A 27-year-old man is brought to the emergency department 45 minutes after being involved in a motor vehicle collision. He is agitated. He has pain in his upper right arm, which he is cradling in his left arm. His temperature is 36.7°C (98°F), pulse is 135/min, respirations are 25/min, and blood pressure is 145/90 mm Hg. His breathing is shallow. Pulse oximetry on 100% oxygen via a non-rebreather face mask shows an oxygen saturation of 83%. He is confused and oriented only to person. Examination shows multiple bruises on the right anterior thoracic wall. The pupils are equal and reactive to light. On inspiration, his right chest wall demonstrates paradoxical inward movement while his left chest wall is expanding. There is pain to palpation and crepitus over his right anterior ribs. The remainder of the examination shows no abnormalities. An x-ray of the chest is shown. Two large-bore IVs are placed. After fluid resuscitation and analgesia, which of the following is the most appropriate next step in management?

Intubation with positive pressure ventilation

Surgical fixation of right third to sixth ribs

A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

Intubation and mechanical ventilation

Insertion of nasogastric tube and enteral nutrition

Intravenous corticosteroid therapy

A 24-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was a restrained driver. On arrival, he is alert and oriented. His pulse is 112/min, respirations are 29/min, and blood pressure is 100/60 mm Hg. The pupils are equal and reactive to light. There is a 3-cm laceration over the forehead and multiple bruises over the trunk. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. The right knee is swollen and tender; range of motion is limited by pain. Infusion of 0.9% saline is begun and intravenous acetaminophen is administered. Two hours later, blood-tinged fluid spontaneously drains from both nostrils, and is made worse by leaning forward. On a piece of gauze, it shows up as a rapidly-expanding clear ring of fluid surrounding blood. Further evaluation of this patient is most likely to show which of the following?

Bilateral periorbital ecchymosis

A 47-year-old man is admitted to the emergency room after a fight in which he was hit in the head with a hammer. The witnesses say that the patient initially lost consciousness, but regained consciousness by the time emergency services arrived. On admission, the patient complained of a diffuse headache. He opened his eyes spontaneously, was verbally responsive, albeit confused, and was able to follow commands. He could not elevate his left hand and leg. He did not remember the events prior to the loss of consciousness and had difficulty remembering information, such as the names of nurses or doctors. His airway was not compromised. The vital signs are as follows: blood pressure, 180/100 mm Hg; heart rate, 59/min; respiratory rate, 12/min; temperature 37.0℃ (98.6℉); and SaO2, 96% on room air. The examination revealed bruising in the right frontotemporal region. The pupils are round, equal, and show a poor response to light. The neurologic examination shows hyperreflexia and decreased power in the left upper and lower limbs. There is questionable nuchal rigidity, but no Kernig and Brudzinski signs. The CT scan is shown in the image. Which of the following options is recommended for this patient?

Surgical evacuation of the clots

Administration of levetiracetam

Administration of methylprednisolone

A mass casualty incident occurs with 25 casualties arriving simultaneously at a community hospital emergency department. The trauma team has limited resources with 2 operating rooms available and 4 surgeons present. Among the arriving patients: Patient A has traumatic amputation of forearm with tourniquet in place and stable vitals; Patient B has flail chest, respiratory distress, and unstable vitals; Patient C is in cardiac arrest with penetrating chest wound; Patient D has a femur fracture with stable vitals; Patient E has GCS 4 with bilateral blown pupils. Evaluate the triage priority according to ATLS mass casualty protocols.

Priority order: B, A, D, with E and C designated expectant

Priority order: C, E, B, A, D - treat most severely injured first

Priority order: A, D, B, E, C - treat all patients equally regardless of prognosis

Priority order: B, A, E, D, C - based on severity alone

Immediate evacuation of all patients to a higher level trauma center

Airway management in trauma for USMLE Step 2 CK: High-Yield Surgery Lessons

Primary Survey - Airway First, Always

Assess: Look, listen, and feel for air movement. Assume C-spine injury in all trauma patients.
Maneuvers: Use jaw-thrust (not head-tilt) to open the airway. Suction to clear blood or vomitus.
Adjuncts:
- Oropharyngeal (OPA): For unconscious patients with no gag reflex.
- Nasopharyngeal (NPA): For conscious patients. ⚠️ Avoid in suspected basilar skull fracture.
Definitive Airway (Intubation): Indicated for GCS ≤ 8, apnea, airway obstruction, or inability to protect the airway.

⭐ In trauma, always assume a cervical spine injury. Perform a jaw-thrust maneuver instead of a head-tilt/chin-lift to open the airway without extending the neck.

Airway Maneuvers: Head-Tilt/Chin-Lift vs. Jaw-Thrust

Difficult Airway - The LEMON Squeeze

📌 LEMON is a rapid assessment for predicting a difficult airway prior to intubation.

Look Externally: Facial trauma, large incisors, beard/moustache, large tongue (macroglossia).
Evaluate 3-3-2 Rule:
- - Incisor Gap: < 3 fingers
- - Hyoid-Mental Distance: < 3 fingers
- - Thyro-Hyoid Distance: < 2 fingers
Mallampati Score: Score ≥ III suggests difficult visualization.
Obstruction/Obesity: Presence of epiglottitis, peritonsillar abscess, or obesity.
Neck Mobility: Limited range of motion, e.g., cervical spine immobilization.

⭐ The 3-3-2 rule is a cornerstone of airway assessment; failure of any component warrants preparation for a surgical airway as a backup.

Definitive Airways - The End Game

Indications for Definitive Airway:
- Inability to maintain a patent airway by other means
- Inability to protect the airway from aspiration (blood, vomit)
- Impending or potential airway compromise (e.g., inhalation injury, neck hematoma)
- Closed head injury requiring controlled ventilation (GCS ≤ 8)
- Apnea
Types of Definitive Airways:
- Orotracheal Intubation (ETI): Most common method. Rapid Sequence Intubation (RSI) is the standard in trauma to secure the airway quickly while minimizing aspiration risk.
- Nasotracheal Intubation: Useful in spontaneously breathing patients where oral access is difficult. ⚠️ Contraindicated with facial fractures or signs of basilar skull fracture.
- Surgical Airway (Cricothyroidotomy): Indicated when intubation fails or is contraindicated (e.g., laryngeal fracture, severe maxillofacial trauma). It is an emergency, temporizing measure.

Cricothyroidotomy Landmarks and Incision Site

⭐ Exam Favorite: The Glasgow Coma Scale (GCS) is a critical tool. A score of 8 or less is a strong indication for intubation to protect the airway - “GCS less than 8, intubate!”

High‑Yield Points - ⚡ Biggest Takeaways

Assume cervical spine injury in all trauma patients; maintain manual in-line stabilization.

A GCS score < 8 is a primary indication for a definitive airway.

Orotracheal intubation is the preferred method for securing a definitive airway.

Avoid nasotracheal intubation in patients with suspected basilar skull fracture.

If intubation fails, immediately proceed to a surgical airway, typically a cricothyroidotomy.

Rapid Sequence Intubation (RSI) is the standard of care for emergency airway management.

Continue reading on Oncourse

CONTINUE READING — FREE

or get the app

App Store|Google Play