Curated Commentary

Q1 Walk through your initial assessment of this patient. What are the critical aspects of the assessment of this patient?

In responding to this question, Dr. Titone and Thompson pointed out a couple of key concepts. First, as brought up by Dr. Titone, a standardized approach to the initial assessment of the patient is crucial. It is very easy (as Dr. Titone points out) to get mentally distracted by dramatic physical exam findings. In addition, performing these assessments in an unfamiliar environment is an added challenge that could lead to missed injuries or inattention to the basics of prehospital resuscitation. Dr. Thompson very nicely addressed this by listing out an ABCD outline of the patient’s problems. For some more reading on the basic approach to the blunt trauma patient in the prehospital environment, check out this podcast done with Dr. Steuerwald that outlines his, quite rigorous, approach to these patients.

Second, most everyone was in strong agreement that this patient would need to have their airway managed. Indeed this patient does have several reasons that might lead you take secure his airway. As pointed out by Dr. Titone and Thompson, both the patient’s current mental status and his predicted clinical course would suggest intubation is warranted. Dr. O’Brien however brought up the possibility of using an extraglottic device to manage the patient’s airway, at least initially. Indeed, there were several varied opinions on how best to proceed with airway management, which were highlighted in the responses to questions 2 and 3.

Q2 Do any procedures need to be performed on this patient? If so, who performs the procedures? In what order should they be done? Where do you do these procedures (squad/in flight/receiving hospital)?

Airway Management

Most commenters leaned towards intubation and RSI for this patient. Dr. Renne was rightly concerned about the administration of an induction agent and a paralytic in a patient, who is presumed to be deep in the throws of hemorrhagic shock and currently hypotensive. He brings up the possibility of beginning aggressive resuscitation with product first before going forward with RSI. Indeed hemodynamics as well as oxygenation are going to be incredibly important in this patient who we presume to have a significant TBI. Wanting to avoid hypotension and hypoxia at all costs, several commenters brought up the preference for using ketamine as their induction agent (and potentially at a slightly lower dose as pointed out by Dr. Renne) and brought up the importance of pre-oxygenation. While no one it up, apneic oxygenation is going to be a crucial component of this patient’s eventual intubation. Dr. O’Brien brought up the possibility of using an extra-glottic device like an i-Gel. The idea of a “rapid-sequence airway” is interesting primarily because it is exceptionally fast and may be just as effective as placing an endotracheal tube. Given this patient’s mental status, one should expect that, just like after intubation, some sedative medication would be required in order to maintain the EGD.

Other Procedures Mentioned in the Discussion