Advanced Trauma Life Support ATLS Student Course Manual 2018

34
CHAPTER 2 n Airway and Ventilatory Management
A
A
B
B
n FIGURE 2-12 Intubation through an Intubating Laryngeal Mask.
A. Once the laryngeal mask is introduced, B. a dedicated
endotracheal tube is inserted into it, allowing therefore a “blind”
intubation technique.
C
n FIGURE 2-14 Insertion of the GEB designed to aid in difficult
intubations. A. The GEB is lubricated and placed in back of the
epiglottis with the tip angled toward the front of the neck. B. It
slides under the epiglottis and is maneuvered in a semiblind or blind
fashion into the trachea. C. Placement of the GEB into the trachea
may be detected by the palpable “clicks” as the tip passes over the
cartilaginous rings of the trachea.
n FIGURE 2-13 Eschmann Tracheal Tube Introducer (ETTI). This
device is also known as the gum elastic bougie.
With the laryngoscope in place, pass the GEB blindly
beyond the epiglottis, with the angled tip positioned
anteriorly (see Gum Elastic Bougie video on MyATLS
mobile app.) Confirm tracheal position by feeling clicks
as the distal tip rubs along the cartilaginous tracheal
rings (present in 65%–90% of GEB placements); a GEB
inserted into the esophagus will pass its full length
without resistance (n FIGURE 2-14).
After confirming the position of the GEB, pass a
lubricated endotracheal tube over the bougie beyond
the vocal cords. If the endotracheal tube is held up at
the arytenoids or aryepiglottic folds, withdraw the
tube slightly and turn it counter-clockwise 90 degrees
to facilitate advancement beyond the obstruction.
Then, remove the GEB and confirm tube position with
auscultation of breath sounds and capnography.
Following direct laryngoscopy and insertion of an
orotracheal tube, inflate the cuff and institute assisted
ventilation. Proper placement of the tube is suggested—
but not confirmed—by hearing equal breath sounds
bilaterally and detecting no borborygmi (i.e., rumbling
or gurgling noises) in the epigastrium. The presence
of borborygmi in the epigastrium with inspiration
suggests esophageal intubation and warrants removal
of the tube.
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