A patient is admitted following a road traffic accident. He has sustained significant blunt injury to his head, chest and abdomen and has a Glasgow Coma Scale score of 8/15. His saturations are poor at 89% on 15 L of oxygen a rebreathing mask. You note bruising around both eyes and blood-stained fluid issuing from his left ear, which forms concentric circles when dripped on a white sheet. You wish to suppo his airway to improve oxygenation. The first choice of airway adjunct would be
This patient has sustained a significant head injury which complicates your choice of airway. -A patient with a GCS score of 8 may still gag on the Guedel airway, although with a patient thus obtunded, it is possible it will be tolerated without sedation. An endotracheal tube may well be required later in the resuscitation because this patient has a severe head injury; however, endotracheal intubation requires an anaesthetist and significant time. Guedel airway placement should still be considered the first choice adjunct as it is quick, allowing fur-ther assessment of the patient to continue, and it acts as a bridge to intubation. -Any suspicion of a basal skull fracture is an absolute contraindication to nasopharyngeal airway and nasogastric tube inseion. This is because of the risk of penetrating through the damaged cribriform plate and damaging the brain. Basal skull fracture include: periorbitalecchy-mosis (panda eyes/raccoon eyes), retroauricular ecchymosis (battle sign), CSF leakage from the nose or ears VII/VIII cranial nerve dysfunction. The internal carotid aery may also be injured resulting in dissection or pseudoaneurysm. -CSF leakage can be differentiated from blood by dripping the fluid on a white sheet; CSF will form concentric circles whereas blood will simply make a spot With nasopharyngeal tube placement contraindicated, the first option in this patient would be Guedel oropharyngeal airway place-ment.
Oropharyngeal airway
Nasopharyngeal tube
Laryngeal mask
Intubation
Trauma