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Difficulty: MediumTrauma and Burns

A 45-year-old man is brought to the emergency department via ambulance following a high-speed motor vehicle collision. On arrival, he is unresponsive with a Glasgow Coma Scale score of 6. His respiratory rate is 8/min and shallow. His blood pressure is 85/50 mm Hg and heart rate is 135/min. Examination reveals an open, severely deformed right lower extremity with pulsatile arterial bleeding. According to current Advanced Trauma Life Support (ATLS) protocols, arrange the following management steps in the correct chronological sequence from first to last.

  1. 1Apply a tourniquet to the right lower extremity
  2. 2Secure the airway with endotracheal intubation
  3. 3Establish large-bore intravenous access
  4. 4Perform a Focused Assessment with Sonography for Trauma (FAST) exam
  5. 5Transfer the patient for computed tomography (CT) imaging

Answer

The correct chronological sequence is: 1. Apply a tourniquet to the right lower extremity, 2. Secure the airway with endotracheal intubation, 3. Establish large-bore intravenous access, 4. Perform a Focused Assessment with Sonography for Trauma (FAST) exam, 5. Transfer the patient for computed tomography (CT) imaging.
The correct sequence follows the standard ATLS <C>ABCDE protocol: Catastrophic hemorrhage control, Airway, Breathing, Circulation, Disability, Exposure, followed by primary survey adjuncts, and finally the secondary survey/definitive imaging.

Step-by-Step Solution

1
Identify the immediate life-threatening injury that supersedes airway management.
The patient has pulsatile arterial bleeding from a deformed right lower extremity.
According to the updated ATLS 10th edition, catastrophic hemorrhage (<C>) must be controlled before Airway (A) management because exsanguination occurs more rapidly than death from hypoxia.
2
Determine the next priority in the primary survey (<C>ABCDE).
The patient has a GCS of 6 and a shallow respiratory rate of 8/min.
Airway (A) is the next priority. A GCS less than 8 necessitates definitive airway management with endotracheal intubation, along with cervical spine protection.
3
Identify the subsequent step in the primary survey.
The patient is hypotensive (BP 85/50 mm Hg) and tachycardic (HR 135/min).
Circulation (C) follows Airway and Breathing. Large-bore intravenous access must be established to initiate fluid and blood product resuscitation for hypovolemic shock.
4
Determine the role of diagnostic adjuncts in the initial evaluation.
The FAST exam is performed at the bedside.
FAST is an adjunct to the primary survey. It is used to rapidly identify the source of internal bleeding (e.g., intra-abdominal) without removing the unstable patient from the resuscitation area.
5
Determine the appropriate timing for definitive imaging.
The CT scan of the head and cervical spine is ordered.
CT imaging is part of the secondary survey. It requires leaving the trauma bay and should only be performed once the primary survey is complete and the patient's airway and hemodynamics are stabilized.

Key Concept

Advanced Trauma Life Support (ATLS) Primary Survey Sequence (<C>ABCDE)
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Topics

Trauma and Burns

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