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Intramuscular Ketamine and IM Suxamethonium if it was apparent after 2-3 minutes that access was going to be difficult and secure the airway - which certainly sounds like a primary problem. I always get depressed hearing IV access nightmares - I honestly believe if you get experienced and senior staff present EARLY (before every possible site is knackered) you can ALWAYS get some sort of vascular access If tolerating the OPA, I would also have inserted bilateral NPA (carefully) and manually supported his breathing while all of this is going on - I have found the combination of an OPA + 2 NPA's and a good seal with a bag mask can salvage a lot of problem airways who you cannot immediately intubate. Craig . >>> [log in to unmask] 04/23/01 08:49 >>> 30 yr old male driver - head on crash into concrete wall at ?30mph. Hit face and upper chest on steering wheel causing major bend in steering wheel and ?maxillary fracture - GCS 7 - trapped with poor access for 40min. IV access and Oxygen in the car and oral airway on release. Rapid assessment showed bilateral reasonable air entry and no gross skeletal or abdominal injury, warm pink fingers and a radial pulse of 112. Transit time to hospital was 5min and my intubation skills are a bit out of date so I made no attempt to intubate on scene - SaO2 in transit 80-85%. Hospital alerted of need for trauma team. At hospital IVI lost when transferring patient to trolley. Now GCS 8 and trashing about. 30min then spent by trauma team establishing IV access - arms tried 3-4 times, femorals 2-3 each side, interoseous once, ankle cut down twice - second successful. During this time SaO2 running at 65 - 75%. Once IV established he was sedated (?propafol) and intubated - Sa02 went up to 92%. I don't feel we served this man well between us - any thoughts? Martin Hargreaves CCH Secure Mail Server ******************************************************************************** [INFO] -- Virus Manager: No Viruses were detected in this message. ******************************************************************************** CCH Secure Mail Server ******************************************************************************** This email or attachment(s) may contain confidential or legally privileged information intended for the sole use of the addressee(s). Any use, redistribution, disclosure, or reproduction of this message, except as intended, is prohibited. If you received this email in error, please notify the sender and remove all copies of the message, including any attachments. Any views or opinions expressed in this email (unless otherwise stated) may not represent those of Capital Coast Health Ltd. (AC_S001) [INFO] -- Virus Manager: No Viruses were detected in this message. ********************************************************************************