Creating airway management guidelines for casualties with penetrating airway injuries

Anaesthetists in the Defence Medical Services (DMS) are currently dealing with casualties who have an increased prevalence of injuries due to blast, fragmentation and gunshot wounds. Despite guidelines already existing for unanticipated difficult tracheal intubation these have been designed for a civilian population and might not be relevant for the anticipated difficult airway experienced in the deployed field hospital. In order to establish an overview of current practice, three methods of investigation were undertaken; a literature review, a survey of DMS Anaesthetists and a search of the UKJoint Theatre Trauma Database. Results are discussed in terms of anatomical site, bleeding in the airway, facial distortion, patient positioning and an anaesthetic approach. There are certain key principles that should be considered in all cases and these are considered. Potential pitfalls are discussed and our initial proposed guidelines for use in the deployed field hospital are presented.