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Difficulty: HardTrauma and Burns

A 35-year-old male construction worker is brought to the emergency department after falling 20 feet (6 meters) from a scaffold. He is secured to a backboard with a rigid cervical collar in place. He is obtunded, opens his eyes only to painful stimuli, and makes incomprehensible sounds. Vital signs are temperature 36.5°C (97.7°F), blood pressure 75/45 mm Hg, pulse 135/min, and respirations 28/min. Pulse oximetry shows 88% on high-flow oxygen. Physical examination reveals copious blood in the oropharynx with audible gurgling. There are absent breath sounds and dullness to percussion over the right hemithorax. The abdomen is grossly distended and rigid. Arrange the following management steps in the most appropriate sequential order according to the Advanced Trauma Life Support (ATLS) protocol.

  1. 1Suction the oropharynx and perform endotracheal intubation
  2. 2Perform a right-sided tube thoracostomy
  3. 3Establish large-bore intravenous access and initiate blood product transfusion
  4. 4Perform a bedside focused assessment with sonography for trauma (FAST)
  5. 5Transfer the patient to the operating room for an exploratory laparotomy

Answer

The correct sequence follows the ATLS primary survey (ABCDE): Airway management (intubation), Breathing (tube thoracostomy), Circulation (blood products), Adjunct evaluation (FAST), and finally Definitive care (laparotomy).
The Advanced Trauma Life Support (ATLS) protocol mandates a strict primary survey sequence: Airway, Breathing, Circulation, Disability, and Exposure. This algorithm ensures that the most imminent threats to life are identified and treated first. In this patient, the obstructed airway (gurgling, GCS 8) must be secured first. Next, the breathing compromise from a hemothorax must be treated with a chest tube. Only then is circulation addressed with blood products. Following stabilization of the ABCs, a FAST exam is used as an adjunct to identify the source of abdominal shock, culminating in definitive surgical management via laparotomy.

Step-by-Step Solution

1
Assess and secure the airway.
The patient undergoes oropharyngeal suctioning and endotracheal intubation.
Airway compromise (gurgling, blood, GCS 8) is the most immediate threat to life and must be addressed first.
2
Assess breathing and ventilation.
A right-sided tube thoracostomy is placed.
The patient has absent breath sounds and dullness to percussion, indicating a massive hemothorax that must be drained to allow lung expansion.
3
Assess and manage circulation.
Intravenous access is obtained and uncrossmatched blood products are administered.
The patient is in hemorrhagic shock (hypotension, tachycardia) and requires immediate volume resuscitation following airway and breathing stabilization.
4
Perform diagnostic adjuncts.
A bedside FAST examination is performed.
With the ABCs addressed, an ultrasound is used to rapidly identify the source of intra-abdominal hemorrhage causing the rigid, distended abdomen.
5
Provide definitive care.
The patient is transferred to the operating room.
An unstable trauma patient with a surgical abdomen requires emergent exploratory laparotomy to definitively control the bleeding.

Key Concept

Advanced Trauma Life Support (ATLS) primary survey sequence prioritizing Airway, Breathing, and Circulation before diagnostic adjuncts and definitive surgical care.
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Topics

Trauma and Burns

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