A 50 year old man is brought into the Emergency Department after acute flexion injury to the neck while surfing. He is unable to move both arms or legs and has a sensory level at C4·5. He ls a heavy smoker with a history of chronic bronchitis.
(b) His breathing is laboured with a rate of 40 and with a paradoxical movement What will you do?
Paradoxical movement in this setting suggests paralysed intercostals and residual diaphragm function. This produces at least 30% loss of FVC and will mean a poor cough in a supine patient. If he is struggling to breathe, he has no hope of effectively coughing. If the candidate had intubated the patient in (a) that was OK. The waverers should put the tube in and explain their technique in detail. There is limited place for non-invasive ventilation in this setting.
As the college points out, paradoxical movement here demonstrates that only the diaphragm is moving the lungs. This is bad.
Thus: the patient needs to be intubated.