A 50-year-old woman presenting after a motor vehicle collision

Abstract

Dr. Daniel McGillicuddy: The patient is a 50-year-oldwoman who was involved in a single car, high-speed motorvehicle collision. The patient was an unrestrained driver ina car without air bags who sustained severe blunt forcefacial trauma secondary to the steering wheel, and wasbrought in as a non-trauma to this community hospital. Shewas also intoxicated and agitated. The patient was unableto provide a past medical history, social history or anyinformation with respect to the accident. The pre-hospitalfingerstick glucose level was normal. The patient’s vitalsigns were a heart rate of 88 beats/min, a blood pressure of160/palpation mmHg, a respiratory rate of 24 breaths/minand an oxygen saturation of 96% on room air. The patientdid not have a temperature recorded. The physical exami-nation revealed a patient who was awake, but agitated. Shewas in cervical spine immobilization as well as immobi-lized on a spine board. The head examination revealedblunt trauma to the left orbit and mid face. She had peri-orbital edema on the left, bilateral massive epistaxis, andshe was actively vomiting blood. The midface was stable,the trachea was midline, and she had normal bilateralbreath sounds. The heart sounds were regular, there was nojugular venous distention, and the pulses were fullthroughout. The abdomen was obese, soft and non-tender.The FAST examination was without free fluid. The pelviswas stable. The Glasgow Coma Score was 12 due toaltered speech. The back and extremity examinations werenormal.Dr. Peter Rosen: Dr. Ban, what is your assessment ofthis patient?Dr. Kevin Ban: The intoxicated, combative traumapatient presents unique challenges for the EmergencyPhysician (EP). The combative behavior may be secondaryto any number of underlying causes, including intoxication(drug or alcohol), head injury, hypoxemia, hypovolemicshock or underlying medical conditions (diabetes withhypoglycemia). The most important priority for the EP is toobtain immediate and definitive control of the patient’sairway to facilitate treatment and diagnosis of the severelyinjured patient. There is controversy as to whether or not toparalyze these patients or to sedate them without additionalneuromuscular blockade as is usually done in a rapidsequence intubation (RSI).Dr. Rosen: Dr. Davis, what is your opinion regardingintubation with sedation alone versus a RSI with neuro-muscular blockade?Dr. Daniel Davis: This is going to be a tough airway,and I’m a bit reluctant to paralyze someone like this. Shehas multiple features that raise concerns about being able tointubate her successfully: obesity, c-collar, facial trauma,blood in the airway. It is reasonable to consider ketamine inthis patient, which might allow an attempt to inspect the