Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 2 n Airway and Ventilatory Management
in their use, knowledgeable of the inherent pitfalls
associated with RSI, and capable of managing the
potential complications.
Surgical Airway
The inability to intubate the trachea is a clear indication
for an alternate airway plan, including laryngeal
mask airway, laryngeal tube airway, or a surgical
airway. A surgical airway (i.e., cricothyroidotomy
or tracheostomy) is indicated in the presence of
edema of the glottis, fracture of the larynx, severe
oropharyngeal hemorrhage that obstructs the airway,
or inability to place an endotracheal tube through the
vocal cords. A surgical cricothyroidotomy is preferable
to a tracheostomy for most patients who require an
emergency surgical airway because it is easier to
perform, associated with less bleeding, and requires
less time to perform than an emergency tracheostomy.
The cannula is then connected to oxygen at 15 L/min
(50 to 60 psi) with a Y-connector or a side hole cut in
the tubing between the oxygen source and the plastic
cannula. Intermittent insufflation, 1 second on and 4
seconds off, can then be achieved by placing the thumb
over the open end of the Y-connector or the side hole.
(See Cricothyroidotomy video on MyATLS mobile app.)
The patient may be adequately oxygenated for 30 to
45 minutes using this technique. During the 4 seconds
that the oxygen is not being delivered under pressure,
some exhalation occurs.
Because of the inadequate exhalation, CO 2
slowly
accumulates and thus limits the use of this technique,
especially in patients with head injuries.
Use percutaneous transtracheal oxygenation (PTO)
with caution when complete foreign-body obstruction
of the glottic area is suspected. Significant barotrauma
can occur, including pulmonary rupture with tension
pneumothorax following PTO. Therefore, careful
attention must be paid to effective airflow in and out.
Needle Cricothyroidotomy
Needle cricothyroidotomy involves insertion of a needle
through the cricothyroid membrane into the trachea
in an emergency situation to provide oxygen on a
short-term basis until a definitive airway can be placed.
Needle cricothyroidotomy can provide temporary,
supplemental oxygenation so that intubation can be
accomplished urgently rather than emergently.
The percutaneous transtracheal oxygenation (PTO)
technique is performed by placing a large-caliber plastic
cannula—12- to 14-gauge for adults, and 16- to 18-gauge in
children—through the cricothyroid membrane into the
trachea below the level of the obstruction (n FIGURE 2-15).
Surgical Cricothyroidotomy
Surgical cricothyroidotomy is performed by making
a skin incision that extends through the cricothyroid
membrane (n FIGURE 2-16). Insert a curved hemostat or
scalpel handle to dilate the opening, and then insert a
small endotracheal or tracheostomy tube (preferably 5
to 7 ID) or tracheostomy tube (preferably 5 to 7 mm OD).
Care must be taken, especially with children, to
avoid damage to the cricoid cartilage, which is the
only circumferential support for the upper trachea.
For this reason, surgical cricothyroidotomy is not
recommended for children under 12 years of age. (See
Chapter 10: Pediatric Trauma.) When an endotracheal
tube is used, it must be adequately secured to prevent
malpositioning, such as slipping into a bronchus or
completely dislodging.
In recent years, percutaneous tracheostomy has
been reported as an alternative to open tracheostomy.
This procedure is not recommended in the acute
trauma situation, because the patient’s neck must be
hyperextended to properly position the head in order
to perform the procedure safely.
Management of oXygenation
n FIGURE 2-15 Needle Cricothyroidotomy. This procedure is performed
by placing a catheter over a needle or over a wire using the Seldinger
technique. Note: Motion of the cervical spine must be restricted, but that
maneuver is not shown in order to emphasize the airway insertion technique.
Oxygenated inspired air is best provided via a tightfitting
oxygen reservoir face mask with a flow rate of
at least 10 L/min. Other methods (e.g., nasal catheter,
nasal cannula, and nonrebreather mask) can improve
inspired oxygen concentration.
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