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Tricky. That combination of multiple injuries would in my practice be an indication for pre-hospital RSI but obviously that would have to wait for the extrication - and the 5 minute run-time would make that less sensible. Dash rolls take a bit of time - any reason why you couldn't have popped an iv in and titrated the ketamine better? That's what I would have done looking smugly through the retrospectoscope from my warm dry armchair. I too would've avoided the N20/02 with his combo of injuries. Cliff Reid -----Original Message----- From: Andy Webster [mailto:[log in to unmask]] Sent: 30 April 2003 11:08 To: [log in to unmask] Subject: Re: Ideas please.... I haven't done any pre-hospital care but entonox is not the ideal agent when there is chest trauma. What about titrating the ketamine further? Careful use of opiates. Scoop and run seemed to be the best thing after extracation...alive and painful is preferable to dead and painless Andy -----Original Message----- From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Vic Calland Sent: 30 April 2003 10:54 To: Andrew Webster 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