Advanced Trauma Life Support ATLS Student Course Manual 2018

BIBLIOGRAPHY 39
team leader should establish the degree of practical
expertise of the airway manager. For
example, some doctors in training, such as
junior residents, may not be comfortable
managing a difficult airway such as in a
patient who has sustained inhalation burns.
The team leader should identify who may be
needed to assist the team and how they can be
quickly contacted.
••
If prehospital information suggests that the
patient will require a definitive airway, it
may be wise to draw up appropriate drugs for
sedation and drug-assisted intubation before
the patient arrives. Equipment for managing
the difficult airway should also be located
within easy access of the resuscitation room.
••
The timing of definitive airway management
may require discussion with consultants to
the trauma team. For example, in patients
with head injuries who are not in obvious
distress, discussion between the neurosurgical
member of the team and the team leader may
be helpful.
••
Patients may require transfer to the CT scan,
operating room, or ICU. Therefore, the team
leader should clarify who will be responsible
for managing a patient’s airway and ventilation
after intubation.
Chapter Summary
1. Clinical situations in which airway compromise is
likely to occur include head trauma, maxillofacial
trauma, neck trauma, laryngeal trauma, and airway
obstruction due to other reasons.
2. Actual or impending airway obstruction should be
suspected in all injured patients. Objective signs
of airway obstruction include agitation, cyanosis,
abnormal breath sounds, hoarse voice, stridor
tracheal displacement, and reduced responsiveness.
3. Recognition of ventilatory compromise and ensuring
effective ventilation are of primary importance.
4. Techniques for establishing and maintaining a
patent airway include the chin-lift and jaw-thrust
maneuvers, oropharyngeal and nasopharyngeal
airways, extraglottic and supraglottic devices,
and endotracheal intubation. A surgical airway
is indicated whenever an airway is needed and
intubation is unsuccessful.
5. With all airway maneuvers, cervical spinal motion
must be restricted when injury is present
or suspected.
6. The assessment of airway patency and adequacy
of ventilation must be performed quickly and
accurately. Pulse oximetry and end-tidal CO 2
measurement are essential.
7. A definitive airway requires a tube placed in
the trachea with the cuff inflated below the
vocal cords, the tube connected to some form
of oxygen-enriched assisted ventilation, and
the airway secured in place with an appropriate
stabilization method. Examples of definitive
airways include endotracheal intubation and
surgical airways (e.g., surgical cricothyroidotomy).
A definitive airway should be established if there
is any doubt about the integrity of the patient’s
airway. A definitive airway should be placed
early after the patient has been ventilated with
oxygen-enriched air, to prevent prolonged periods
of apnea.
8. Drug-assisted intubation may be necessary in
patients with an active gag reflex.
9. To maintain a patient’s oxygenation, oxygenated
inspired air is best provided via a tight-fitting
oxygen reservoir face mask with a flow rate of
greater than 10 L/min. Other methods (e.g., nasal
catheter, nasal cannula, and non-rebreathing mask)
can improve inspired oxygen concentration.
Bibliography
1. Alexander R, Hodgson P, Lomax D, et al. A
comparison of the laryngeal mask airway and
Guedel airway, bag and facemask for manual
ventilation following formal training. Anaesthesia
1993;48(3):231–234.
2. Aoi Y, Inagawa G, Hashimoto K, et al. Airway
scope laryngoscopy under manual inline
stabilization and cervical collar immobilization: a
crossover in vivo cinefluoroscopic study. J Trauma
2011;71(1):32–36.
3. Aprahamian C, Thompson BM, Finger WA, et
al. Experimental cervical spine injury model:
evaluation of airway management and splint-
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