Care of patients in accident cars

[Timothy J Coats (SURG) 7728]

> If you use the Glasgow coma scale for level of
> consciousness remember "Less than 8 you must intubate" this applies to
> any situation or patient position. ..........
> 
> Stacey H.
> NREMT-P
> EMS Instructor 
> 
There are many patients with a GCS of more than 8 who require 
intubation, and some with a GCS of less than 8 who may not. There 
is a big danger of having oversimplified rules (even if they rhyme!). A 
low GCS may have a number of causes, the correction of which 
may not require intubation.

Even in head injury, pattern of change is much more important than 
a single reading. A patient with a GCS of 7 on a rapidly rising trend 
may not need intubation. A patient of GCS 13 that was 15 a few 
minutes ago may need intubation.

So, when to intubate in the trapped patient depends on a large 
number of factors. The following are required: a knowledge of the 
advantages and disadvantages of various treatment options, a 
knowledge of the pathophysiology of the underlying injuries, a 
knowledge of extrication techniques,  and a critical self assessment 
of a practitioner's own experience and ability.

Simple rules will not do. The best course of action may also depend 
on the rest of the trauma system and resources available. You will 
probably have a very different answer for a patient treated in the 
French system compared with the America.

To intubate in a car or not? Sorry, but there is not a simple answer 
other than a definite maybe.

Tim.

PS. Re: Firestone. Can I suggest that when someone puts up a 
post that is totally off the subject of the list we just don't reply? This 
list is large. The volume of email can be large. I know several people 
who would be great contributors but have left due to the volume of 
uninteresting posts. Replying to subjects other than trauma 
management decreases the quality of the list and will loose more 
good contributors.

Timothy J Coats MD FRCS FFAEM
Senior Lecturer in Accident and Emergency / Pre-Hospital Care
Royal London Hospital, UK.