ITLS Airway Management and Ventilation 2 — Questions and Answers

Question 1: A trauma patient with facial fractures and significant oral bleeding is unable to maintain their airway. Oral intubation attempts have failed twice. What is the next appropriate airway intervention?

Repeat oral intubation attempt
Insert a nasopharyngeal airway
Perform a surgical cricothyrotomy (Correct answer)
Apply continuous suctioning only

Correct answer: Perform a surgical cricothyrotomy

After two failed oral intubation attempts in a patient who cannot maintain their airway, a surgical cricothyrotomy provides a definitive surgical airway and is the appropriate rescue technique.

ITLS guidelines establish a clear airway algorithm: basic maneuvers → adjuncts → intubation → surgical airway. After two failed intubation attempts, further attempts have diminishing success and increasing risk of airway swelling and aspiration. A surgical cricothyrotomy involves incising the cricothyroid membrane to insert a cuffed tube directly into the trachea, bypassing upper airway obstruction. Nasopharyngeal airways are contraindicated in suspected facial/basilar skull fractures due to risk of intracranial placement. Continuous suctioning alone cannot provide a patent airway. Supraglottic devices (King LT, i-gel) may be attempted as an intermediate step, but in this scenario with massive facial trauma and oral bleeding, a surgical airway is the most reliable option.

Question 2: What is the primary risk of using a nasopharyngeal airway in a patient with suspected basilar skull fracture?

Aspiration of gastric contents
Intracranial placement through the cribriform plate (Correct answer)
Vagal stimulation causing bradycardia
Laryngospasm

Correct answer: Intracranial placement through the cribriform plate

In basilar skull fractures, the cribriform plate may be disrupted, creating a path for the NPA to be inadvertently passed into the cranial vault.

The cribriform plate is a thin, perforated bone forming the roof of the nasal cavity and the floor of the anterior cranial fossa. Basilar skull fractures can disrupt this structure, creating a communication between the nasal cavity and the intracranial space. Signs of basilar skull fracture include raccoon eyes (periorbital ecchymosis), Battle's sign (mastoid ecchymosis), CSF rhinorrhea or otorrhea, and hemotympanum. If an NPA is inserted through a fractured cribriform plate, it can enter the brain, causing devastating injury. When basilar skull fracture is suspected, an oral airway or other airway management technique should be used instead. This is a classic ITLS teaching point and one of the few absolute contraindications to NPA use.

Question 3: When ventilating a trauma patient with a bag-valve-mask, you notice poor chest rise despite a good mask seal. What should you do first?

Increase the squeeze force on the bag
Reposition the airway and reassess (Correct answer)
Switch to a smaller mask
Perform an emergency tracheostomy

Correct answer: Reposition the airway and reassess

Poor chest rise with a good mask seal most likely indicates inadequate airway positioning. Repositioning the airway (adjusting jaw thrust or head position) should be attempted before escalating interventions.

The most common cause of failed BVM ventilation is improper airway positioning. Even with a good mask seal, if the tongue is occluding the pharynx or the head/neck position is suboptimal, air cannot reach the lungs. The correct response is to reposition: readjust the jaw thrust, consider an oral or nasal airway adjunct, or in non-trauma patients, optimize the sniffing position. Squeezing the bag harder with a malpositioned airway forces air into the stomach (gastric insufflation), increasing aspiration risk. A smaller mask would worsen the seal. Emergency tracheostomy is a last resort after all other methods have failed. The ITLS approach emphasizes mastering basic techniques before escalating to invasive procedures, as most airway problems are solved with proper positioning and adjuncts.

Question 4: What is the recommended oxygen flow rate when using a bag-valve-mask with a reservoir for trauma resuscitation?

6 L/min
10 L/min
15 L/min (Correct answer)
25 L/min

Correct answer: 15 L/min

A BVM with reservoir attached should be connected to oxygen at 15 L/min, which provides close to 100% FiO2, the standard for trauma resuscitation.

The bag-valve-mask with an oxygen reservoir connected at 15 L/min delivers approximately 90-100% FiO2, the highest concentration achievable with standard prehospital equipment. The reservoir bag stores oxygen between ventilations, preventing room air entrainment. At 15 L/min, the reservoir remains inflated, ensuring each delivered breath contains maximal oxygen. At lower flow rates (6 or 10 L/min), the reservoir partially collapses between breaths, entraining room air and reducing FiO2 to 40-60%. At 25 L/min, excess flow is wasted without additional benefit. All trauma patients with significant injuries should receive high-flow oxygen during resuscitation. ITLS emphasizes that trauma-related hypoxia contributes to secondary brain injury and worsens hemorrhagic shock outcomes, making adequate oxygenation a priority.

Question 5: During a rapid trauma assessment, a patient develops gurgling sounds during ventilation. What does this indicate and what action is needed?

Bronchospasm; administer a bronchodilator
Fluid in the airway; immediate suctioning (Correct answer)
Laryngeal edema; prepare for cricothyrotomy
Normal airway sounds during BVM ventilation

Correct answer: Fluid in the airway; immediate suctioning

Gurgling indicates the presence of blood, vomit, or secretions in the airway. Immediate suctioning is required to clear the airway and prevent aspiration.

Gurgling is an abnormal airway sound caused by air passing through liquid material (blood, vomit, secretions) in the upper airway. It indicates an immediate aspiration risk. In trauma patients, the most common sources are bleeding from facial injuries, vomiting, or blood from the nasopharynx. ITLS teaches that suctioning should be performed immediately: use a rigid-tip (Yankauer) suction catheter, limit suctioning to 10-15 seconds to prevent hypoxia, and be prepared to log-roll the patient if vomiting is copious. Bronchospasm produces wheezing, not gurgling. Laryngeal edema produces stridor. There are no normal gurgling sounds during ventilation. Failure to clear the airway of liquid material can lead to aspiration pneumonia, complete airway obstruction, or hypoxia, all of which worsen trauma outcomes.

Question 6: Which patient presentation most strongly indicates the need for assisted ventilation rather than supplemental oxygen alone?

SpO2 of 93% on room air with normal respiratory effort
Respiratory rate of 8 with shallow chest rise and cyanosis (Correct answer)
Respiratory rate of 24 with mild accessory muscle use
Mild dyspnea with clear lung sounds bilaterally

Correct answer: Respiratory rate of 8 with shallow chest rise and cyanosis

A respiratory rate of 8 (bradypnea) with shallow chest rise and cyanosis indicates inadequate ventilation requiring assisted ventilations with a BVM, not just supplemental oxygen.

ITLS defines inadequate ventilation by both rate and quality. A respiratory rate below 10 or above 29, combined with signs of poor gas exchange (shallow breathing, cyanosis, altered mental status), indicates the patient cannot maintain adequate minute ventilation independently. Supplemental oxygen only increases FiO2 but cannot compensate for insufficient tidal volume or rate. Assisted ventilation with a BVM delivers both oxygen and mechanical support to inflate the lungs. An SpO2 of 93% on room air is mildly reduced and may respond to supplemental O2 alone. Tachypnea at 24 with mild accessory muscle use represents increased work of breathing that should be monitored but does not yet require mechanical assistance. Mild dyspnea with clear lungs also warrants oxygen supplementation without assisted ventilation.

ITLS Airway Management and Ventilation 2

A trauma patient with facial fractures and significant oral bleeding is unable to maintain their airway.
Oral intubation attempts have failed twice.
What is the next appropriate airway intervention?