Diagnosis of the cause of respiratory distress must be made promptly. If the patient is making little or no effort to breathe, central nervous system dysfunction due to head trauma, drugs, or spinal cord injury is the most likely problem. If the patient is attempting to breathe but is moving little or no air, upper airway obstruction should be suspected.
The most common cause of upper airway obstruction in comatose patients is prolapse of the tongue into the pharynx. Other causes of upper airway obstruction include dentures; vomitus; or blood clots in the pharynx, larynx, or upper trachea. Occasionally, direct trauma may cause fracture of the larynx or cricotracheal separation. Inspiratory stridor does not usually occur unless there is at least a 70 percent occlusion of the larynx or upper trachea. With any suspected laryngeal injury, cautious endoscopy should be performed in the operating room as soon as possible, but one must also be prepared to perform an emergency tracheostomy immediately if the airway occludes.
If the patient is attempting to breathe and the upper airway appears to be intact but the breath sounds are poor, thoracic problems such as flail chest, hemopneumothorax, diaphragmatic injury, or parenchymal lung damage should be considered. In all cases of respiratory distress, the airway must be secured. Following airway control, optimal oxygenation and ventilation should be provided.
CARDIAC ARREST DURING OR JUST AFTER ENDOTRACHEAL INTUBATION Although Rotondo et al2 have pointed out that urgent paralysis and intubation of trauma patients who are combative or have complex injuries is relatively safe, one of the most frequent times for an emergency department patient to have a cardiac arrest is during or right after endotracheal intubation. Ta.ble 2.5.1-3. lists common causes for cardiac arrest during intubation. If the patient has poor venous return because of hypovolemia, ventilation with excessive pressures can further reduce venous return and cause cardiac arrest. Hypovolemic patients should probably be ventilated with tidal volumes of only 5 to 8 mL/kg at 10 to 14 times per minute until venous return is improved.
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