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CASE PRESENTATION

You are the emergency physician on duty for aeromedical transport calls. You are called to the scene of a motor vehicle collision in a remote area. Seventeen minutes into the flight, you hear from the on-scene paramedics that a young man hit a tree and flipped his car. He is the only occupant and is still trapped in the car. The rescuers have difficulty extricating him from the vehicle. On landing, you see firefighters preparing to use a heavy-extrication tool (“Jaws of Life”). As you exit the helicopter, the ground paramedic informs you that the accident scene is secure and that the patient is a 25-year-old obese man, unconscious, with stable vital signs. As you approach the vehicle, you note major front-end damage to the car, encroaching on the vehicle’s interior, the airbag deployed, and the patient apparently unresponsive behind the steering column. The A- and B-column on the driver’s side of the car appeared to have struck the left side of the patient’s head, and both lower extremities are trapped under the dashboard. Vital signs are stable and he is unresponsive to pain. He is breathing spontaneously with high-flow oxygen delivered via a non-rebreather face mask; a cervical spine collar has been applied and two large-bore intravenous cannulas placed in the antecubital fossae.

PATIENT CONSIDERATIONS

What Are the Considerations in Extricating the Patient from the Vehicle?

Given that organized traffic control and firefighters ensure scene safety, the urgency of extrication must now be considered. A rapid extrication may be necessary in cases of impending arrest or uncontrollable bleeding. Priority is governed by “life before limb” and accepts the risk of further injuries to extremities and spine. A planned and deliberate rescue approach might be appropriate if there are no immediate life-threatening situations, such as a burning vehicle or markedly unstable vital signs. In the case of this patient, access had already been provided by the rescuers, permitting clinical assessment by emergency medical services (EMS) personnel and application of basic airway maneuvers and insertion of intravenous lines. Following initial medical interventions, the rescuers can then use a heavy-extrication tool to remove the roof of the vehicle and a hydraulic spreader to create space under the dashboard. The patient can then be extricated with full spine precautions.

What Are the Major Considerations According to the Trauma Guidelines?

According to the Prehospital Trauma Life Support (PHTLS) and Advanced Trauma Life Support (ATLS) guidelines, the primary assessment of a patient addresses the airway, breathing, circulation, and disability (ABCD).1,2 After ensuring rescuer and patient safety and a short check for critical bleeding, airway management has the highest priority. In this unconscious patient, the airway is in jeopardy and needs to be secured early, and it must be assumed that the patient has suffered a severe traumatic brain injury. Oxygenation and ventilation are ...

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