A 35-year-old woman is brought to the emergency department by paramedics after being struc… — USMLE Step 3

A $35$ -year-old woman is brought to the emergency department by paramedics after being struck by a speeding delivery truck while walking in a crosswalk. Upon arrival in the trauma bay, she is unresponsive to verbal commands and only groans in response to painful stimuli.

Her vital signs are:
Temperature: $36.1^\circ\text{C}$ ( $97.0^\circ\text{F}$ )
Heart rate: $138/\text{min}$
Blood pressure: $72/40 \text{ mmHg}$
Respiratory rate: $32/\text{min}$
Oxygen saturation: $84\%$ on room air

Physical examination reveals a massive, actively spurting laceration over the right anteromedial thigh. The right lower extremity is deformed. Breath sounds are present and symmetric bilaterally. The abdomen is grossly distended and tense.

Arrange the following initial management steps in the most appropriate chronological order according to advanced trauma life support protocols.

1Apply a mechanical tourniquet to the right lower extremity.
2Perform rapid sequence intubation with in-line cervical spine stabilization.
3Establish large-bore vascular access and initiate blood product transfusion.
4Perform a bedside focused assessment with sonography for trauma (FAST).
5Transfer the patient to the operating room for an exploratory laparotomy.

Answer

The correct chronological order for managing this major trauma patient is: 1) Apply a mechanical tourniquet to the right lower extremity, 2) Perform rapid sequence intubation with in-line cervical spine stabilization, 3) Establish large-bore vascular access and initiate blood product transfusion, 4) Perform a bedside focused assessment with sonography for trauma (FAST), and 5) Transfer the patient to the operating room for an exploratory laparotomy.

The <C>ABCDE algorithm dictates the sequence of trauma resuscitation. Catastrophic external hemorrhage (<C>) is controlled first with a tourniquet. Next, the Airway (A) is secured via intubation due to the patient's unresponsiveness. Circulation (C) is then supported with IV access and blood products. Following these stabilization steps, adjuncts like the FAST scan are utilized to diagnose internal bleeding, leading finally to definitive management with an exploratory laparotomy.

Step-by-Step Solution

Assess for and control massive external bleeding.

Application of a tourniquet to the right thigh.

Major arterial bleeding will rapidly cause death; the <C> (Catastrophic hemorrhage) step of ATLS must precede all other interventions.

Evaluate and secure the airway.

Rapid sequence intubation with cervical spine precautions.

The patient cannot protect her own airway (unresponsive to verbal commands) and has signs of respiratory failure, requiring definitive airway control as step 'A'.

Support circulation and restore intravascular volume.

Intravenous access and blood product transfusion.

Step 'C' involves managing hemorrhagic shock with volume resuscitation using blood products, rather than just crystalloids, in the setting of severe trauma.

Identify sources of internal hemorrhage.

Performance of a FAST examination.

Once the primary <C>ABC steps are completed, diagnostic adjuncts like FAST are used to determine the cause of the distended abdomen and ongoing shock.

Provide definitive surgical care.

Transfer to the operating room for laparotomy.

Hemodynamically unstable patients with intra-abdominal hemorrhage require immediate surgical exploration, which is the final definitive step in this triage sequence.

Key Concept

In major trauma resuscitation, the sequence follows the <C>ABCDE protocol: control of Catastrophic external hemorrhage must precede Airway, Breathing, and Circulation interventions, and definitive imaging or surgical care follows initial stabilization.

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