airway

CORE

Core Principles of Airway Management

Foundational doctrine governing every airway decision in the tactical setting.

▼

The Setting Matters

Airway management must be of prime concern for any trauma casualty. The setting, conditions, and injuries must all be taken into account for every casualty. In the tactical setting, hemorrhage control and shock resuscitation are more important than definitive airway management. Aggressive airway management is warranted in some casualties; in many, simple repositioning of an airway will solve the airway, breathing, and oxygenation problems all at once.

The Governing RuleA patient who can breathe on his own should be allowed to breathe on his own — UNLESS the injury pattern or predicted clinical course warrants a more aggressive action.

Three Things to Always Assess

The current setting (Care Under Fire, Tactical Field Care, Tactical Evacuation, or Extended Care)
The patient's current condition (conscious, unconscious, obstructed, breathing on their own)
The patient's predicted clinical course — especially if a long transport or worsening trajectory is anticipated

The Tactical Trade-OffDefinitive airway procedures expose the medic and casualty to time, light, and noise risk. The handbook prioritizes hemorrhage control and shock resuscitation FIRST because more casualties die from preventable bleeding than from preventable airway loss in combat.

CUF

Care Under Fire — Airway

What the medic does for an airway problem while still under effective fire.

▼

The Rule

Airway management, other than patient positioning, is generally best deferred until the Tactical Field Care phase.

What This Means in PracticeWhile under fire, the medic does NOT perform a cricothyroidotomy, insert a nasopharyngeal airway, or attempt advanced airway maneuvers. The medic CAN reposition the casualty (recovery position, sit them up if conscious) so that gravity and posture protect the airway while fire superiority is established. Hemorrhage control happens here. Airway happens after.

TFC 1

Tactical Field Care — Unconscious WITHOUT Airway Obstruction

Four-step sequence for the unconscious casualty whose airway is not occluded.

▼

The Sequence

1

Inspect oropharynx and remove any foreign body from airway or lip. Do NOT conduct blind finger sweeps — only remove what you can see.

2

Chin-lift or jaw-thrust maneuver to reposition the tongue and open the airway.

3

Nasopharyngeal airway (NPA) to maintain airway patency.

4

Place casualty in the recovery position to allow secretions and blood to drain by gravity.

Why No Blind Finger SweepsBlind finger sweeps can push foreign material deeper, lacerate the medic's finger on broken teeth, or convert a partial obstruction into a complete one. Look first; only remove what you can see.

TFC 2

Tactical Field Care — Airway Obstruction or Impending Obstruction

Stepwise escalation when the casualty has or will soon have an obstructed airway.

▼

The Sequence

1

Inspect oropharynx and remove any foreign body from airway or lip. Do NOT conduct blind finger sweeps.

2

Chin-lift or jaw-thrust maneuver.

3

Nasopharyngeal airway.

4

Allow conscious casualty to assume any position that best protects the airway, including sitting up.

5

Place unconscious casualty in the recovery position.

6

If previous measures are unsuccessful: Surgical cricothyroidotomy — with pain control if the casualty is conscious.

The Conscious Casualty DecisionIf the casualty is awake and gasping, let them sit up or lean forward. Posture is often the most effective airway intervention. Do not force a conscious casualty supine for "easier" treatment — that can kill them by collapsing the airway.

TACEVAC

Tactical Evacuation Care

Same algorithms as TFC plus supraglottic airway and continuous reassessment.

▼

The TACEVAC ImperativeWith every evacuation movement of a casualty, confirm airway placement and reassess airway patency. Tubes dislodge with every load, lift, and litter transfer.

Unconscious Casualty Without Airway Obstruction

Same sequence as Tactical Field Care: inspect oropharynx (no blind finger sweeps), chin-lift or jaw-thrust, nasopharyngeal airway, recovery position.

Casualty With Airway Obstruction or Impending Obstruction

Same first five steps as Tactical Field Care. The difference is in the final escalation:

If above measures are unsuccessful, options expand to:
- Surgical cricothyroidotomy — with pain control if conscious
- Supraglottic airway — available in TACEVAC, not in TFC

Spinal Immobilization Note

Penetrating Trauma ExceptionSpinal immobilization is not necessary for casualties with penetrating trauma. Forcing C-spine precautions on a penetrating-trauma casualty wastes time and can compromise airway management.

IND

Indications for Airway Management

Six conditions that drive the airway intervention decision.

▼

The Six Indications

#	Indication	Why It Matters
1	Airway obstruction due to trauma, edema, excess secretions, foreign body, or tongue	Direct mechanical blockage of the airway
2	Apnea	No respiratory drive at all — ventilation must be provided
3	Excess work of breathing — accessory muscle use, fatigue, diaphoresis, or tachypnea when respiratory failure is imminent	The casualty will exhaust and crash if not supported
4	Hypoxia (SpO2 less than 90 percent)	Cellular injury and brain injury accelerate below this threshold
5	Shock	Tissues are not being perfused; oxygen demand exceeds supply
6	Predicted clinical course preceding long transport	If you anticipate deterioration during evacuation, secure the airway now while you can

The Predicted Clinical Course PrincipleIndication number 6 is the one most often missed by new medics. If the casualty has a face full of shrapnel, swelling is going to get worse, and the evacuation is two hours out, you secure the airway BEFORE you lose the ability to do so safely.

FLOW

Airway Management Protocol Flow

The decision flowchart from trauma assessment to definitive airway.

▼

Top of the Flowchart

Trauma Assessment → identify if the casualty meets one or more of the six indications for airway management.

Branch Point 1 — Surgical Airway Indicated?

NO — Reposition Airway Manually

Jaw-thrust
Head tilt / chin lift
Suction as needed

YES — Branch to Step 2

Move to the "Near Death?" decision.

Branch Point 2 — Near Death?

YES (peri-arrest): Perform immediate surgical cricothyroidotomy. There is no time for sedation.
NO: Administer pain control or sedation medications and local anesthesia → perform surgical cricothyroidotomy.

Conscious Casualty Branch — Are They Stable Enough?

After repositioning the airway, ask: is the casualty conscious WITH spontaneous respirations, with a respiratory rate greater than 8 OR less than 30, AND SpO2 greater than 90 percent?

YES: Continue care — assist ventilation with BVM as needed, monitor airway continuously, suction as required, restart protocol if respiratory problems arise.
NO: Insert nasopharyngeal airway (NPA). Consider a second NPA as may be required, or provide additional ventilatory support → assist ventilations with BVM as required → establish definitive airway in accordance with cricothyroidotomy procedures.

Goal If Providing Ventilation

Ventilation TargetGoal EtCO2 35-45 mmHg if providing ventilation. This is the normal physiologic range — not the herniation hyperventilation target of 32-38.

Universal Reminder

Any airway adjunct(s) should be confirmed and reconfirmed to be patent before AND after any movement of patient.

DOPE

DOPE — Troubleshooting an Established Airway

Four-letter mnemonic for the deteriorating intubated patient.

▼

If a previously stable airway patient deteriorates suddenly, run through DOPE in order:

Letter	Problem	Action
D	Dislodgement	Check tube placement — tube may have backed out, advanced into a mainstem bronchus, or come out entirely
O	Obstruction	Consider suctioning — secretions, blood, or debris may be blocking the tube
P	Pneumothorax	Consider needle chest decompression — positive pressure ventilation can cause or worsen tension pneumothorax
E	Equipment failure	Disconnect the ventilator and switch to BVM — ventilator malfunction is common

The Hidden Threat — Pressure PneumothoraxPositive pressure ventilation is a known cause of tension pneumothorax. If a vented casualty deteriorates, the "P" in DOPE is not academic — reassess the chest, check breath sounds, and decompress if indicated.

GCS

Glasgow Coma Scale

Three-axis neurologic scoring used in airway and TBI decision-making.

▼

Eye Opening (E)

Score	Response
4	Spontaneous
3	To Voice
2	To Pain
1	None

Verbal Response (V)

Score	Response
5	Oriented
4	Confused
3	Inappropriate Words
2	Incomprehensible Words
1	None

Motor Response (M)

Score	Response
6	Obeys Commands
5	Localizes Pain
4	Withdraws (Pain)
3	Flexion (decorticate)
2	Extension (decerebrate)
1	None

Documentation FormatDocument as: E___ + V___ + M___ = ___ (total range 3-15). A GCS of 8 or less classically triggers the consideration of definitive airway protection.

VERIFY

Airway Placement Verification

Confirming a tube is where it should be — never rely on a single technique.

▼

Five Verification Techniques

Visualization — direct visual confirmation of the tube passing through the cords or membrane
Misting of the tube — condensation appearing inside the tube with each exhalation
Auscultation — listen for equal bilateral breath sounds and absence of sounds over the epigastrium
End-tidal CO2 monitor — the gold standard. A capnography waveform confirms tube is in the trachea, not the esophagus
Increase in SpO2 if the casualty was hypoxic — a rising saturation supports correct placement

Critical RuleDO NOT rely on auscultation OR visual misting as the SOLE placement confirmation. Both can be misleading in the presence of esophageal intubation, gastric inflation, or environmental noise. Use a minimum of 2 techniques, preferably including EtCO2 capnography.

CRIC IND

Surgical Cricothyroidotomy — Indications

Four conditions that mandate moving to a surgical airway.

▼

The Four Indications

1

Severe airway obstruction due to trauma, edema, excess secretions, foreign body, or tongue.

2

Failure of airway positioning — chin-lift or jaw-thrust did not establish or maintain a patent airway.

3

Failure of nasopharyngeal airway — the NPA did not maintain a patent airway.

4

Unable to manually ventilate — you cannot move air into the casualty even with bag-valve-mask and adjuncts.

The Stepwise PrincipleCricothyroidotomy is rarely the FIRST airway intervention. The usual progression is: positioning → chin-lift / jaw-thrust → NPA → BVM → cric. Skip steps only when the casualty is "near death" per the protocol flowchart, in which case you go directly to immediate cric without sedation.

CRIC KIT

Cricothyroidotomy — Equipment and Documentation

What goes into the cric kit and what gets recorded after the procedure.

▼

Equipment Needed

Scalpel
Tracheal hook or Bougie
Povidone, chlorhexidine, or alcohol swab
Gloves
Sterile 4x4 sponge
ET tube
Bag-Valve-Mask (BVM)
Curved hemostats (if required)
Securing device, tape, or suture
Suction (recommended)

Documentation

Detailed assessment
Vital signs
SpO2
Glasgow Coma Scale
Tube check results
Lung sounds
Complications encountered

Tube SizeThe handbook specifies a 6.0 to 7.0 endotracheal tube or a cric-specific tube for adult casualties. Cuff inflation volume: 10 mL of air.

PROC

Cricothyroidotomy — Procedure Steps

Sequential steps from patient assessment to continuous monitoring.

▼

1

Patient assessment — confirm the indication is real.

2

Prepare the cric kit.

3

Position the patient in a stable supine position that promotes exposure of anatomical landmarks. Keep head and neck midline.

4

If the casualty is conscious: administer procedural sedation medications and inject lidocaine 2-4 mL into the cricothyroid membrane and trachea.

5

Identify the cricothyroid membrane — the soft aspect just inferior to the larynx, midline, anterior trachea.

6

Cleanse the site.

7

Stabilize the larynx between thumb and index finger of the non-dominant hand.

8

Make a VERTICAL skin incision over the cricothyroid membrane, then carefully incise horizontally through the membrane.

9

If needed: insert a tracheal hook into the cricothyroid membrane, hook the cricoid cartilage, apply anterior displacement, and widen the incision.

10

Insert a 6.0 to 7.0 ET tube or cric-specific tube through the midline of the membrane and direct the tube distally into the trachea 2 cm past the cricothyroid membrane.

11

Inflate the cuff with 10 mL of air.

12

Confirm tube placement with a minimum of 2 techniques: EtCO2, tube misting, breath against cheek or wrist, auscultate breath sounds, monitor SpO2.

13

Secure the tube to prevent dislodging.

14

Attach BVM and ventilate the patient if required.

15

Ventilate as needed.

16

Monitor continuously. Ensure adequate ventilation with BVM — 1 breath every 6-8 seconds OR 8-10 breaths per minute.

Vertical, Then HorizontalThe skin incision is VERTICAL (top to bottom). The membrane incision is HORIZONTAL. Reversing this risks transecting the vocal cords or injuring vessels alongside the trachea.

PEARLS

Cricothyroidotomy — Key Points and Pitfalls

Three rules that separate a successful cric from a complicated one.

▼

1

Maintain strict C-spine precautions if concerned for C-spine injury — remember, only penetrating-trauma casualties are exempt from spinal immobilization.

2

If the patient desaturates (SpO2 less than 90 percent) during the procedure, STOP the procedure and ventilate for 30-60 seconds before reattempting. Do not push through hypoxia.

3

Secure the tube with a securing device, suture in place, or IV tubing. An adhesive seal can be used as an adjunct but NOT as a sole securing device — sweat and blood will defeat adhesive alone.

The Recurrent ReminderAny airway adjunct(s) should be confirmed and reconfirmed to be patent before AND after any movement of patient. This applies to NPA, supraglottic, ET tube, and cric tubes alike. Every transfer is a chance to lose the airway.

EXT

Extended Care — Monitoring and the SAVe II Ventilator

Long-duration airway management when surgical evacuation is delayed.

▼

Five Extended Care Tasks

1

Monitoring: maintain continuous pulse oximetry and EtCO2; document serial vital signs.

2

Verify airway patency with any evacuation or movement of the patient.

3

Suction: consider periodic suctioning of the oropharynx and the established airway tube.

4

Ventilation: use the SAVe II ventilator (details below).

5

Local wound care and further securing of the cricothyroidotomy site if applicable.

The SAVe II Ventilator

Feature	Detail
Form factor	Small, lightweight ventilator
Auto-recommended settings	ARDSnet lung-protective settings based on the patient's height
Default PEEP	NO PEEP by default. The medic must manually set the vent to a PEEP of 5 at minimum
Oxygen requirement	Does NOT require an external O2 source — runs on room air if needed
Supplemental O2	Can be attached, set at no higher than 6 L/min, which provides 62 percent oxygen
Battery	Limited duration on any ventilator battery — alternate with BVM and PEEP valve for extended periods

Two Things to Burn Into Memory(1) The SAVe II default settings have NO PEEP — YOU must dial in PEEP of 5 minimum. (2) Positive pressure ventilation is a known cause of tension pneumothorax — a vented casualty who deteriorates needs an immediate chest reassessment, not just a vent troubleshoot.