The Value of Intubating and Paralyzing Patients with Suspected Head Injury in the
Emergency Department.
Inability to secure an airway delays resuscitation and diagnosis in agitated, combative trauma
patients with suspected head injuries. Of 100 consecutive patients intubated with either vecuronium
or succinylcholine, 59% had a positive CT scan. Only 2 patients had lateral cervical spine films
before intubation and 7 patients were found to have cervical fractures. Cricothyroidotomy was
required in 3 patients with facial fractures. Following IV administration of the paralytic agent,
cricoid pressure was applied and the patients pre-oxygenated. A three-person technique was used
with one to intubate, one to stabilize the cervical spine, and one to apply cricoid pressure and suction
the airway. All patients intubated with succinylcholine (1.5 mg/kg IV) received vecuronium (0.15
-0.3 mg/kg) to maintain paralysis. Heart rate and arterial oxygen saturation were monitored continu
ously. The authors advocate taking combative patients with severe facial trauma who are not hypoxic
to the OR for intubation, as the 3 patients who required cricothyroidotomy had arterial desaturation.
Neither neurologic exam or GCS could distinguish patients who suffered intracranial injury from
those who did not. Early CT scan was vital to detect and treat intracranial lesions soon after injury.
Fifteen patients required emergent neurosurgical procedures. Seizure activity should be recognized
and treated before paralysis, as these patients can go on to unrecognized status epilepticus. J. Trauma
31:371 March 91.