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Introduction
A patient with severe facial injuries and airway compromise is presented (see figure 1 ). Patients with this type of injury are uncommon and often have related head injuries. Prehospital airway management is considered to be difficult 1 and serious facial injuries are an obvious challenge to airway management. 2 Some patients require immediate rapid tracheal intubation, with the use of drugs, to prevent hypoxaemia and airway contamination. Facial and airway swelling soon after burns are well recognised; a similar situation may occur after serious facial injury.
Case notes
A 38-year-old previously healthy male cyclist collided with a van at the bottom of a hill. The cyclist was wearing a safety helmet. Bystanders kept the patient on his side and supported his head and neck in a neutral position.
When the ambulance arrived, the patient was semiconscious (Glasgow Coma Score (GCS)=11) with bleeding facial injuries. The ambulance crew applied manual inline cervical stabilisation, gave oxygen and kept the patient lying on his side to allow postural drainage of blood.
The patient was in this position 17 min after the incident when the HEMS doctor-paramedic team arrived. Rapid assessment showed severe facial injuries, soft tissue loss and multiple fractures. There was also a de-gloving injury of the right forearm and a compound fracture of the left elbow. GCS was 11 (E2V4M5), and apparent cerebral irritation led to intolerance of the oxygen mask. Initial blood pressure was 138/74 mm Hg, heart rate...