Airway and cervical spine

Airway

His airway is at risk: He is unconscious and tolerating a Guedel airway.

Intubation provides a definitive airway and prevents aspiration.

Cervical spine

He should be immobilised using a collar, sand bags and tape until it is cleared clinically or radiologically (including CT scan). This may not be possible. Using only a collar may be a necessary compromise in uncooperative patients or those with breathing problems.

Breathing

He is tachypnoeic (RR 28/min) and requires high-flow oxygen via a non-rebreathing mask with reservoir bag. Possible causes include pneumothorax, haemothorax, lung contusions, flail chest, aspiration and infection.

Diagnosis by clinical examination (and portable chest X-ray if available) is important as a chest drain may be required. A simple pneumothorax can become a tension pneumothorax if positive pressure ventilation is started before a chest drain is inserted.

Circulation

He is slightly hypertensive (145/90). This may be due to respiratory distress or pain, and does not exclude hypovolaemia.

Disability

Conscious level is reduced. This may be due to head injury or sedatives. If available, a CT scan should be done only after intubation and stabilisation.