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A 23-year-old driver is involved in a motor vehicle crash (MVC) in which her car has collided with an oncoming vehicle. On arrival at the scene, the emergency medical services (EMS) field team estimates a prolonged extrication time and difficult airway problem, and calls for EMS physician-on-call back-up. Upon arriving at the scene, you note that she appears to be unconscious inside the vehicle and is not making effective respiratory efforts. She is slumped back against her seat.

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16.2.1 According to the Advanced Trauma Life Support (ATLS) Guidelines, What Are the Immediate Issues that Need to Be Addressed?

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The prehospital environment can be an unpredictable and unstable environment for the patient and the EMS practitioner. Thus, prior to the initiation of resuscitation protocols, scene safety must be assessed and assured. Assessment and management of the airway, breathing, and then circulation (ABCs) follows Advanced Trauma Life Support Guidelines (ATLS).1 After scene safety, for the critically injured patient, airway management remains the greatest priority and challenge. In this unconscious patient, rapid extrication from the vehicle is unlikely, so airway assessment and management must be performed immediately while the patient is still in the vehicle.

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In this patient, the practitioner must assume that the patient has suffered a severe traumatic brain injury (TBI). Oxygenation and ventilation in the setting of severe TBI is of utmost importance in initiating treatment as prolonged hypoxia and hypercapnia are associated with increased morbidity and mortality. Associated injuries are likely in this patient: cervical spine injury; cardiothoracic injuries such as pneumothorax, hemothorax, flail chest, cardiopulmonary contusions, and cardiac tamponade; as well as intrabdominal injuries. Once the airway is adequately managed, the EMS team will need to assess the patient for these injuries, while recognizing that a complete assessment and definitive intervention will require expeditious transport to adequate in-hospital facilities.

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16.2.2 How Does This Prehospital Setting Affect Your Management of This Patient?

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Field management of this patient's airway is second only to scene safety considerations. The scenario described is an example of a worst-case situation and the field environment will have a significant impact on the options and interventions available. The practitioner will not be able to make the same judgments or carry out the same assessments possible in a controlled hospital environment. In this context, the practitioner will have to choose the optimal method of airway management in this patient while considering other options, should the primary attempt fail. While prehospital intubation has traditionally been used as the definitive airway in the field environment, there is growing evidence that it may be associated with no patient benefit at best2 and possibly an increased risk of adverse patient outcomes3,4 at worst. If tracheal intubation is found to be difficult or impossible, or beyond the skill set of the responder, the use of alternative airway techniques, including the extraglottic devices (EGDs), should be considered.

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