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Difficulty: HardTrauma and Burns

A 45-year-old man is brought to the emergency department after being ejected from a vehicle during a high-speed rollover collision. On arrival, he is unresponsive. His blood pressure is 65/40 mm Hg, heart rate is 142/min, and respiratory rate is 8/min. Examination reveals active, pulsatile arterial bleeding from a severe crush injury to the right thigh. The patient has snoring respirations and significant maxillofacial trauma. Breath sounds are markedly decreased over the left hemithorax, and the trachea is deviated to the right. The pelvis is mechanically unstable on physical examination. Arrange the following steps in the most appropriate chronological sequence of management according to current Advanced Trauma Life Support (ATLS) principles.

  1. 1Apply a commercial tourniquet to the right thigh
  2. 2Secure the airway with endotracheal intubation while maintaining cervical spine stabilization
  3. 3Perform a left-sided needle or finger thoracostomy
  4. 4Apply a pelvic binder and administer uncrossmatched blood products
  5. 5Assess the Glasgow Coma Scale score and pupillary light reflexes

Answer

The correct sequence follows the ATLS algorithm: apply a tourniquet (Catastrophic hemorrhage), secure the airway with endotracheal intubation (Airway), perform a thoracostomy (Breathing), apply a pelvic binder and administer blood (Circulation), and assess the Glasgow Coma Scale score (Disability).
Current Advanced Trauma Life Support (ATLS) guidelines emphasize the <C>ABCDE algorithm for the primary survey. <C> stands for Catastrophic hemorrhage control, which is the absolute first priority and is addressed by applying a tourniquet to the pulsatile thigh injury. Next is A (Airway with cervical spine protection), addressed via intubation for this unresponsive patient. B (Breathing) follows, managed by thoracostomy for the suspected tension pneumothorax. C (Circulation) involves pelvic binding and transfusion for hemorrhagic shock. Finally, D (Disability) involves assessing the GCS and pupillary reflexes.

Step-by-Step Solution

1
Identify the most immediate threat to life.
The patient has active, pulsatile arterial bleeding from a crush injury to the thigh.
Catastrophic hemorrhage (<C>) causes exsanguination within minutes and supersedes airway management in the initial trauma survey.
2
Assess and secure the airway with cervical spine precautions.
The patient is unresponsive with snoring respirations and facial trauma, requiring endotracheal intubation.
Airway (A) obstruction is the next most rapid cause of preventable death in trauma patients.
3
Evaluate breathing and ventilation.
Decreased breath sounds and tracheal deviation indicate a tension pneumothorax, necessitating a decompression thoracostomy.
Breathing (B) compromise must be rapidly identified and relieved after the airway is secured.
4
Assess circulation and treat hemorrhagic shock.
Profound hypotension and an unstable pelvis indicate massive internal bleeding, requiring a pelvic binder and blood products.
Circulation (C) must be supported with definitive mechanical hemorrhage control and volume resuscitation.
5
Perform a focused neurologic evaluation.
The patient requires a formal Glasgow Coma Scale and pupillary assessment.
Disability (D) is formally assessed only after establishing adequate oxygen delivery to the brain to prevent secondary brain injury.

Key Concept

The Advanced Trauma Life Support (ATLS) primary survey follows the <C>ABCDE sequence: Catastrophic hemorrhage control, Airway, Breathing, Circulation, Disability, and Exposure.
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Topics

Trauma and Burns

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