Hi Martin
Do you think his loss oxygenation was due to airway obstruction, poor
ventilation or circulatory hypoperfusion?
My initial impressions are:
Obtunded head injury but reasonable airway and short extrication/transit.
Difficult physical access to patient during 40 minute extrication. NP airway
would be dodgy with maxillary injury - too much danger of associated basal
skull fracture - Guedel is my choice too. Slightly low sats but the good air
entry and tachycardia suggests C rather than A as cause. You established IV
access early (?volume infused - might have been candidate for deliberately
hypotensive resuscitation)(but poor access to patient/quick transit might
have meant no BP available). Was hypothermia an issue?
Other options - delay on scene, Combitube/PTLA for airway control (easier
skill retention), perhaps under Ketamine/Midazolam. Large volume challenge
(risk of blowing off clot and creating major hypovolaemia). Rapid infusion
device or IO access at scene. Warmed fluids.
You certainly could and should not have paralysed/intubated him at scene -
not unless you have great access to the patient both sides and behind.
But having said that, I think your team's response was fine. What was the
eventual outcome?
Andrew
PS Would you mind if I use this scenario as the "Complicated Airway" skill
station on the 5-day ICC next week! Send me a pic if you've got one!
-----Original Message-----
From: The list will be of relevance to all trainees including
undergraduates and [mailto:[log in to unmask]] On Behalf Of Martin
Hargreaves
Sent: Sunday, April 22, 2001 9:50 PM
To: [log in to unmask]
Subject: Scenario - Intubation and IV access
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Transit time to hospital was 5min and my intubation skills are a bit out of
date so I made no attempt to intubate on scene - SaO2 in transit 80-85%.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
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