Advanced Trauma Life Support ATLS Student Course Manual 2018

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APPENDIX G n Skills
STEP 6. Observe the epiglottis and then the vocal
cords. External laryngeal manipulation
with backward, upward, and rightward
pressure (BURP) may be helpful for
better visualization.
STEP 7.
Insert the endotracheal tube not more than
2 cm (1 inch) past the cords.
STEP 8. Carefully check placement of the tube by bag
ventilation, observing lung inflations, and
auscultating the chest and abdomen with
a stethoscope. Confirm correct placement
of the tube by the presence of CO 2
. A chest
x-ray exam is helpful to assess the depth
of insertion of the tube (i.e., mainstem
intubation), but it does not exclude
esophageal intubation.
STEP 9. If endotracheal intubation is not accomplished
within 30 seconds or in the same
time required to hold your breath before
exhaling, discontinue attempts, ventilate
the patient with a bag-mask device, and
try again.
STEP 10. Secure the tube. If the patient is moved, tube
placement should be reassessed.
STEP 11. Attach a CO 2
detector to the secured
endotracheal tube between the adapter and
the ventilating device to confirm the position
of the endotracheal tube in the trachea.
STEP 12. If not already done, attach a pulse oximeter
to one of the patient’s fingers (intact
peripheral perfusion must exist) to measure
and monitor the patient’s oxygen saturation
levels and provide an immediate assessment
of therapeutic interventions.
Needle Cricothyrotomy
STEP 1. Assemble and prepare oxygen tubing by
cutting a hole toward one end of the tubing.
Connect the other end of the oxygen tubing
to an oxygen source capable of delivering
50 psi or greater at the nipple, and ensure
the free flow of oxygen through the
tubing. Alternatively, connect a bag mask
by introducing a 7.5 mm endotracheal
tube connector to a 3 cc syringe wtih the
plunger removed.
STEP 2. Place the patient in a supine position.
Have an assistant restrict the patient’s
cervical motion.
STEP 3. Attach a 12- or 14-gauge over-the-needle
cannula to a 5-ml syringe (16-18 gauge for
infants and young children).
STEP 4. Surgically prepare the neck, using antiseptic
swabs.
STEP 5. Palpate the cricothyroid membrane anteriorly
between the thyroid cartilage and
the cricoid cartilage. Stabilize the trachea
with the thumb and forefinger of the nondominant
hand to prevent lateral movement
of the trachea during the procedure.
STEP 6. Puncture the skin in the midline with the
cannula attached to a syringe, directly over
the cricothyroid membrane.
STEP 7. Direct the cannula at a 45-degree angle
caudally, while applying negative pressure
to the syringe.
STEP 8. Carefully insert the cannula through the
lower half of the cricothyroid membrane,
aspirating as the needle is advanced. The
addition of 2-3 cc of saline to the syringe
will aid in detecting air.
STEP 9. Note the aspiration of air, which signifies
entry into the tracheal lumen.
STEP 10. Remove the syringe and withdraw the
needle while gently advancing the cannula
downward into position, taking care not to
perforate the posterior wall of the trachea.
STEP 11. Attach the jet insufflation equipment to the
cannula, or attach the oxygen tubing or 3 mL
syringe (7.5) endotracheal tube connector
combination over the catheter needle hub,
and secure the catheter to the patient’s neck.
STEP 12. Apply intermittent ventilation either by
using the jet insufflation equipment, or
using your thumb to cover the open hole
cut into the oxygen tubing or inflating with
an ambu bag. Deliver oxygen for 1 second
and allow passive expiration for 4 seconds.
Note: Adequate PaO 2
can be maintained for only
around 30 to 45 minutes, and CO 2
accumulation
can occur more rapidly.
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