Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 2 n Airway and Ventilatory Management
can be associated with profuse bleeding, and can
be time-consuming. Surgical cricothyroidotomy,
although not preferred in this situation, can be a
lifesaving option.
Penetrating trauma to the larynx or trachea can be
overt and require immediate management. Complete
tracheal transection or occlusion of the airway with
blood or soft tissue can cause acute airway compromise
requiring immediate correction. These injuries are
often associated with trauma to the esophagus, carotid
artery, or jugular vein, as well as soft tissue destruction
or swelling.
Noisy breathing indicates partial airway obstruction
that can suddenly become complete, whereas the
absence of breathing sounds suggests complete obstruction.
When the patient’s level of consciousness is
depressed, detection of significant airway obstruction
is more subtle, and labored breathing may be the only
clue to airway obstruction or tracheobronchial injury.
If a fracture of the larynx is suspected, based on
the mechanism of injury and subtle physical findings,
computed tomography (CT) can help diagnose
this injury.
Objective Signs of Airway Obstruction
Patients with objective signs of airway difficulty or
limited physiological reserve must be managed with
extreme care. This applies, among others, to obese
patients, pediatric patients, older adults, and patients
who have sustained facial trauma.
The following steps can assist clinicians in identifying
objective signs of airway obstruction:
1. Observe the patient to determine whether
he or she is agitated (suggesting hypoxia) or
obtunded (suggesting hypercarbia). Cyanosis
indicates hypoxemia from inadequate
oxygenation and is identified by inspecting
the nail beds and circumoral skin. However,
cyanosis is a late finding of hypoxia, and it
may be difficult to detect in pigmented skin.
Look for retractions and the use of accessory
muscles of ventilation that, when present, offer
additional evidence of airway compromise.
Pulse oximetry used early in the airway
assessment can detect inadequate oxygenation
before cyanosis develops.
2. Listen for abnormal sounds. Noisy breathing
is obstructed breathing. Snoring, gurgling,
and crowing sounds (stridor) can be associated
with partial occlusion of the pharynx or larynx.
Hoarseness (dysphonia) implies functional
laryngeal obstruction.
3. Evaluate the patient’s behavior. Abusive and
belligerent patients may in fact be hypoxic; do
not assume intoxication.
Ventilation
Ensuring a patent airway is an important step in
providing oxygen to patients, but it is only the first
step. A patent airway benefits a patient only when
ventilation is also adequate. Therefore, clinicians must
look for any objective signs of inadequate ventilation.
Problem Recognition
Ventilation can be compromised by airway obstruction,
altered ventilatory mechanics, and/or central nervous
system (CNS) depression. If clearing the airway does
not improve a patient’s breathing, other causes of the
problem must be identified and managed. Direct trauma
to the chest, particularly with rib fractures, causes pain
with breathing and leads to rapid, shallow ventilation
and hypoxemia. Elderly patients and individuals with
preexisting pulmonary dysfunction are at significant
risk for ventilatory failure under these circumstances.
Pediatric patients may suffer significant thoracic injury
without rib fractures.
Intracranial injury can cause abnormal breathing
patterns and compromise adequacy of ventilation.
Cervical spinal cord injury can result in respiratory
muscle paresis or paralysis. The more proximal
the injury, the more likely there will be respiratory
impairment. Injuries below the C3 level result in
maintenance of the diaphragmatic function but loss
of the intercostal and abdominal muscle contribution
to respiration. Typically these patients display a seesaw
pattern of breathing in which the abdomen is pushed
out with inspiration, while the lower ribcage is pulled
in. This presentation is referred to as “abdominal
breathing” or “diaphragmatic breathing.” This pattern
of respiration is inefficient and results in rapid, shallow
breaths that lead to atelectasis and ventilation perfusion
mismatching and ultimately respiratory failure.
Objective Signs of Inadequate
Ventilation
The following steps can assist clinicians in identifying
objective signs of inadequate ventilation:
1. Look for symmetrical rise and fall of the
chest and adequate chest wall excursion.
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