Airway & Ventilatory Management
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| What should be administered to all severely injured trauma patients? | Supplemental Oxygen
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| List three things that are detrimental to patients with intracranial injury | 1-Hypoxia 2-Hypercarbia 3-Upper Airway Stimulation
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| What three things suggest laryngeal fracture? | 1-Hoarseness 2-Subcutaneous emphysema 3-Palpable fracture
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| What level of C-spine injury spares phrenic nerve? | below C3-C4
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| If phrenic nerve is spared, what is the result? (2) | 1-abdominal breathing 2-paralysis of intercostal muscles
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| How many people should be involved in removing a motorcycle helmet? | Two
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| What GCS score requires prompt intubation? | GCS < 8
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| 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
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| Which is easier to perform: cricothyroidotomy or tracheostomy? | Cricothyroidotomy
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| What size needle for jet insufflation? | Adult 12-14 g Child 16-18
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| What is the amount of oxygen for jet insufflation? | 15 L/min (40-50 psi)
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| What is the cycle of jet insufflation? | 1 sec on, 4 sec off, using thumb over open end of Y-connector
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| Where does the needle go in jet insufflation? | Through the cricothyroid membrane
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| Give three relative contraindications to jet insufflation | 1-Chest trauma 2-COPD 3-Complete glottic obstruction
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| What tube size used for cricothyroidotomy? | 5 to 7 mm ET tube
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| What is a relative contraindication to cricothyroidotomy? | Age less than 12
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| What are two indication for cricothyroidotomy? | 1-Complete upper airway obstruction 2-Fractured mandible body
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| Give three causes of left shift of hemoglobin saturation curve | 1-Alkalemia (elevated pH) 2-Lower temperature 3-Lower PaCO2
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| 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
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| The first priorities in ATLS are | Airway and Ventilation
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| Three considerations regarding airway compromise. Can be | 1-sudden and complete
2-insidious and partial
3-progressive and recurrent
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| Early sign of of airway or ventilatory compromise? | tachypnea, though may be related to pain or anxiety or both
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| Facial fractures can be associated with (3) | 1-hemorrhage
2-increased secretions
3-dislodged teeth
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| Fractures of mandible can cause | loss of normal airway support
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| Patient refusing to lie down may be experiencing | difficulty maintaining airway or handling secretions
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| If airway compromise is suspected | a definitive airway is required
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| Noisy breathing indicates | partial airway obstruction that suddenly can become complete
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| Most important early measure to assess airway | talk to patient and elicit a verbal response
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| Agitation suggests | hypoxia
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| Obtundation suggests | hypercarbia
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| Cyanosis indicates | hypoxemia due to inadequate oxygenation
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| Cyanosis is identified by inspection of (2) | 1-nail beds
2-circumoral skin
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| Additional evidence of airway compromise (2) | 1-retractions
2-use of accessory muscles of ventilation
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| Three objective findings of airway compromise | 1-observe the patient
2-listen for abnormal sounds
3-feel location of trachea for deviation or fracture
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| 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
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| Three measures to improve ventilation | 1-airway maintenance techniques
2-definitive airway measures
3-methods of providing supplemental ventilation
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| Optional method of removing a motorcycle helmet | cast cutter
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| OPA in conscious or unconscious patient? | unconscious
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| Two ways to insert OPA | 1-tongue blade
2-upside down and rotate
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| Upside down OPA insertion should not be used in | children, because rotation can damage mouth and pharnyx
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| NPA in conscious or unconscious patient? | either
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| OPA | oropharyngeal airway
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| NPA | nasopharyngeal airway
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| LMA | laryngeal mask airway
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| When patient arrives in ER with LMA | prepare for definitive airway
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| Is LMA a definitive airway? | No
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| MEA | multilumen esophageal airway
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| Is MEA a definitive airway? | No
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| When patient arrives in ER with MEA | prepare for definitive airway
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| LTA | laryngeal tube airway
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| When patient arrives in ER wit LTA | prepare for definitive airway
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| Is LTA a definitive airway? | No
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| GEB | gum elastic bougie
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| Description of GEB | 60-cm long, 15-Fr resinstylette with Coude tip angled 40 degrees 3.5 cm from tip with 10-cm graduations
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| GEB is used when | vocal cords cannot be visualized on direct laryngoscopy
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| 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
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| Three types of definitive airway | 1-orotracheal tube
2-nasotracheal tube
3-surgical airway (cricothyroidotomy or tracheostomy)
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| 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
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| ETTI, also known as | Eschmann Tracheal Tube Introducer, gum elastic bougie
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| Normal lateral C-spine film ____ exlude possibility of C-spine injury | does not
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| BURP | backward, upward, and rightward pressure aids in visualizing the vocal cords
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| 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
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| Borborygmi | rumbling or gurling noises in epigastrium
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| Presence of borborygmi suggest | esophageal intubation
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| 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
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| If CO2 is not detected | esophageal intubation has occurred
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| 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
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| When proper position of ET tube is determine | secure in place
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| When patient is moved with ET tube in | reasses tube placement by auscultation and CO2 detection
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| Blind NT intubation requires____ and is contraindicated in patient with ____. | spontaneous breathing apnea
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| Relative contraindications for NT intubation (4) | 1-facial fractures
2-frontal sinus fractures
3-basilar skull fractures
4-cribriform plate fractures
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| 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
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| L E M O N | Look externally
Evaluate the 3-3-2 Rule
Mallampati
Obstruction
Neck Mobility
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| 3-3-2 Rule | 3 fingers between incisor teeth
3 fingers between hyoid and chin
2 fingers between thryoid notch and floor of mouth
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| 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
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| Dose of etomidate | 0.3 mg/kg (usually 20 mg)
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| Dose of succinylcholine | 1 to 2 mg/kg (usually 100 mg)
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| Etomidate effect on BP | not significant
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| Onset and duration of succinylcholine | <1 min 5 min or less
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| 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
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| Thiopental and sedatives | lower blood pressure, potentially dangerous in patients with hypovolemia
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| To reverse sedative effects of BZD, use | flumazenil
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| Surgical cricothyroidotomy preferable over tracheostomy for three reasons | 1-easier to perform
2-associated with less bleeding
3-requires less time
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| How long can jet insufflation be used? | 30 to 45 minutes
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| Cricothyroidotomy can damage ____ in children | cricoid cartilage, the only circumferential support for upper trachea in children
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| Regarding percutaneous tracheostomy in trauma | it is not safe and not recommended
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| Prolonged periods of inadequate or absent ventilation and oxygenation | should be avoided
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| Tight fitting mask with reservoir flow rate is | at least 11 L/min
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| Pulse oximetry measures ____, not ____. | oxygen saturation of blood O2 sat partial pressure of oxygen PaO2
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| O2 sat > ____ suggests adequate ____, greater than ____. | 95% adequate PaO2 70%
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| Pulse oximetry cannot distinguish | oxyhemoglobin from carboxyhemoglobin or methemoglobin
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| Pulse oximetry is limited in patients with | 1-severe vasoconstriction
2-carbon monoxide poisoning
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| Reliability of pulse oximetry is decreased with (2) | 1-anemia Hg <5 g/dL
2-hypothermia <30 C or <86 F
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| Bag-mask ventilation should be performed by ____ persons | two when possible
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| Two complications of bag-mask ventilation causeing gastric distension | 1-vomiting and aspiration
2-pressure on vena cava, causing hypotension and bradycardia
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| How does doctor know when to abort intubation? | hold breath and abort when YOU must breathe
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