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Difficulty: HardInitial Stabilization and Triage

A 42-year-old construction worker is brought to the emergency department by paramedics after falling approximately 25 feet from a scaffold. The patient is immobilized on a backboard with a rigid cervical collar in place. He is obtunded, and pooling of blood and secretions is visible in his oropharynx. Vital signs are temperature 36.2°C (97.2°F), blood pressure 72/40 mmHg, pulse 142/min, and respirations 36/min. Pulse oximetry shows 84% on a 15-L nonrebreather mask. Physical examination reveals a Glasgow Coma Scale score of 7 (E2, V2, M3). His trachea is deviated to the right. There are absent breath sounds over the left hemithorax and hyperresonance to percussion. Jugular venous distention is present. His abdomen is distended and firm. Bilateral large-bore peripheral intravenous access is immediately established by nurses. Arrange the following management steps in the most appropriate chronological order.

  1. 1Perform endotracheal intubation with in-line cervical spine stabilization
  2. 2Perform needle or finger thoracostomy on the left side
  3. 3Administer uncrossmatched type O negative packed red blood cells
  4. 4Perform a focused assessment with sonography for trauma (FAST) examination
  5. 5Transport the patient to radiology for a computed tomography (CT) scan

Answer

The correct sequence strictly follows the Advanced Trauma Life Support (ATLS) primary survey algorithm (ABCDE): secure the Airway, decompress the left chest for Breathing, administer blood products for Circulation, perform a FAST exam as an adjunct, and finally transport for CT imaging once stabilized.
In severe polytrauma, management must strictly adhere to the ABCDE algorithm. This patient presents with multiple immediate life threats. His GCS of 7 and pooled secretions mandate intubation (Airway). His rightward tracheal deviation and absent left breath sounds indicate a tension pneumothorax, requiring immediate decompression (Breathing). His profound hypotension and distended abdomen suggest hemorrhagic shock, requiring blood products (Circulation). Only after these ABCs are addressed should bedside diagnostics like the FAST exam be performed. Finally, transport for CT scanning is strictly reserved for patients who have been hemodynamically stabilized; transporting an unstable patient risks cardiac arrest outside the resuscitation bay.

Step-by-Step Solution

1
Secure the airway with endotracheal intubation.
The airway is protected from aspiration and oxygenation can be mechanically supported.
A GCS less than 8 and pooled secretions indicate airway failure, which is the most immediate threat to life (Airway).
2
Decompress the left hemithorax with a needle or finger thoracostomy.
Intrathoracic pressure decreases, allowing the mediastinum to shift back to midline and venous return to the heart to resume.
The patient has a tension pneumothorax causing obstructive shock, which must be managed immediately after securing the airway (Breathing).
3
Initiate massive transfusion with uncrossmatched blood.
Intravascular volume and oxygen-carrying capacity begin to be restored.
With the obstructive shock relieved, hemorrhagic shock from the likely intra-abdominal injury must be addressed (Circulation).
4
Perform a FAST exam.
Rapid identification of intra-abdominal hemorrhage or pericardial effusion is achieved.
This is the primary diagnostic adjunct to the ABCs to guide the necessity for emergency laparotomy.
5
Transport to the CT scanner.
Detailed anatomical evaluation of injuries is obtained.
Advanced imaging is part of the secondary survey and is contraindicated until the patient's airway, breathing, and hemodynamics are stabilized.

Key Concept

Advanced Trauma Life Support (ATLS) sequential prioritization: Airway, Breathing, Circulation, Disability, Exposure (ABCDE), followed by adjunct diagnostics and secondary survey imaging.
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Topics

Initial Stabilization and Triage

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