A 28-year-old male was injured in a motorcycle accident in which he was not wearing a helmet. On admission to the emergency room he was in severe respiratory distress and hypotensive (blood pressure 80/40 mm. Hg), and appeared cyanotic. He was bleeding profusely from the nose and had an obviously open femur fracture with exposed bone. Breath sounds were decreased on the right side of the chest. The initial management priority should be:
Airway remains the first priority in the management of any patient with multiple injuries. Control of the airway in a patient with head, face, and neck injury can be extremely challenging. In the patient presented, the best option given for control of the airway is endotracheal intubation with in-line cervical traction. This requires at least two persons, one to maintain the head in the neutral position and one to inse the endotracheal tube under direct vision. An alternative in this case would be emergency cricothyroidotomy, tracheostomy, or needle-jet insufflation. Nasotracheal intubation is not an option in the presence of a mid-face fracture and a nasal hemorrhage. Clearly, attention must also be directed at assuring adequacy of ventilation (potential right pneumothorax), assessing and treating obvious hemorrhage, determining if there is occult intra-abdominal or thoracic hemorrhage, and determining the patient's neurologic status. While management of these other issues can occur simultaneously, they do not take priority over securing an adequate airway. In this patient the airway is so tenuous that time should not be spent obtaining a cross-table cervical spine film and chest film prior to definitive control of the airway.
Control of hemorrhage with anterior and posterior nasal packing.
Tube thoracostomy in the right hemithorax.
Endotracheal intubation with inline cervical traction.
Obtain intravenous access and begin emergency type O blood transfusions.
Trauma