Advanced Trauma Life Support ATLS Student Course Manual 2018

AIRWAY 25
It is important to anticipate vomiting in all injured
patients and be prepared to manage the situation. The
presence of gastric contents in the oropharynx presents
a significant risk of aspiration with the patient’s next
breath. In this case, immediately suction and rotate the
entire patient to the lateral position while restricting
cervical spinal motion.
Pitfall
Aspiration after
vomiting
Maxillofacial Trauma
prevention
• Ensure functional suction
equipment is available.
• Be prepared to rotate the
patient laterally while
restricting cervical spinal
motion when indicated.
Trauma to the face demands aggressive but careful airway
management (n FIGURE 2-2). This type of injury frequently
results when an unrestrained passenger is thrown into
the windshield or dashboard during a motor vehicle
crash. Trauma to the midface can produce fractures
and dislocations that compromise the nasopharynx
and oropharynx. Facial fractures can be associated
with hemorrhage, swelling, increased secretions, and
dislodged teeth, which cause additional difficulties in
maintaining a patent airway. Fractures of the mandible,
especially bilateral body fractures, can cause loss of
normal airway structural support, and airway obstruction
can result if the patient is in a supine position. Patients
who refuse to lie down may be experiencing difficulty
in maintaining their airway or handling secretions.
Furthermore, providing general anesthesia, sedation,
or muscle relaxation can lead to total airway loss due to
diminished or absent muscle tone. An understanding
of the type of injury is mandatory to providing adequate
airway management while anticipating the risks.
Endotracheal intubation may be necessary to maintain
airway patency.
Neck Trauma
Penetrating injury to the neck can cause vascular
injury with significant hematoma, which can result in
displacement and obstruction of the airway. It may be
necessary to emergently establish a surgical airway if
this displacement and obstruction prevent successful
endotracheal intubation. Hemorrhage from adjacent
vascular injury can be massive, and operative control
may be required.
Both blunt and penetrating neck injury can cause
disruption of the larynx or trachea, resulting in
airway obstruction and/or severe bleeding into the
tracheobronchial tree. This situation urgently requires
a definitive airway.
Neck injuries involving disruption of the larynx and
trachea or compression of the airway from hemorrhage
into the soft tissues can cause partial airway obstruction.
Initially, patients with this type of serious airway injury
may be able to maintain airway patency and ventilation.
However, if airway compromise is suspected, a definitive
airway is required. To prevent exacerbating an existing
airway injury, insert an endotracheal tube cautiously
and preferably under direct visualization. Loss of airway
patency can be precipitous, and an early surgical airway
usually is indicated.
Laryngeal Trauma
Although laryngeal fractures rarely occur, they can
present with acute airway obstruction. This injury is
indicated by a triad of clinical signs:
1. Hoarseness
2. Subcutaneous emphysema
3. Palpable fracture
n FIGURE 2-2 Trauma to the face demands aggressive but careful
airway management.
Complete obstruction of the airway or severe
respiratory distress from partial obstruction warrants
an attempt at intubation. Flexible endoscopic intubation
may be helpful in this situation, but only if it can
be performed promptly. If intubation is unsuccessful,
an emergency tracheostomy is indicated, followed
by operative repair. However, a tracheostomy is
difficult to perform under emergency conditions,
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