Slide Guide

STUDENT COURSE n Slide Guide 1

STUDENT COURSE
CHAPTER 2: AIRWAY AND VENTILATORY
MANAGEMENT

SLIDE 2–1 Title Slide

SLIDE 2–2 Intro

• The instructor needs to establish:

1. Content of the interactive discussion: Airway and Ventilatory

Management

2. Aim of the interactive discussion:

a. To allow participants to apply the ATLS knowledge they have

gained from reading the Student Manual chapter.

b. Session will be run as an interactive discussion guided by an

unfolding case with stimulus questions.

c. Participants are required to engage with the discussion and

respond to questions.

d. This is a supportive learning environment in which we learn

from each other. People need to be supportive of one another’s
input. If you are unsure how to respond to a question, feel free
to request help from a fellow participant (i.e., work together).

1
­2 STUDENT COURSE n Chapter 2: Airway and Ventilatory Management

SLIDE 2–3 Objectives

• Read each of the learning objectives so that the participants under-
stand the key learning outcomes for this discussion. In addition,
explain the common language that ATLS teaches and its importance.
Discuss the roles of trauma team members.

• This interactive discussion must cover the Key Points for this chapter:

• Key Learning Points (these will be summarized at end of discussion):

1. One of earliest priorities is recognizing a compromised airway.

2. All trauma patients should receive supplemental oxygen.

3. Risk of airway compromise and difficult airway management can

be predicted.

4. Alterations in mental status (agitation, combativeness, confusion,

or obtundation) may indicate the need for airway management.

5. A definitive airway (cuffed tube in trachea below vocal cords)

should be obtained in cases of airway compromise.

SLIDE 2–4 Case Scenario

 STUDENT COURSE n Slide Guide 3

SLIDE 2–5 Discussion Questions:

• The participants’ responses should include the following information:

1. The facts that the patient was in a small vehicle, traveling at high
speed on an icy road, and that he experienced a driver’s-side im-
pact all put him at risk for airway compromise. The potential for
injury to the occupant of a crashed vehicle is related to: collision
type (e.g., side impact); injury pattern (external vs. internal colli-
sion); and energy exchanged. Other issues of concern that can be
raised include:

• Positioning (supine/spinal limitation)

• Body habitus (obesity)

• Possible facial or neck injuries

• Possible head injury

• Possible intoxicants (alcohol or drugs)

• Other medical comorbidities 

2. Of the patient’s vital signs reported, combativeness is the sign of

potential airway compromise. Combativeness may represent an
altered mental status due to direct injury (e.g., blunt head inju-
ry), preexisting conditions (e.g., intoxication), or an attempt to
compensate for potentially life-threatening injury. Agitation and
combativeness suggest hypoxia; obtundation suggests hyper-
carbia; cyanosis, which is a late finding, is evidenced by nail beds
and circumoral skin and suggests hypoxemia due to inadequate
oxygenation.

• If the participants do not provide the information, ask additional

questions to elicit the information from the participants, rather than
providing it yourself. For example:

• What crash details might you see in patients with airway compro-
mise?

• What type of injuries would be worrisome for airway compro-

mise?

• What patient characteristics could contribute to airway compro-

mise?
­4 STUDENT COURSE n Chapter 2: Airway and Ventilatory Management

SLIDE 2–6 Discussion Questions:

• The participants’ responses should include the following information:

3. Look and listen. A talking patient suggests that the airway is

functionally patent at the moment of assessment. Quick assess-
ment of the soft and bony structures that comprise the airway for
gross abnormality allows further evaluation of airway patency
and potential compromise. Altered mental status may indicate
brain injury or inadequate oxygenation/ventilation with hypox-
emia or hypercarbia. Patients with decreased level of conscious-
ness or significant agitation may require a secure airway. Look
for cyanosis and facial or neck injuries that may indicate airway
injury. Listen for abnormal upper airway sounds such as gurgling,
hoarseness, stridor, and evidence of adequate thoracic air move-
ment bilaterally. Use pulse oximetry and capnography.

4. Discussion may include these specific risk factors for difficult

airway:

• C-spine injury

• Significant maxillofacial or mandibular trauma

• Limited mouth opening

• Obesity

• Anatomical variations (e.g., receding chin; overbite; and a

short, muscular neck)

• If the participants do not provide the information, ask additional

questions to elicit the information from the participants, rather than
providing it yourself. For example:

• What could be causing this patient’s altered mental status (head

injury, intoxication, shock, etc.)?

• How does this affect your airway decisions?

SLIDE 2–7 Discussion Questions:

• The participants’ responses should include the following information:

5. Additional factors in trauma patients include age (pediatric pa-

tients) and severe arthritis of the c-spine.

6. Airway assessment tool: Use the LEMON tool to predict difficult

airways.

• If the participants do not provide the information, ask additional

questions to elicit the information from the participants, rather than
providing it yourself.
 STUDENT COURSE n Slide Guide 5

SLIDE 2–8 Case Scenario Progression

SLIDE 2–9 Discussion Questions:

• The participants’ responses should include the following information:

1. Ventilation is the movement of air between the environment and

the lungs via inhalation and exhalation. Symptoms of inadequate
ventilation include patient report of difficulty breathing, short-
ness of breath, and the request to sit up to breathe.

2. Objective signs of inadequate ventilation include:

• Tachypnea, tachycardia, and/or arrhythmia

• Altered mental status ranging from combativeness and agita-

tion to frank lethargy

• Use of accessory muscles and nasal flaring

• Diminished breath sounds

• Low oxygen saturation on pulse oximetry reading

• If the participants do not provide the information, ask additional

questions to elicit the information from the participants, rather than
providing it yourself. For example:

• What is the significance of the patient’s lethargy?

• Why are the tachycardia and tachypnea significant?

• You may wish to refer to the Airway Decision Scheme (Figure 2-4, Page
29 of the Student Manual).
­6 STUDENT COURSE n Chapter 2: Airway and Ventilatory Management

SLIDE 2–10 Discussion Questions:

• The participants’ responses should include the following information:

3. Recognize the need for prompt airway intervention due to com-

promised airway. Remember, all trauma patients should receive
supplemental oxygen.

4. An oral airway or nasal airway may temporarily assist with venti-

lation. Students should mention equipment required for intuba-
tion including suction, laryngoscope, ETTs, LMA or LTA, bougie,
as well as equipment for cricothyrotomy if intubation cannot be
carried out.

• If the participants do not provide the information, ask additional

questions to elicit the information from the participants, rather than
providing it yourself.

SLIDE 2–11 Case Scenario Progression

 STUDENT COURSE n Slide Guide 7

SLIDE 2–12 Discussion Questions:

• The participants’ responses should include the following information:

1. A definitive airway is required. This is defined as a cuffed tube

below the vocal cords. Endotracheal intubation or surgical airway
will be required. Because the patient is unresponsive, prompt
definitive airway control is indicated. There are three types of
definitive airways: orotracheal tubes, nasotracheal tubes, and
surgical airways (i.e., cricothyroidotomy or tracheostomy). Blind
nasotracheal intubation requires a patient to be spontaneously
breathing.

2. Preparation for intubation involves preparation for failure. Con-

tinue to preoxygenate the patient. Gather the appropriate equip-
ment for intubation and to rescue the airway in case of failure. A
rescue airway such as LTA or LMA may be helpful if difficulties
occur. Gum elastic bougie and fiberoptic intubation are also use-
ful tools.

3. Adjuncts for intubation include:

•  Suction: oral suction to remove secretions from view and gas-

tric suction to minimize the risk of aspiration during intubation
as well as the risk of hypotension due to vagal response

• Manual laryngeal manipulation technique: backward, upward,

and rightward pressure (BURP)

• Gum elastic bougie: used if orotracheal intubation is unsuccess-

ful on the first attempt or if the cords are difficult to visualize

• Anesthetics, analgesics, and neuromuscular blocking agents for

drug-assisted intubation

• If the participants do not provide the information, ask additional

questions to elicit the information from the participants, rather than
providing it yourself. For example:

• What tools might improve your view when attempting orotra-

cheal intubation?

• What might you do if patient responses are interfering with

your ability to intubate?

SLIDE 2–13 Case Scenario Progression

­8 STUDENT COURSE n Chapter 2: Airway and Ventilatory Management

SLIDE 2–14 Discussion Questions:

• The participants’ responses should include the following information:

1. Surgical airway should be performed in a patient, who is in ex-

tremis. This should also be performed early if there is difficulty
ventilating or oxygenating.

2. Awake fiberoptic intubation could be considered prior to de-

compensation in some patients. (Instructor may mention video
intubation if available in the region.)

• If the participants do not provide the information, ask additional

questions to elicit the information from the participants, rather than
providing it yourself. For example:

• What would you do if the patient was desaturating?

• What would you do if the patient became bradycardic?

• Are there any other devices that could be helpful in the case of a
difficult airway?

SLIDE 2–15 Case Scenario Progression

 STUDENT COURSE n Slide Guide 9

SLIDE 2–16 Discussion Questions:

• The participants’ responses should include the following information:

1. The most likely situation is that the endotracheal tube (ETT) has
become kinked, been advanced to a right mainstem intubation, or
that there is occlusion of the left mainstem bronchus with blood
and secretions. The ETT should be assessed and suctioned.

2. Students should also consider other possibilities, such as develop-

ment of pneumothorax or positive pressure ventilation. Patients
may develop a tension pneumothorax following intubation, so
clinicians must be watchful. Needle decompression, simple tho-
racostomy, or tube thoracostomy at the fifth intercostal space an-
terior axillary line would be appropriate immediate management.

• If the participants do not provide the information, ask additional

questions to elicit the information from the participants, rather than
providing it yourself. For example:

• What could be happening to this patient? (differential diagnoses

listed above)

• How can you assess this? (repeat airway, breathing, circulation –

ABCs)

• What emergency is notable for hypotension and decreased breath

sounds? (tension pneumothorax)

• Why did this suddenly worsen? (addition of positive pressure

ventilation)

SLIDE 2–17 Case Scenario Conclusion

SLIDE 2–18 Any Questions?

­10 STUDENT COURSE n Chapter 2: Airway and Ventilatory Management

SLIDE 2–19 Objectives

• Specifically state how each of the learning objectives was achieved
during the interactive discussion.

• Encourage participants to:

1. Reflect on these learning objectives and on their confidence in

completion of the objectives.

2. Review the ATLS Student Manual chapter to reinforce ATLS prin-

ciples and material not specifically discussed in this session.

SLIDE 2–20 Key Learning Points

• Summarize for the participants the Key Points from this interactive
discussion.