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Not much more you could do although you could give him more Ketamine IM . If could get IV then give some Midazolam too? I too would also have used Entonox in the circumstances. I am sure Vic would watch out for any developing tension pneumo and react accordingly!! Would it be possible to use intra-nasal diamorphine. It works on kids so why not adults? Any views or am I being totally idiotic? Iain McNeil ----- Original Message ----- From: "Vic Calland" <[log in to unmask]> To: <[log in to unmask]> Sent: Wednesday, April 30, 2003 10:53 AM Subject: Ideas please.... > Attended a MVC last night. Driver doing a 100mph plus put his car under > the end of an HGV only doing 50mph. Dragged 200-300 yards down the road > as the driver of the lorry regained control and came to a halt. > > Driver was late twenties, physically fit but on the heavier end of > normal weight range. Trapped upright until the fire crew did a dash > roll. Had 8cm transverse laceration of forehead with bit of skull in > wound but amazingly had GCS of 12-13. Had bilateral bracing fractures; > left elbow was a posterior dislocation, radius & ulna a comminuted > compound fracture as crunchy as a bag of crisps; his right was a more > classical Monteggia apart from the fact it was compound and the bone was > protruding. He also has a fractured pelvis with a dislocation of the > left hip. > > He had breath sounds bilaterally so we didn't realise he had a ruptured > left hemidiaphragm until the CXR came back. At the time he wasn't too > shut down, so we splinted the arms, gave him 50mg Ketamine im and free > flow Entonox for the extrication (long board to the rear). We were only > 5 minutes from the hospital so we ran with him rather than established > an i.v. on scene. There they ended up with a right femoral vein access > with a "security guard" watching it. > > I'd be interested to know if anyone has clever ideas for dealing with > this kind of situation because his pain relief was not ideal by any > means. > > Vic Calland