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Current Tactical Combat Casualty Care (TCCC) guidelines direct medical interventions based on three phases of care: care under fire, tactical field care, and tactical evacuation care [18]. The Tactical Emergency Casualty Care (TECC) guidelines, the civilian equivalent of TCCC, similarly specify three phases: direct threat care, indirect threat care, and evacuation care [19] (see Chapter 107). In both guidelines, the range of potential airway management techniques increases in scope as the threat diminishes. Sophisticated airway interventions are usually not in the best interest of safety for the clinician, the tactical team, or the patient in the highest threat environments. Other than positioning the patient to protect the airway, if feasible, airway procedures are generally deferred to the tactical field care phase of operations.

During tactical field care and indirect threat care stages, the clinician and patient have been able to move to safe cover. Here, more attention can generally be afforded to airway management. Both TCCC and TECC guidelines advocate for simple airway maneuvers in the field, to include chin lift/jaw thrust, nasopharyngeal airway placement, and placement of the casualty in the recovery position for unconscious casualties without airway obstruction. For those patients with airway obstruction or impending airway obstruction, all of the above techniques are useful, including sitting the patient up to allow blood and secretions to drain. If unsuccessful, the military recommends a supraglottic airway (if unconscious) or surgical cricothyroidotomy. TECC recommends the same, with considerations for oral or nasotracheal intubation and placement of supraglottic airway devices.

In the evacuation phase of field care, the clinician and patient are normally on their way to higher levels of care via air, ground, or sea. Airway management interventions at this point more closely mirror the normal prehospital environment. TCCC and TECC recommend expanding options, including supraglottic airway placement, endotracheal intubation, and surgical cricothyroidotomy.

The choice of airway management technique can affect the exposure of the tactical clinician above cover or concealment. In one study, the time to first ventilation was relatively similar for both King LT and standard intubation (59.7 seconds and 63.3 seconds, respectively). The time to ventilation was longer for digital intubation (125.4 seconds), and there was greater risk due to exposure over a concealment barricade (23.5 inches above the barricade for digital intubation vs. 17.7 inches for King LT placement) [20].

Tactical operations may occur under low light or near‐blackout conditions. Night vision goggles can be used, but times to intubation are much longer than in typical lighting situations [21].

A study assessing prehospital airway interventions during the wars in Iraq and Afghanistan noted that roughly 4.9% of patients in the data set had prehospital airway interventions. These interventions consisted of nasal airways, cricothyroidotomy, endotracheal intubation, and supraglottic airway placement. Of such interventions, endotracheal intubation and cricothyroidotomy were the most common procedures [22].