Advanced Trauma Life Support ATLS Student Course Manual 2018

AIRWAY MANAGEMENT 35
A carbon dioxide detector (ideally a capnograph or
a colorimetric CO 2
monitoring device) is indicated
to help confirm proper intubation of the airway.
The presence of CO 2
in exhaled air indicates that the
airway has been successfully intubated, but does
not ensure the correct position of the endotracheal
tube within the trachea (e.g., mainstem intubation
is still possible). If CO 2
is not detected, esophageal
intubation has occurred. Proper position of the tube
within the trachea is best confirmed by chest x-ray,
once the possibility of esophageal intubation is
excluded. Colorimetric CO 2
indicators are not useful
for physiologic monitoring or assessing the adequacy of
ventilation, which requires arterial blood gas analysis
or continous end-tidal carbon dioxide analysis.
After determining the proper position of the tube,
secure it in place. If the patient is moved, reassess tube
placement with auscultation of both lateral lung fields
for equality of breath sounds and by reassessment for
exhaled CO 2
.
If orotracheal intubation is unsuccessful on the first
attempt or if the cords are difficult to visualize, use
a GEB and initiate further preparations for difficult
airway management.
Pitfall
Inability to intubate
Equipment failure
Drug-Assisted Intubation
prevention
• Use rescue airway devices.
• Perform needle
cricothryotomy followed
by surgical airway.
• Establish surgical airway.
• Perform frequent
equipment checks.
• Ensure backup equipment
is available.
In some cases, intubation is possible and safe without
the use of drugs. The use of anesthetic, sedative, and
neuromuscular blocking drugs for endotracheal
intubation in trauma patients is potentially dangerous.
Yet occasionally, the need for an airway justifies
the risk of administering these drugs; therefore, it
is important to understand their pharmacology, be
skilled in the techniques of endotracheal intubation,
and be capable of securing a surgical airway if
neces-sary. Drug-assisted intubation is indicated in
patients who need airway control, but have intact gag
reflexes, especially in patients who have sustained
head injuries.
The technique for drug-assisted intubation is as follows:
1. Have a plan in the event of failure that includes
the possibility of performing a surgical airway.
Know where your rescue airway equipment
is located.
2. Ensure that suction and the ability to deliver
positive pressure ventilation are ready.
3. Preoxygenate the patient with 100% oxygen.
4. Apply pressure over the cricoid cartilage.
5. Administer an induction drug (e.g., etomidate, 0.3
mg/kg) or sedative, according to local protocol.
6. Administer 1 to 2 mg/kg succinylcholine intravenously
(usual dose is 100 mg).
After the patient relaxes:
7. Intubate the patient orotracheally.
8. Inflate the cuff and confirm tube placement by
auscultating the patient’s chest and determining
the presence of CO 2
in exhaled air.
9. Release cricoid pressure.
10. Ventilate the patient.
The drug etomidate (Amidate) does not negatively
affect blood pressure or intracranial pressure, but it
can depress adrenal function and is not universally
available. This drug does provide adequate sedation,
which is advantageous in these patients. Use etomidate
and other sedatives with great care to avoid loss of the
airway as the patient becomes sedated. Then administer
succinylcholine, which is a short-acting drug. It has a
rapid onset of paralysis (