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Difficulty: EasyInitial Stabilization and Triage

A 35-year-old woman is brought to the emergency department by paramedics following a high-speed motor vehicle collision. On arrival, she is unresponsive to verbal or painful stimuli. Vital signs show a temperature of 36.2°C (97.2°F), blood pressure of 75/40 mmHg, heart rate of 145/min, and respiratory rate of 6/min with shallow, irregular breaths. Oxygen saturation is 81% on room air. There is no visible external bleeding. Arrange the following stabilization and diagnostic steps in the most appropriate chronological order for this patient.

  1. 1Perform endotracheal intubation with in-line cervical spine stabilization
  2. 2Establish bilateral large-bore intravenous access and administer warmed isotonic crystalloids
  3. 3Perform a Focused Assessment with Sonography for Trauma (FAST) examination
  4. 4Transport the patient to the radiology department for computed tomography (CT) imaging

Answer

The correct sequence follows standard trauma resuscitation protocols (ATLS): securing the airway first, followed by circulatory resuscitation, then primary survey adjuncts (FAST exam), and finally definitive diagnostic imaging (CT scan).
The Advanced Trauma Life Support (ATLS) algorithm dictates a strict sequence of priorities: Airway, Breathing, Circulation, Disability, and Exposure (ABCDE). In this patient, the immediate life threat is airway compromise (unresponsiveness, bradypnea, hypoxia), which must be managed with intubation (Airway). Following this, her severe hypotension and tachycardia dictate immediate intravenous fluid resuscitation (Circulation). Once the ABCs are managed, primary survey adjuncts like the FAST exam are used to locate the source of bleeding. Only after the patient is stabilized and the primary survey is complete should the patient be moved for definitive diagnostic imaging like a CT scan.

Step-by-Step Solution

1
Assess and secure the airway.
Endotracheal intubation with in-line cervical stabilization is performed.
The patient is unresponsive (GCS < 8) with a low respiratory rate and hypoxia, indicating a complete inability to protect her airway. This must be addressed before any other intervention to prevent immediate death.
2
Assess and stabilize circulation.
Large-bore intravenous access is established and crystalloids are administered.
The patient is in profound hypovolemic shock (hypotension, marked tachycardia). Immediate volume expansion is required to maintain end-organ perfusion.
3
Identify life-threatening internal hemorrhage in the resuscitation bay.
A FAST examination is performed.
Because there is no external bleeding, the source of shock must be internal. FAST is a rapid, bedside adjunct to the primary survey that can detect intraperitoneal or pericardial bleeding without delaying resuscitation.
4
Obtain definitive diagnostic imaging.
The patient is transported for a CT pan-scan.
CT imaging is part of the secondary survey. It provides definitive anatomic details but requires leaving the resuscitation bay. It should only be undertaken after the primary survey is complete and initial stabilization is underway.

Key Concept

Advanced Trauma Life Support (ATLS) primary and secondary survey sequencing
Estimated Time:1m 0s
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Topics

Initial Stabilization and Triage

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