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ATLS - Ch 2

Airway & Ventilatory Management

What should be administered to all severely injured trauma patients? Supplemental Oxygen
List three things that are detrimental to patients with intracranial injury 1-Hypoxia 2-Hypercarbia 3-Upper Airway Stimulation
What three things suggest laryngeal fracture? 1-Hoarseness 2-Subcutaneous emphysema 3-Palpable fracture
What level of C-spine injury spares phrenic nerve? below C3-C4
If phrenic nerve is spared, what is the result? (2) 1-abdominal breathing 2-paralysis of intercostal muscles
How many people should be involved in removing a motorcycle helmet? Two
What GCS score requires prompt intubation? GCS < 8
Give three complications of basilar skull fracture 1-CSF Rhinorrhea 2-Ecchymosis of eyes bilaterally (Raccoon Eyes) and behind ears (Battle Sign) 3-CSF Otorrhea
Which is easier to perform: cricothyroidotomy or tracheostomy? Cricothyroidotomy
What size needle for jet insufflation? Adult 12-14 g Child 16-18
What is the amount of oxygen for jet insufflation? 15 L/min (40-50 psi)
What is the cycle of jet insufflation? 1 sec on, 4 sec off, using thumb over open end of Y-connector
Where does the needle go in jet insufflation? Through the cricothyroid membrane
Give three relative contraindications to jet insufflation 1-Chest trauma 2-COPD 3-Complete glottic obstruction
What tube size used for cricothyroidotomy? 5 to 7 mm ET tube
What is a relative contraindication to cricothyroidotomy? Age less than 12
What are two indication for cricothyroidotomy? 1-Complete upper airway obstruction 2-Fractured mandible body
Give three causes of left shift of hemoglobin saturation curve 1-Alkalemia (elevated pH) 2-Lower temperature 3-Lower PaCO2
List complications of cricothyroidotomy (9) 1-Laryngeal injury 2-Tracheal injury 3-Esophageal injury 4-Subglottic edema/stenosis 6-Laryngeal stenosis 7-Aspiration 8-Hemorrhage or hematoma 9-Creation of false passage in ST neck
The first priorities in ATLS are Airway and Ventilation
Three considerations regarding airway compromise. Can be 1-sudden and complete 2-insidious and partial 3-progressive and recurrent
Early sign of of airway or ventilatory compromise? tachypnea, though may be related to pain or anxiety or both
Facial fractures can be associated with (3) 1-hemorrhage 2-increased secretions 3-dislodged teeth
Fractures of mandible can cause loss of normal airway support
Patient refusing to lie down may be experiencing difficulty maintaining airway or handling secretions
If airway compromise is suspected a definitive airway is required
Noisy breathing indicates partial airway obstruction that suddenly can become complete
Most important early measure to assess airway talk to patient and elicit a verbal response
Agitation suggests hypoxia
Obtundation suggests hypercarbia
Cyanosis indicates hypoxemia due to inadequate oxygenation
Cyanosis is identified by inspection of (2) 1-nail beds 2-circumoral skin
Additional evidence of airway compromise (2) 1-retractions 2-use of accessory muscles of ventilation
Three objective findings of airway compromise 1-observe the patient 2-listen for abnormal sounds 3-feel location of trachea for deviation or fracture
Three signs of adequate ventilation 1-symmetrical rise and fall of chest 2-auscultation of air movement on both sides 3-pulse oximetry and end-tidal CO2
Three measures to improve ventilation 1-airway maintenance techniques 2-definitive airway measures 3-methods of providing supplemental ventilation
Optional method of removing a motorcycle helmet cast cutter
OPA in conscious or unconscious patient? unconscious
Two ways to insert OPA 1-tongue blade 2-upside down and rotate
Upside down OPA insertion should not be used in children, because rotation can damage mouth and pharnyx
NPA in conscious or unconscious patient? either
OPA oropharyngeal airway
NPA nasopharyngeal airway
LMA laryngeal mask airway
When patient arrives in ER with LMA prepare for definitive airway
Is LMA a definitive airway? No
MEA multilumen esophageal airway
Is MEA a definitive airway? No
When patient arrives in ER with MEA prepare for definitive airway
LTA laryngeal tube airway
When patient arrives in ER wit LTA prepare for definitive airway
Is LTA a definitive airway? No
GEB gum elastic bougie
Description of GEB 60-cm long, 15-Fr resinstylette with Coude tip angled 40 degrees 3.5 cm from tip with 10-cm graduations
GEB is used when vocal cords cannot be visualized on direct laryngoscopy
Tracheal positioning of GEB is confirmed (3) 1-feeling for clicks as tip rubs cartilaginous tracheal rings 2-tube rotates right or left when entering bronchus 3-when tube is held up at bronchial tree
Three types of definitive airway 1-orotracheal tube 2-nasotracheal tube 3-surgical airway (cricothyroidotomy or tracheostomy)
Criteria for definitive airway (6) 1-apnea 2-inability to maintain patent airway 3-protection from aspiration (blood or vomitus) 4-impending or potential compromise of airway 5-closed head injury (GCS <8) 6-inadequate oxygenation by facemask
ETTI, also known as Eschmann Tracheal Tube Introducer, gum elastic bougie
Normal lateral C-spine film ____ exlude possibility of C-spine injury does not
BURP backward, upward, and rightward pressure aids in visualizing the vocal cords
How do you confirm ET tube placement? (5) 1-Auscultation bilateral breath sounds 2-Watching chest rise & fall 3-End-tidal CO2 detector 4-Visualizing ETT through cords 5-CXR
Borborygmi rumbling or gurling noises in epigastrium
Presence of borborygmi suggest esophageal intubation
Presence of CO2 in exhaled air indicates ____ but does not ensure ____ 1-airway has been successfully intubated 2-the correct position of the ET tube
If CO2 is not detected esophageal intubation has occurred
Preparation for intubation(12) 1-suction 2-oxygen 3-bag-mask 4-laryngoscope 5-GEB 6-LMA 7-LTA 8-crico kit 9-ET tube 10-pulse ox 11-CO2 detector 12-drugs
When proper position of ET tube is determine secure in place
When patient is moved with ET tube in reasses tube placement by auscultation and CO2 detection
Blind NT intubation requires____ and is contraindicated in patient with ____. spontaneous breathing apnea
Relative contraindications for NT intubation (4) 1-facial fractures 2-frontal sinus fractures 3-basilar skull fractures 4-cribriform plate fractures
Factors predicting difficult intubation 1-cervical spine injury 2-severe cervical spine arthritis 3-significant maxillofacial or mandibular trauma 4-limited mouth opening 5-receding chin 6-overbite 7-short muscular neck
L E M O N Look externally Evaluate the 3-3-2 Rule Mallampati Obstruction Neck Mobility
3-3-2 Rule 3 fingers between incisor teeth 3 fingers between hyoid and chin 2 fingers between thryoid notch and floor of mouth
Mallampati Classification Class I: pillars, soft palate, uvula, fauces Class II: soft palate, uvula, fauces Class III: soft palate, base of uvula Class IV: hard palate only
Dose of etomidate 0.3 mg/kg (usually 20 mg)
Dose of succinylcholine 1 to 2 mg/kg (usually 100 mg)
Etomidate effect on BP not significant
Onset and duration of succinylcholine <1 min 5 min or less
Succinylcholine not used in patients with _____ because of ____. severe crush injuries, major burns, electrical injuries, preexisting chronic renal failure, chronic paralysis, chronic neuromuscular disease potential for severe hyperkalemia
Thiopental and sedatives lower blood pressure, potentially dangerous in patients with hypovolemia
To reverse sedative effects of BZD, use flumazenil
Surgical cricothyroidotomy preferable over tracheostomy for three reasons 1-easier to perform 2-associated with less bleeding 3-requires less time
How long can jet insufflation be used? 30 to 45 minutes
Cricothyroidotomy can damage ____ in children cricoid cartilage, the only circumferential support for upper trachea in children
Regarding percutaneous tracheostomy in trauma it is not safe and not recommended
Prolonged periods of inadequate or absent ventilation and oxygenation should be avoided
Tight fitting mask with reservoir flow rate is at least 11 L/min
Pulse oximetry measures ____, not ____. oxygen saturation of blood O2 sat partial pressure of oxygen PaO2
O2 sat > ____ suggests adequate ____, greater than ____. 95% adequate PaO2 70%
Pulse oximetry cannot distinguish oxyhemoglobin from carboxyhemoglobin or methemoglobin
Pulse oximetry is limited in patients with 1-severe vasoconstriction 2-carbon monoxide poisoning
Reliability of pulse oximetry is decreased with (2) 1-anemia Hg <5 g/dL 2-hypothermia <30 C or <86 F
Bag-mask ventilation should be performed by ____ persons two when possible
Two complications of bag-mask ventilation causeing gastric distension 1-vomiting and aspiration 2-pressure on vena cava, causing hypotension and bradycardia
How does doctor know when to abort intubation? hold breath and abort when YOU must breathe
Created by: tcrouch2000



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