SCRAM™ · Tactical airway preparation
Tactical SCRAM™
A compact emergency airway bag that opens into a structured preparation layout, designed around the demands of tactical care.
The clinical friction
The conditions change. Preparation still has to be organised.
A critically injured casualty may need airway support before reaching hospital. The preparation required depends on their injuries and condition, the threat and the capabilities of the team providing care. Some patients may need pre-hospital emergency anaesthesia (PHEA), making preparation for a complex intervention part of their care before transfer.
Military research identifies airway compromise as a leading cause of potentially survivable battlefield death. Blood and vomit can obscure the airway and make intubation more difficult, so preparation needs to include suction as well as equipment for airway support.
In tactical care, the place, lighting and team available can change. Finding equipment, making space to lay it out and preparing for escalation add work alongside assessment and treatment. The design question was how much of that preparation could be organised before the team reached the casualty.
The system
A compact bag that opens into a preparation layout.
SCRAM™ stands for Structured CRitical Airway Management. Its purpose is to organise preparation before the team needs to perform the intervention. Tactical SCRAM™ brings that approach into a compact emergency airway bag, with stencilled equipment positions and integrated panels that open into prepared working layouts.
In the configuration shown, opening the bag gives access to suction and basic airway adjuncts, including nasopharyngeal airways, on the right, with an i-gel and surgical-airway equipment on the left.
Suction can be reached before the intubation panels are lifted. The original setup uses the SEADUC™ with DuCanto Catheter®, combining a manually operated suction unit with a large-bore catheter. Its position makes preparation for a contaminated airway part of the opening layout.
Lifting the panels reveals the prepared intubation layout: a size 8 endotracheal tube and backup laryngoscope on the left, with a video laryngoscope and size 7 endotracheal tube on the right. This arrangement keeps the initial equipment accessible while allowing the team to reach the intubation layout without assembling a separate kit dump beside the casualty.
The pull-out surgical-airway panel provides a separate working layout, with a blue configuration for the Combat Medical Technician (CMT) and a yellow configuration for the Medical Emergency Response Team (MERT). Equipment selection and clinical use follow the needs of the casualty, the team’s capabilities and current service guidance.
1 / 5 · Stocked layout with equipment held in position
The design
How tactical care shaped the design.
Tactical SCRAM™ was developed using the principles of Tactical Combat Casualty Care (TCCC) and Battlefield Advanced Trauma Life Support (BATLS). Development began by mapping airway interventions across three phases of care, which distinguish the conditions in which care is delivered in relation to the threat:
- Care Under Fire / Threat
- Tactical Field Care
- Tactical Evacuation Care
That mapping was considered alongside the airway evidence and four practical requirements: differences in team capability, preparation for airway escalation, environmental lighting, and the time, errors and physical effort involved in using the equipment. Together, these shaped how the bag opens, how its contents are arranged and how the surgical-airway configurations differ.
Organise access around the intervention.
Suction, basic airway adjuncts and rescue equipment are accessible when the bag is opened. Lifting the panels reveals the prepared intubation layout underneath. The team can reach the equipment needed for the intervention without first unpacking and organising the whole bag.
Prepare before the pressure arrives.
Stencilled positions give equipment a defined place for stocking, checking and replenishment. That work is completed before deployment, so the team starts with a prepared layout beside the casualty. The design carries more of the preparation work, leaving less to find, arrange and remember while assessing and treating the patient.
Make limited space work.
There may be little room to carry equipment or lay it out beside a casualty. The panels fold the prepared layouts into a compact bag, keeping equipment organised until it is needed. This makes Tactical SCRAM™ useful in tactical and evacuation care, and in other clinical settings where space is at a premium.
Reducing cognitive load during preparation.
Cognitive load is the mental effort involved in processing information, remembering what matters and deciding what to do. In time-critical care, assessment, treatment priorities and the possibility of deterioration already place demands on the clinician. Searching for equipment and reconstructing a layout add preparation work alongside those decisions.
Briefings give the team a shared plan. Rehearsed workflows establish a familiar sequence, and checklists provide a reference for checking that important steps have been completed. Standardising equipment and its arrangement brings that same approach to the physical preparation. These are complementary ways of reducing how much the team has to remember and organise in the moment.
Hick’s Law describes how increasing the number of alternatives can lengthen choice-response time under controlled conditions. It offers an insight for the design: which parts of preparation can be resolved before the clinician is making decisions about the patient?
Tactical SCRAM™ applies that thinking through a layout that can be stocked and checked beforehand. Stencilled positions provide a reference for what belongs where, while retained equipment allows that preparation to travel with the team. The system takes on more of the predictable preparation work, with the aim of leaving more attention available for assessment, treatment and changes in the patient’s condition.
In a 2018 simulation study, advance preparation of equipment and drugs shortened the emergency-anaesthesia procedure, reduced errors and lowered the reported cognitive load of the intubator’s assistant. A 2020 simulated kit-dump study found quicker preparation, fewer errors and lower reported difficulty with SCRAM. These findings support the wider preparation approach; they do not establish patient outcomes for Tactical SCRAM™.
Original development references (19 sources)
The original development reading covers tactical care, airway preparation, rescue techniques and human factors. The equipment configurations illustrated on this page reflect that development. Guidance has since changed: CoTCCC Change 24-1 removed extraglottic airways, including devices such as the i-gel, from its recommended airway adjuncts. The 1 May 2026 TCCC guidelines (PDF) reflect the revised approach. Services should configure and use the equipment in line with their current guidance. The Joint Trauma System guidance directory links to the maintained resources.
Hick’s choice-reaction research informs the design reasoning above. The preparation studies examine the effects of organising the work differently; these are distinct contributions to the argument. A later analysis of Hick’s Law in design explains why visual search and other tasks need to be considered separately.
Airway contamination and repeated attempts. Research in intensive care identified blood in the airway as a factor associated with first-attempt video-laryngoscopy failure. Research on emergency intubation found that repeated attempts were associated with more complications. These findings support preparation for airway difficulty; neither study evaluated Tactical SCRAM™.
- Lockey DJ, Crewdson K, Lossius HM. Pre-hospital anaesthesia: the same but different. Br J Anaesth. 2014;113:211–219. doi: 10.1093/bja/aeu205.
- van der Velden MW, Ringburg AN, Bergs EA, Steyerberg EW, Patka P, Schipper IB. Pre-hospital interventions: time wasted or time saved? An observational cohort study of management in initial trauma care. Emerg Med J. 2008;25:444–449. doi: 10.1136/emj.2007.052662.
- Swinton P, Corfield AR, Moultrie C, Percival D, Proctor J, Sinclair N, Perkins ZB. Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load. Scandinavian journal of trauma, resuscitation and emergency medicine. 2018 Dec;26:82.
- Benjamin D Walrath, Stephen Harper, Ed Barnard, Joshua M Tobin, Brendon Drew, Cord Cunningham, Chetan Kharod, James Spradling, Craig Stone, Matthew Martin, Airway Management for Trauma Patients, Military Medicine, Volume 183, Issue suppl_2, September-October 2018, Pages 29–31, https://doi.org/10.1093/milmed/usy124
- Committee on Tactical combat Casualty Care. Tactical Combat Casualty Care Guidelines for Medical Personnel, dated 18 October 2019. https://www.naemt.org/docs/default-source/educationdocuments/tccc/tccc-mp/guidelines/tccc-guidelines-for-medical-personnel-180801.pdf?sfvrsn=13fc892_2
- Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Annals of emergency medicine. 2012 Mar 1;59(3):165-75.
- Wimalasena Y, Burns B, Reid C, Ware S, Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Annals of emergency medicine. 2015 Apr 1;65(4):371-6.
- McGill J. Airway management in trauma: an update. Emergency medicine clinics of North America. 2007 Aug 1;25(3):603-22.
- Nakstad AR, Bredmose PP, Sandberg M. Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists. Scandinavian journal of trauma, resuscitation and emergency medicine. 2013 Dec;21(1):59.
- Reardon R, Joing S, Hill C. Bougie-guided cricothyrotomy technique. Academic Emergency Medicine. 2010 Feb;17(2):225-.
- Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesthesia & Analgesia. 2004 Aug 1;99(2):607-13
- Joshi R, Hypes CD, Greenberg J, et al. Difficult airway characteristics associated with first-attempt failure at intubation using video laryngoscopy in the intensive care unit. Annals of the American Thoracic Society. 2017 Mar;14(3):368-75.
- DuCanto, J., Serrano, K. D., Thompson, R. J. (2017). Novel Airway Training Tool that Simulates Vomiting: Suction-Assisted Laryngoscopy Assisted Decontamination (SALAD) System. The western journal of emergency medicine, 18(1), 117–120. doi:10.5811/westjem.2016.9.30891
- Combes X, Jabre P, Jbeili C, et al. Prehospital standardization of medical airway management: Incidence and risk factors of difficult airway. Acad Emerg Med. 2006;13:828-34.
- Gaither J, Spaite D, Stolz U, et al. Prevalence of difficult airway predictors in cases of failed prehospital endotracheal intubation. J Emerg Med. 2014;47:294-300.
- Mosier J, Stolz U, Chiu S, et al. Difficult airway management in the emergency department: GlideScope videolaryngoscopy compared to direct laryngoscopy. J Emerg Med. 2012;42:629-34.
- Burns B, Habig K, Eason H, et al. Difficult intubation factors in prehospital rapid sequence intubation by an Australian helicopter emergency medical service. Air Med J. 2016;35:28-32.
- Schyma BM, Wood AE, Sothisrihari S, Swinton P. Optimising remote site airway management kit dump using the SCRAM bag—a randomised controlled trial. Perioperative Medicine. 2020 Dec;9(1):1-6.
- Hick WE. On the rate of gain of information. Quarterly Journal of Experimental Psychology. 1952;4(1):11–26. Original publication ↗
Features
The details that support preparation and reuse.
Practical detail
Specify the layout for the team using it.
The example kit list and photographs show how Tactical SCRAM™ can be stocked. Confirm the equipment configuration and what is supplied with the bag when ordering.
Compact format
The manufacturer lists dimensions of 30 × 24 × 14 cm (height × width × depth), with a grab handle for carrying.
Stencilled preparation areas
Integrated kit dumps provide marked equipment positions for pre-stocking, checking and laying out the equipment for use.
CMT and MERT surgical-airway panels
A pull-out layout provides a designated area for surgical-airway preparation: blue for CMT and yellow for MERT configurations.
Visibility and access
High-contrast equipment markings and prominent pull indicators identify the layout and access points. Openhouse specifies compatibility with Red, Green and Blue environments.
Airway suction within the setup
The original design accommodates the SEADUC™ with DuCanto Catheter® as part of preparation for a contaminated airway. View the SEADUC™ product bulletin (PDF) ↗
Checklist pouch
A visible pouch keeps the preparation checklist with the equipment it supports.
Materials and cleaning
Weatherproof, wipe-clean micrAgard™ material supports cleaning after use. Manufacturer’s material information ↗
Designed for pressure
Preparation begins before the next casualty.
After use, replacing equipment in its stencilled positions restores the layout for the next case. That moves the work of finding and arranging those items into the time available for preparation, so the next team starts with equipment already organised.
When the bag is opened, the layout carries that preparation into the working area. The team can check what is present and prepare the equipment appropriate to the casualty and the care they can provide.
Systemisation, standardisation, cognitive offloading, human factors and good governance underpin this approach. In practice, that means trained clinicians using a rehearsed preparation process, a familiar equipment arrangement, and clear responsibility for checking and replenishment. Reviewing problems found in use allows the service to improve the system as well as maintain it.
Orders and enquiries
Where to order Tactical SCRAM™.
Openhouse Products
Product specifications, configuration and global orders.
Order Tactical SCRAM™ ↗
The Resus Tailor
Contact the US distributor about Tactical SCRAM™ supply and configuration.
Enquire about Tactical SCRAM™ ↗Tactical SCRAM™ was developed by Paul Swinton, building on the original SCRAM™ system.
The SCRAM™ StoryHow the original preparation system developed, and what the research found.Read the story →Disclosure. Paul Swinton co-invented SCRAM™ with Neil Sinclair and have a commercial interest in the system. Openhouse Products manufactures and distributes; The Resus Tailor is a distributor.
Explore the SCRAM range
Explore the SCRAM™ range.
Equipment, medication and procedural preparation for different clinical settings.
Designed for the realities of emergency airway management.
A compact preparation layout for teams working in tactical care.
Photography credits
MERT force protection / Chinook photograph: contains public sector information licensed under the Open Government Licence v3.0.
U.S. Air Force photographs: Staff Sgt. Mozer O. Da Cunha — “U.S. Airmen, Sailors, Soldiers, team up for joint MEDEVAC exercise”; Senior Airman Giovanni Sims — “PJs sharpen skills during Razor’s Edge”. Credits retained from the original page.