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CASE PRESENTATION

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A 29-year-old male motorcyclist presents to the emergency department (ED) accompanied by a paramedic rescue team after being involved in a high-speed motor vehicle crash (MVC). The motorcyclist was traveling at approximately 65 kilometers per hour (40 miles per hour) when he drove through an intersection and collided with a car. Although damage to the car was minimal, the motorcycle was severely damaged and the patient was found approximately 50 meters (160 feet) from the point of impact. The patient's vital signs at the scene were: HR 110 beats per minute (bpm), BP 120/70 mm Hg, RR 24 breaths per minute, and SpO2 93% on room air. Paramedics placed the patient on a spine board and transferred him to the ED. In the ED, he complains of pain in his chest, difficulty breathing, and pain in his legs. He is wearing a non-modular full-face helmet. His vital signs are found to be HR 120 bpm, BP 110/50 mm Hg, RR 32 breaths per minute, SpO2 89% and he is becoming confused. There is clinical evidence of a compound fracture of his right femur.

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PATIENT CONSIDERATIONS

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What Are the Initial Steps in the Management of This Patient?

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The general principles of trauma care and resuscitation apply to this patient. An initial, rapid survey of the patient's vital functions is undertaken including his airway, breathing, and circulation (the ABCs).1 Large-bore intravenous access, oxygen, and basic monitoring (pulse oximetry, ECG, and serial blood pressure readings) are instituted quickly. Supplemental oxygen had been provided in the field by placing an inverted simple face mask through the opening of the helmet, an acceptable maneuver if the helmet cannot be easily or safely removed for a primary survey. He is non-obese. His airway assessment shows that he is wearing a full-face, non-modular type motorcycle helmet, obscuring his mouth from view. His nose and nares are visible above the line of the face shield portion of the helmet, and his anterior neck is visible and displays normal anatomy. Rapid examination of his chest demonstrates equal air entry bilaterally and his pulses are equal. Although the patient is protecting his airway, he is breathing and has an adequate blood pressure. After completion of the primary survey he may require intervention to control his airway and breathing.

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Are There Recommendations in the Advanced Trauma Life Support® (ATLS®) Guidelines for the Removal of Helmets Prior to Transport?

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There is currently no consensus regarding whether pre-hospital personnel should routinely remove a patient's helmet prior to transport to hospital. Individual patient factors and coexisting injuries will guide this decision. If possible, the helmet should remain in place unless emergency airway intervention or respiratory support is needed, in which case the helmet should be carefully removed in a manner that minimizes cervical spine motion. Most helmet removal techniques endorse a ...

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