achilles
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A 32 yr old hispanic male is brought to the ER after being resuscitaated by the EMT's from a road accident site. on arrival in the ER he is unconcious, with a bleeding scalp laceration. his vitals are- temp:98.9F, pulse rate:130/min, BP:90/50mmhg, RR:20/min. his pupils are 5mm dilated and are equally reactive to light. which of the following is the most appropriate next step in the management of this patient?
a) establish airway with facemask and deliver oxygen with rapid infusion of RL and rapid suture of scalp laceration
b) establish airway with orotracheal intubation, rapid infusion of RL and suturing scalp laceration
c) establish airway with orotracheal intubation, rapid infusion of packed RBC's and suturing of scalp laceration
d) establish airway with a needle cricothyroidotomy, rapid infusion of packed RBC's and lateral x-ray of spine
e) rapid infusion of RL, suturing the scalp laceration and lateral x-ray of the spine
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| DrS
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b) establish airway with orotracheal intubation, rapid infusion of RL and suturing scalp laceration
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| achilles
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good DrS...well done!! like i said you hardly get a question wrong...
i got this one wrong so i posted it...
my confusion is that the patient has a scalp laceration and is unconcious...a cervical spine injury cannot be ruled out in such a patient...is orotracheal intubation a safe option then in this patient without knowing if there is injury to his spine or not?? is'nt nasotracheal intubation aa better option or still cricothyroidotomy, which i know is more preferred in the field and not in the ER...
i'll be waiting for your answer...
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" it's not whether you get knocked down, it's whether you get up"
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| DrS
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Thanks for the compliments achilles! But yes, you make a very good point  . A patient who is unconscious with a scalp laceration following a road traffic accident should be considered to be having a cervical spine injury until proved otherwise. I wasn't very happy with the given answer as well, 'cos i feel the orotracheal intubation should be accompanied by cervical spine stabilization simultaneously as is the norm in the ATLS protocol. I chose B 'cos i felt it was the most logical of the given answers even though i don't think it is entirely correct. Just as you say, cervical spine stabilization before any maneuvers is mandatory in this patient.
Regarding the type of airway, i believe the method of choice in an unconscious patient is orotracheal intubation. Needle cricothyroidotomy is used when there is some sort of obstruction in the trachea (blood, oedema, etc) or when orotracheal intubation fails.
A little more on airway management in trauma courtesy of emedicine.com (http://www.emedicine.com/orthoped/topic640.htm)
"
Definitive airway management Definitive airway management achieves the 3 P's: provides airway patency, protects the lungs from aspiration, and allows for positive pressure ventilation. - Orotracheal intubation is the criterion standard of airway management. An endotracheal tube is placed between the vocal cords under direct visualization. Immediately afterward, the physician must (1) check breath sounds, (2) check for gastric distension/borborygmi, (3) check for exhaled carbon dioxide using a colorimeter, (4) ensure that the oxygen saturation by pulse oximetry remains at 95-100%, and (5) obtain a chest radiograph to confirm proper placement of the tip 2-3 cm above the carina.
Nasotracheal intubation is indicated for a spontaneously breathing patient. It may be associated with bleeding from trauma to the nasal passages, but it is better tolerated by an awake patient because it is more comfortable and less likely to induce vomiting than orotracheal intubation. It is contraindicated in patients with facial trauma or basilar skull fractures. Check tube placement afterwards, as with the orotracheal tube.
Surgical airway is usually a last resort and is indicated when orotracheal intubation is unsuccessful, obstruction of the trachea (by edema, blood) is complete, or the airway is totally transected. Surgical cricothyroidotomy is indicated in patients older than 5-12 years. Needle-jet insufflation is indicated for pediatric patients.
Intubation can be extremely difficult in the trauma setting. In-line cervical stabilization must be maintained, and the airway is frequently obscured by edema, blood, or vomitus. Intubation may be performed without medication in polytraumatized, obtunded, or comatose patients. Sedation alone, using etomidate or a benzodiazepine, may be sufficient to relax the muscles of the jaw and neck. Rapid sequence intubation with paralytics is rarely indicated for obtunded patients because paralyzing the patient means he or she cannot breathe independently or protect the airway if intubation is unsuccessful. Any time intubation is considered, failure is a possibility. Prepare for this inevitable situation by having backup airway devices and a cricothyroidotomy tray available. Lack of an airway is one of the few situations in medicine in which seconds count. "
Hope this helps!!!!!!! 
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| achilles
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it sure did...thanks DrS...you are a gem.
and i too believe that the given options were not the best. and this was straight from UW.
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" it's not whether you get knocked down, it's whether you get up"
" i have miles to go before i sleep "
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| achilles
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and i like your pic...it looks like the light at the end of the tunnel
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" it's not whether you get knocked down, it's whether you get up"
" i have miles to go before i sleep "
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| DrS
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Well, welll thank you very much!!
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| frontal
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DrS, you are already delighting in those compliments so I'm refraining from posting a few myself. All I'll say is- you cracked a tough one.
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