Advanced Trauma Life Support ATLS Student Course Manual 2018

AIRWAY MANAGEMENT 33
n TABLE 2-1 outlines the indications for a definitive airway.
The urgency of the patient’s condition and the
indications for airway intervention dictate the
appropriate route and method of airway management
to be used. Continued assisted ventilation can be aided
by supplemental sedation, analgesics, or muscle
relaxants, as indicated. Assessment of the patient’s
clinical status and the use of a pulse oximeter are
helpful in determining the need for a definitive
airway, the urgency of the need, and, by inference,
the effectiveness of airway placement. The potential
for concomitant c-spine injury is a major concern in
patients requiring an airway.
Endotracheal Intubation
Although it is important to establish the presence or
absence of a c-spine fracture, do not obtain radiological
studies, such as CT scan or c-spine x-rays, until after
establishing a definitive airway when a patient clearly
requires it. Patients with GCS scores of 8 or less require
prompt intubation. If there is no immediate need
table 2-1 indications for
definitive airway
NEED FOR
AIRWAY PROTECTION
Severe maxillofacial
fractures
• Risk for aspiration
from bleeding and/or
vomiting
Neck injury
• Neck hematoma
• Laryngeal or tracheal
injury
• Inhalation injury from
burns and facial burns
• Stridor
• Voice change
Head injury
• Unconscious
• Combative
NEED FOR VENTILATION
OR OXYGENATION
Inadequate respiratory
efforts
• Tachypnea
• Hypoxia
• Hypercarbia
• Cyanosis
• Combativeness
• Progressive change
• Accessory muscle use
• Respiratory muscle
paralysis
• Abdominal breathing
• Acute neurological
deterioration or
herniation
• Apnea from loss of
consciousness or
neuromuscular paralysis
for intubation, obtain radiological evaluation of the
c-spine. However, a normal lateral c-spine film does
not exclude the possibility of a c-spine injury.
Orotracheal intubation is the preferred route taken
to protect the airway. In some specific situations and
depending on the clinician’s expertise, nasotracheal
intubation may be an alternative for spontaneously
breathing patients. Both techniques are safe and
effective when performed properly, although the
orotracheal route is more commonly used and results
in fewer complications in the intensive care unit (ICU)
(e.g., sinusitis and pressure necrosis). If the patient has
apnea, orotracheal intubation is indicated.
Facial, frontal sinus, basilar skull, and cribriform
plate fractures are relative contraindications to
nasotracheal intubation. Evidence of nasal fracture,
raccoon eyes (bilateral ecchymosis in the periorbital
region), Battle’s sign (postauricular ecchymosis), and
possible cerebrospinal fluid (CSF) leaks (rhinorrhea
or otorrhea) are all signs of these injuries. As with
orotracheal intubation, take precautions to restrict
cervical spinal motion.
If clinicians decide to perform orotracheal intubation,
the three-person technique with restriction of cervical
spinal motion is recommended (see Advanced Airway
video on MyATLS mobile app).
Cricoid pressure during endotracheal intubation
can reduce the risk of aspiration, although it may also
reduce the view of the larynx. Laryngeal manipulation
by backward, upward, and rightward pressure (BURP)
on the thyroid cartilage can aid in visualizing the
vocal cords. When the addition of cricoid pressure
compromises the view of the larynx, this maneuver
should be discontinued or readjusted. Additional hands
are required for administering drugs and performing
the BURP maneuver.
Over the years, alternative intubation devices have
been developed to integrate video and optic imaging
techniques. Trauma patients may benefit from their
use by experienced providers in specific circumstances.
Careful assessment of the situation, equipment, and
personnel available is mandatory, and rescue plans
must be available.
n FIGURE 2-12 illustrates intubation through an
intubating laryngeal mask. Once the mask is introduced,
a dedicated endotracheal tube is inserted, allowing a
blind intubation technique.
The Eschmann Tracheal Tube Introducer (ETTI),
also known as the gum elastic bougie (GEB), may be
used when personnel encounter a problematic airway
(n FIGURE 2-13). Clinicians use the GEB when a patient’s
vocal cords cannot be visualized on direct laryngoscopy.
In fact, using the GEB has allowed for rapid intubation
of nearly 80% of prehospital patients in whom direct
laryngoscopy was difficult.
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