Best Practices: Airway Management in the Limited Access Patient

Editor's note: We have retooled the "Best Practices" column to address operational issues that may surface in particular incidents rather than focus on administrative issues as we have previously done. If you have an interesting EMS incident which you would like to submit for critique, evaluation or just to ask a question about a best practice related to direct patient care or incident management, send it along with a maximum of 3 questions or discussion points to Dr. Jaslow at jaslowd@einstein.edu. We can not guarantee that the case will be reviewed, but we will provide you feedback within about one month.

Case submissions should be succinct and contain pertinent dispatch, scene and patient care details. The preface should list the date, EMS agency, location of incident, incident type, and injuries sustained. Scan ECGs or convert to PDF when necessary.

This column is not a "guess the diagnosis" or "prove the receiving ED wrong" forum. Therefore, discharge diagnoses or a solid ED working diagnosis should be present so that the readership can understand why this case has educational value to our nation's EMS professionals. Do not guess about the diagnosis! The ideal case for presentation will also contain one or more photos depicting scene conditions, patient pathophysiology, etc. The photo must be altered to prevent identification of the patient. Obviously, we assume that patient care was not compromised to obtain the photos and we hold authors responsible to this standard.

Case Presentation:

Date: April 13, 2006
EMS Agency: University Medevac, Hahnemann University Hospital, Philadelphia, PA
Location of incident: Bucks County, PA
Incident type: Motor vehicle collision with rescue
Injuries sustained: Pneumocephalus, ventricular hemorrhage with midline shift, left frontal lobe hemorrhage, right temporal lobe hemorrhage, left orbital fractures, approximately eight inch wooden impalement to the left eye, and fractured left superior pubis ramus

Summary of incident:

This is a single vehicle crash into a tree with two patients, a female found outside the vehicle and a male subject still entrapped in the driver's seat upon arrival of initial fire and EMS units. The vehicle left the right side of the highway at a moderate rate of speed, yawed to the right, turned 180° and struck a large tree in the driver door between the "A" and "B" posts. Ground EMS called for aeromedical transport due to an approximately six-inch impaled branch in the driver's eye, anticipated extended extrication time and a lengthy ground transport time to the nearest trauma center. Medevac 3 responded with a standard crew configuration of pilot/nurse/paramedic from their base in Philadelphia.

Thirty-two minutes after the first call to the PSAP MedEvac 3 arrived on location and received a progress report from ground EMS. The patient was confused, had a GCS of 11 (E3, M4, V4) and palpable radial pulses. He complained of pain and had to be restrained to prevent him from pulling out the impaled object. Initial treatment had been limited to c-collar placement and IV initiation due to the degree of entrapment. The MedEvac 3 crew recommended oxygen initiation as access permitted, pain management with fentanyl (unavailable to ground EMS), airway assessment and preparation for emergent airway interventions due to potential decompensation in the patient's mental/ventilatory status.

Fifty-two minutes after the initial call to the PSAP, a sharp decline in the patient's mental status was observed. The extrication process was halted to allow for patient assessment by the Medevac 3 crew. The patient was noted to be unresponsive with a GCS of 5 (E1, M1, V3) necessitating the need for advanced airway management. Passive ventilations were continued with oxygen at 15 lpm via non-rebreather mask since the patient's minute volume was still adequate. Because of the potential for difficult intubation associated with physical access to the patient the MedEvac 3 crew opted to proceed with an intubation attempt utilizing sedatives but no paralytics (facilitated intubation).