Pain management in the special operations environment: regional anesthetics.

Pain relief is an essential component of combat casualty care. For the injured soldier, analgesia is not only a matter of comfort. Alleviating pain may allow the soldier to remain quiet when noise discipline is at a premium. It may also allow that person to continue to move, thus avoiding detection and potentially permitting the mission to carry on. Regional anesthetics provide an alternative to systemic medications and thus may avoid a clouded sensorium, limit narcotic administration, and provide superior pain relief. Standard local anesthetics and newer agents with potential field applicability are discussed along with their side effect profiles. Simple nerve block techniques that can be used by Army Special Forces medics, Navy SEAL and Reconnaissance corpsmen, and Air Force pararescuemen in the far forward environment are described step by step. The advantages of these regional anesthetic methods should make their use a must for every special operations medical care provider.

Intraosseous infusion devices: a comparison for potential use in special operations.

OBJECTIVE: To determine which intraosseous (IO) devices were easy to learn to use, easy to use once the skill was obtained, and appropriate for the Special Operations environment. METHODS: Thirty-one Navy SEAL corpsmen, Air Force pararescuemen, Army Special Forces, and Ranger medics, in a prospective, randomly assigned, cross-over study, tested four commercially available, Food and Drug Administration-cleared IO devices. The systems included the injection models First Access for Shock and Trauma (FAST, Pyng Medical) and Bone Injection Gun (Wais Medical, Kress USA Corporation) and the hand-driven threaded-needle SurFast (Cook Critical Care) and straight-needle Jamshidi needle (Baxter) models. The Special Operations medical care providers received a lecture regarding IO use, viewed videotapes of the injection models, and practiced with demonstration units in the classroom. Each participant then entered the cadaver lab where all four of the IO devices were placed in randomly assigned order. A poststudy questionnaire was then completed. The FAST was placed in the sternum, whereas the other units were placed in either medial proximal or distal medial tibia. Each participant was assessed for time, number of attempts, and success. The presence of marrow, extravasation, quality of flow, and security of needle were evaluated in combination to help determine success. RESULTS: All four devices were believed to be easy to learn as well as easy to place. FAST was successful in 29 of 30 insertions (94%) with a placement time of 114 +/- 36 (mean +/- SD) seconds. The Bone Injection Gun was similarly successful (29 of 31 insertions, 94%) with a mean placement time of 70 +/- 33 seconds. This time was statistically significantly faster (p < 0.05) than that with FAST, but not with the other devices. Thirty of 31 SurFast placements (97%) were successful, on average taking 88 +/- 33 seconds to place. The Jamshidi needle also had 30 of 31 successful placements (97%) at an average 90 +/- 59 seconds. No one device was rated by the participants as significantly better than the others; however, the Bone Injection Gun did have 65% of participants rate it as first or second (closest was Jamshidi needle at 52%). CONCLUSION: These IO devices were easy to teach and learn as well as easy to use. Insertion times compared favorably with peripheral intravenous catheter placement in the face of hemorrhage. All four devices can be appropriately used in the Special Operations environment and are reasonable alternatives when intravenous access cannot be gained. Although no device was rated higher than the others, particular features are desirable (low weight/size, simplicity, reusability, secure, clean, well protected).

Combat trauma airway management: endotracheal intubation versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance combat corpsmen.

BACKGROUND: Airway management takes precedence regardless of what type of life support is taking place. The gold standard for airway control and ventilation in the hands of the experienced paramedic remains unarguably the endotracheal tube. Unfortunately, laryngoscopy and endotracheal intubation require a skilled provider who performs this procedure on a frequent basis. Special Operations corpsmen and medics receive training in the use of the endotracheal tube, but they use it infrequently. The use of alternative airways by Navy SEAL and Reconnaissance combat corpsmen has not been evaluated. Our objective was to compare the ability of Special Operations corpsmen to use the endotracheal tube (ETT), laryngeal mask airway (LMA), and esophageal-tracheal combitube (ETC) under combat conditions. METHODS: This study used a prospective, randomized, crossover design. Twelve Navy SEAL or Reconnaissance combat corpsmen participated in a 2-week Advanced Battlefield Trauma course. During the first week, instruction included the use of ETT, LMA, and ETC, viewing of videotapes for ETC and LMA, and mannequin training. The Special Operations corpsmen were required to reliably insert each airway within 40 seconds. During the second week, participants dealt with a number of active combat trauma scenarios under fire in combat conditions. Each SEAL or Reconnaissance corpsman was asked to control his "casualty's" airway with a randomized device. All participants were evaluated in the use of each of the three airways. RESULTS: Thirty-six airway insertions were evaluated. No failures occurred. All incorrect placements were detected and corrected. Mean time to place the ETT was 36.5 seconds versus 40.0 seconds for the ETC. The LMA insertion time of 22.3 seconds was significantly shorter than the other times (p < 0.05). The mean number of attempts per device was similar with all devices: LMA (1.17), ETC (1.17), and ETT (1.25). CONCLUSION: The Special Operations corpsmen easily learned how to use the ETC and LMA. In this study, they showed the ability to appropriately use the ETT as well as the ETC and LMA. For SEAL corpsmen, the alternative airways should not replace the ETT; however, on occasion an advanced combat casualty care provider may not be able to use the laryngoscope or may be unable to place the ETT. The LMA and ETC are useful alternatives in this situation. If none of these airways are feasible, cricothyrotomy remains an option. Regardless of the airway device, refresher training must take place frequently.

Progress in the development of ultra-long-acting local anesthetics.

BACKGROUND AND OBJECTIVES: Local anesthetic agents with a duration of action longer than the currently available local anesthetics could have widespread clinical application for the treatment of both chronic and acute pain. Over the last several decades, several different approaches have been used in the development of ultra-long-acting agents. There are currently promising preparations in development which may prove clinically useful in the near future. METHODS: A Medline search was conducted for relevant articles published in peer-reviewed journals between 1971 and 1996. Investigations related to prolongation of the effect of local anesthetics either by alterations in the local anesthetic molecule, use of new or novel agents, or use of new delivery systems were reviewed. In addition, bibliographies of relevant articles were searched to capture any articles that were missed by the Medline search. RESULTS: Over the last several decades, numerous attempts have been made to prolong the duration of action of local anesthetics. Initially, research focused on alterations in the local anesthetic molecule or the identification of new agents with local anesthetic action. Recently, the focus of much of the work has shifted to new drug-delivery systems such as polymers and liposomes. CONCLUSIONS: Although encouraging results have been reported in the literature, there is currently no agent or delivery system that has shown reliable and practical prolongation of local anesthetic effect in humans. There have been several encouraging reports in animals that have shown local anesthetic effects lasting up to several days, but these results must be validated and then performed in human studies before a clinically useful agent is found. Further research is warranted.