ATLS Airway and Ventilatory Management 2 — Questions and Answers
Question 1: A trauma patient presents with a GCS of 7, copious oral bleeding, and suspected cervical spine injury. What is the most appropriate airway management approach?
- Nasotracheal intubation
- Rapid sequence intubation with in-line cervical stabilization (Correct answer)
- Surgical cricothyroidotomy
- Bag-valve-mask ventilation until CT clears the spine
Correct answer: Rapid sequence intubation with in-line cervical stabilization
RSI with manual in-line stabilization is the standard approach for securing the airway in trauma patients with potential cervical spine injuries and a GCS less than 8.
RSI with MILS involves an assistant providing manual stabilization while the front of the cervical collar is removed to allow jaw opening. This minimizes cervical spine movement while permitting orotracheal intubation. Nasotracheal intubation is contraindicated with suspected base of skull fracture.
Question 2: Which clinical sign most reliably indicates tension pneumothorax requiring immediate intervention?
- Subcutaneous emphysema
- Unilateral absent breath sounds with hypotension and tracheal deviation (Correct answer)
- Oxygen saturation below 90%
- Paradoxical chest wall movement
Correct answer: Unilateral absent breath sounds with hypotension and tracheal deviation
The classic presentation of tension pneumothorax includes absent breath sounds on the affected side, hypotension, and contralateral tracheal deviation.
Tension pneumothorax is a clinical diagnosis that should not await radiographic confirmation. Treatment is immediate needle decompression at the 2nd intercostal space, midclavicular line, followed by tube thoracostomy.
Question 3: What is the primary indication for performing a surgical cricothyroidotomy in trauma?
- Patient refusal of orotracheal intubation
- Failed orotracheal intubation with inability to ventilate (Correct answer)
- Suspected cervical spine fracture
- Bilateral rib fractures with flail chest
Correct answer: Failed orotracheal intubation with inability to ventilate
Surgical cricothyroidotomy is the definitive rescue airway when orotracheal intubation has failed and the patient cannot be adequately ventilated.
Surgical cricothyroidotomy is indicated in the 'cannot intubate, cannot oxygenate' (CICO) scenario. It is generally contraindicated in children under 12 and in laryngeal fractures where tracheostomy is preferred.
Question 4: During the primary survey, a patient has oxygen saturation of 85% despite high-flow oxygen. Breath sounds are present bilaterally. What should be evaluated next?
- Check for flail chest or pulmonary contusion (Correct answer)
- Order a CT angiogram for pulmonary embolism
- Perform bilateral chest tube insertion
- Begin continuous positive airway pressure
Correct answer: Check for flail chest or pulmonary contusion
Persistent hypoxemia despite supplemental oxygen with bilateral breath sounds suggests underlying pulmonary pathology such as pulmonary contusion or flail chest.
When hypoxemia persists despite high-flow oxygen with bilateral breath sounds present, evaluate for pulmonary contusion, flail chest, aspiration, or hemothorax. Pulmonary contusion may not manifest on initial chest X-ray for 4-6 hours.
Question 5: Which of the following patients would be most appropriate for needle cricothyroidotomy rather than surgical cricothyroidotomy?
- A 45-year-old with massive facial trauma
- An 8-year-old with a failed intubation attempt (Correct answer)
- A 30-year-old with laryngeal fracture
- A 60-year-old with known tracheal stenosis
Correct answer: An 8-year-old with a failed intubation attempt
Needle cricothyroidotomy with transtracheal jet ventilation is the preferred emergency surgical airway in children under 12 because the cricothyroid membrane is small.
In children under 12, the cricothyroid membrane is small and the larynx is funnel-shaped. Needle cricothyroidotomy with transtracheal jet ventilation provides temporary oxygenation (up to 30-45 minutes) while a definitive surgical airway is prepared.
Question 6: A trauma patient develops progressive hoarseness, stridor, and subcutaneous emphysema in the neck. Which injury should be most strongly suspected?
- Esophageal perforation
- Laryngeal fracture (Correct answer)
- Tension pneumothorax
- Carotid artery dissection
Correct answer: Laryngeal fracture
The triad of hoarseness, stridor, and subcutaneous emphysema in the neck is highly suggestive of laryngeal fracture.
Laryngeal fracture presents with hoarseness, stridor, and subcutaneous emphysema. Tracheostomy (not cricothyroidotomy) is the surgical airway of choice because the injury may involve the cricothyroid membrane.
ATLS Airway and Ventilatory Management 2
A trauma patient presents with a GCS of 7, copious oral bleeding, and suspected cervical spine injury.
What is the most appropriate airway management approach?