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Emergency Medicine

Answer 1
  1. Secure the patient’s airway. Gaining control of the airway is always the first priority in trauma management and should not be delayed to obtain radiologic studies or even to perform a brief neurological assessment. Early intubation is crucial for this patient with a severe head injury to protect her airway because of a reduced level of consciousness and loss of pharyngeal muscle tone. Intubation is also essential for providing a reliable route for supplying high oxygen concentrations to limit secondary brain injury and to hyperventilate the patient when necessary to lower elevated partial pressures of carbon dioxide.1 The patient’s hypertension is a physiologic response to brain injury and raised intracranial pressure (Cushing’s reflex). Normal findings on lateral radiography of the cervical spine do not rule out an unstable cervical spine injury and therefore should not delay intubation. Although this patient undoubtedly requires a computed tomographic (CT) scan of her brain, her airway must be protected and secondary brain injury minimized before progressing to CT scanning.2

     Chestnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-22.

    2. Hill DA, Abraham KJ, West RH. Factors affecting outcome in the resuscitation of severely injured patients. Aust NZ J Surg 1993;63:604-9.

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