equipment available: • The tactical situation. • Casualties with inadequate respiration will need assisted ventilation. If available, seek specialist advice • This can be done by mouth, by bag and from hospital teams, aeromed teams mask or by automatic ventilators. or incident response teams. on September 28, 2021 by guest. Protected copyright. SKILLS STATIONS: The casualty with a definitive airway in place 1. Basic Airway Management and Ventilation 0451. Best practice is that they are 2. Advanced Airway Management: Adult evacuated by trained personnel with Orotracheal Intubation appropriate anaesthetic and intensive care skills and electronic monitors. If there is Aim concern about the ability to care for an The aim of these skills stations is to intubated casualty (for example, replacing a demonstrate and practise basic and displaced endotracheal tube) during advanced airway management.You will also evacuation, consider providing a definitive discuss the indications for oral endotracheal surgical airway. In casualties being evacuated by air, inflate the cuff with saline; intubation and associated complications. air expands at altitude. On successfully completing these stations, The casualty at risk from aspiration but a you will be proficient in: definitive airway cannot be provided 0452. Maintain the airway with a Guedel • Basic airway clearing techniques. or nasopharyngeal airway and transfer the • Oropharyngeal airway insertion. casualty in the lateral position with an • Nasopharyngeal airway insertion. escort who has oxygen, suction and can care • Ventilation without intubation. for the casualty en route. Continue cervical • Orotracheal intubation. BATLS Chapters 3 & 4 224 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

Equipment Airway management in the casualty with a fractured maxilla. Adult intubation manikins. • Using the Mr Hurt manikin with Adult endotracheal tubes size 7.0, 8.0 and 9.0. maxillary fractures, practice pulling the Laryngoscope handles. fracture forward to clear the airway. Laryngoscope blades, adult, curved. Extra batteries for laryngoscope handles. Airway management in the casualty whose Extra laryngoscope bulbs. head is not in the neutral position. Stethoscopes. • Gently move the casualty’s head into the Lubricant (for example, silicone spray that accompanies intubation manikin). neutral position if the airway cannot be Semi-rigid cervical collar applied to one adult intubation manikin, or sandbags. cleared and maintained in the non-neutral Magill’s forceps. position. Malleable endotracheal introducers. • Stop moving the head if: Oropharyngeal airways size 2, 3 and 4. • There is resistance to movement. Nasopharyngeal airways size 6.0 and 7.0. • The casualty complains of pain. Airway management in the combative Bag-valve-mask devices. casualty who will not accept sand bags and Pocket face masks (with a one-way valve to prevent back-flow of air and secretions). tape Rigid suction devices (Yankauer sucker). • Compromise by using a semi-rigid Safety pins. cervical collar only. Scissors. 1” open weave cotton bandage. Oropharyngeal Airway Insertion • Select the correct sized airway. Place the airway against the casualty’s face. The SKILLS STATIONS 1 correct sized airway will extend from the BASIC AIRWAY MANAGEMENT centre of the casualty’s mouth to the angle AND VENTILATION of the jaw. • Open the casualty’s mouth with the chin- Aim lift manoeuvre. This skill station allows you to practice • Insert the tip of the airway along the roof basic airway techniques and develop a of the mouth to the soft palate (see fig system for airway management. 4.3). The order for performing tasks will • Rotate the airway 180°, directing the depend on the situation, the personnel concavity of the airway towards the feet available and their skills. Some tasks will be and slip the airway over the tongue.

done simultaneously if more than one • If necessary, ventilate the casualty with http://militaryhealth.bmj.com/ person is available. mouth-to-mask or bag-valve-mask This skill station assumes there is an technique. assistant to help you. Nasopharyngeal Airway Sequence of actions: Insertion • Approach and reassure casualty. • Assess the nasal passages for any apparent React to the casualty’s response. obstruction (fractures, haemorrhage, polyps). Choose a nostril that is patent. • Provide manual inline immobilisation of • Select the correct size airway. Size 7 for

the cervical spine when indicated. the adult female and size 8 for an adult on September 28, 2021 by guest. Protected copyright. male. • Hand over manual inline immobilisation • Insert the safety pin across the nostril end to your assistant (get them to place their of the airway. hands over yours then gently remove your • Lubricate the nasopharyngeal airway with hands as they apply immobilisation). If a water-soluble lubricant or water. assistance is not available your sole aim is • Insert the tip of the airway into the nostril to clear the airway. and direct it posteriorly and towards the • Clear the airway using: ear lobe. • Finger sweeps to remove solid • Gently slide the nasopharyngeal airway debris (if safe to do so). through the nostril into the hypopharynx • Magill forceps to remove solid with a slight rotating motion until the debris. flange rests against the nostril. • Yankauer sucker to remove blood • If an obstruction is encountered try the and fluid from the oropharynx. other nostril or try a smaller • Jaw-thrust. nasopharyngeal airway. Trying to force the • Chin-lift. nasopharyngeal airway past an obstruction • Provide high flow oxygen from a mask may cause severe bleeding. with a reservoir bag. • If necessary, ventilate the casualty with • Decide if the casualty needs an mouth-to-mouth or bag-valve-mask oropharyngeal or nasopharyngeal airway. technique. 225 BATLS Chapters 3 & 4 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

Ventilation Without Intubation Mouth-to-mask ventilation, adult (one man technique) • Attach oxygen tubing to the Laerdal pocket mask. • Adjust the oxygen flow rate to 10 litres per minute. • If there is no oxygen inlet, place the oxygen tubing under the side of the mask. • Insert an oropharyngeal airway. • Apply the face mask to the casualty using both hands. • Open the airway using the jaw-thrust manoeuvre, three fingers on the underside of the jaw. • Take a deep breath and place your mouth over the mouth port and blow. • Assess the ventilatory efforts by observing the casualty’s chest movement. • Ventilate the casualty in this manner every five seconds.

Bag-valve-mask ventilation, adult (two man technique) • Select the correct sized mask to fit the casualty’s face. • Connect the oxygen tubing to the bag- valve device and adjust the flow of oxygen to 10 litres per minute. • Ensure the patency of the casualty’s airway. • The first person applies the mask to the casualty’s face, making a tight seal with both hands. • The second person ventilates the casualty

by squeezing the bag with both hands. http://militaryhealth.bmj.com/ • Assess the adequacy of ventilation by observing the casualty’s chest movement. • Ventilate the casualty in this manner Fig 4.7 Endotracheal tube insertion. every five seconds. • Ensure that adequate ventilation and oxygenation are in progress. Bag-valve-mask ventilation, adult (one man • Connect the laryngoscope blade and technique) handle; check the bulb for brightness, also • Follow the first three steps for the two check both small and larger endotracheal man technique. tubes are to hand, their cuffs are working • Use one hand to apply the mask to the and the suction is working. on September 28, 2021 by guest. Protected copyright. casualty’s face. Use the index finger and • If indicated, have an assistant manually thumb to hold the mask in place and use immobilize the head and neck. the other fingers to perform a jaw-thrust.• • If indicated, have an assistant apply Squeeze the bag with the other hand and cricoid pressure. ventilate as before. • Hold the laryngoscope in the left hand. SKILLS STATIONS 2 • Insert the laryngoscope into the right side ADVANCED AIRWAY MANAGEMENT of the casualty’s mouth, displacing the ADULT OROTRACHEAL INTUBATION tongue to the left. • Look for the epiglottis and place the tip of the blade in the vallecula. Lift the Aim epiglottis forward by pulling the handle of This skill station allows you to practice the laryngoscope forward and visualize adult orotracheal intubation (see Fig 4.7). the vocal cords. It also helps you to develop systems to • Gently insert the endotracheal tube into substitute manual immobilization by using the trachea without applying pressure to a cervical collar, sandbags and tape, and the teeth or oral tissues. check that the endotracheal tube is • Check the placement of the endotracheal correctly placed. tube by bag-valve tube ventilation. • Inflate the cuff with enough air to provide Sequence of actions: a gas-tight seal. BATLS Chapters 3 & 4 226 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

• Visually observe lung expansion with Scalpel handle with blades. ventilation. Small artery forceps. • Attach end-tidal CO2 monitoring if Tracheal dilating tongs. available. Cuffed tracheostomy tubes size 6.0 with connector. • Auscultate the chest with a stethoscope in Lignocaine 1% (20 ml) with adrenaline. both axillae and over the abdomen to Syringes 5 ml. check that the tube is not in a main Blue needles 23 gauge. bronchus (usually the right) or in the oesophagus. Scissors. • If endotracheal intubation requires several Swabs. attempts, discontinue and ventilate the Sharps disposable boxes. casualty between each attempt with a bag- Plastic rubbish bag. valve-mask device. You should practice Anatomical models. taking a deep breath when starting an attempt at intubation. If you have to take Role of jet insufflation of oxygen via needle a further breath before intubation is cricothyroidotomy achieved, abort the attempt (at This technique has only very limited intubation) and ventilate the casualty. application on the battlefield but may have • Remember that the best way to ensure a role in the field hospital (see Fig 4.8). A 12 that the tube is not in the oesophagus is to or 14 gauge cannula is inserted over a see it lying between the vocal cords. needle through the cricothyroid membrane • Allow cricoid pressure to be released (needle cricothyroidotomy) and oxygen when correct endotracheal tube insufflated into the lungs under pressure. placement is confirmed and the cuff is This technique can be done without an inflated. insufflator by attaching the cannula to • Fix the tube in position by tying it with an oxygen running at 15 litres per minute. A Y- open weave cotton bandage. connector or side hole is incorporated into • Reapply cervical spine immobilisation. the connector tubing. Occluding the open • Consider placing a Geudel airway in the end of the Y-connector or side hole one casualty’s mouth next to the endotracheal second in every five, forces a stream of tube to help stabilise the tube’s position oxygen into the trachea. Without a proper and to protect it by acting as a bite block. insufflator, this technique will only be effective in casualties with normal Complications of orotracheal intubation pulmonary function in the absence of Hypoxia from: significant chest injury. A casualty with little • Prolonged attempts to intubate. or no ventilatory effort will not be • Unrecognised oesophageal intubation. adequately oxygenated using the Y- http://militaryhealth.bmj.com/ • Aspiration of gastric contents during attempts to intubate. connector/side hole technique in the Damage to the cervical spinal cord if the neck has not been immobilized when there is an unstable neck fracture. absence of an insufflator. Pushing the tube too far down into one of the main bronchi (usually the right). Because the chest wall in children is more The unintubated lung does not get ventilated and eventually collapses. elastic than in adults, a needle Rupture or leak of the endotracheal tube cuff, resulting in loss of seal during ventilation and cricothyroidotomy attached to high flow necessitating re-intubation. oxygen is a useful technique to achieve Airway haemorrhage secondary to injury. oxygenation prior to tracheostomy in an Damage to the larynx. emergency (See supplement No 1). The Chipping or loosening of the teeth (caused by levering the laryngoscope blade against the teeth). risks of barotrauma, including lung rupture

and tension pneumothorax, are high if the on September 28, 2021 by guest. Protected copyright. technique is not applied with great care. SKILLS STATIONS 3 SURGICAL AIRWAYS

Aim The aim of this skills station is to give you the opportunity to practise and demonstrate the technique of surgical cricothyroidotomy on anatomical models. The instructor will also demonstrate needle cricothyroidotomy and oxygen insufflation. Fig 4.8 Needle cricothyroidotomy Equipment Procedure gloves and disposable aprons. Surgical Cricothyroidotomy Medicut IV cannulae 12 gauge. • Place the casualty supine with the neck in Bag-valve-mask devices. the neutral position. If not Oxygen tubing and Y-connector. contraindicated, extend the neck and Full oxygen cylinders with flow meters. place a sandbag (or suitable alternative) 227 BATLS Chapters 3 & 4 J R Army Med Corps: first published as 10.1136/jramc-146-03-12 on 1 October 2000. Downloaded from

under the shoulders; this will bring the and rotate it 90° to open the airway. (You landmarks into more prominence. Palpate can use artery forceps instead of the the thyroid notch and cartilage, scalpel handle). cricothyroid membrane and cricoid • Insert a 6 mm cuffed tracheostomy tube cartilage. into the cricothyroid membrance incision, • Clean the skin and infiltrate with local directing the tube distally into the anaesthetic (unless the casualty is deeply trachea. unconscious). This is illustrated at Fig • Inflate the cuff. 4.9. • If spontaneous breathing does not occur, ventilate the casualty. • Observe lung inflations and auscultate the chest for adequate ventilation. • Secure the tube by stitch or tape, or both. Complications of surgical cricothyroidotomy

Creation of a false passage into the tissues. Asphyxia. Aspiration (for example, blood). Laceration of the trachea. Fig 4.9 Surgical cricothyroidotomy Laceration of the oesophagus. • Stablise the thyroid cartilage with the left Haemorrhage or haematoma formation. hand. Mediastinal emphysema. • Make a horizontal skin incision over the Subglottic stenosis/oedema. cricothyroid membrane. • Carefully incise through the membrane The Professor of Military Surgery horizontally. wishes to thank the Technical Author • Insert the scalpel handle into the incision for his assistance with this project. http://militaryhealth.bmj.com/ on September 28, 2021 by guest. Protected copyright.