Coworkers rush a -year-old butcher into the trauma bay following an occupational accident. While cutting meat, he accidentally struck his right forearm with a large cleaver. On arrival, the patient is lethargic, extremely pale, and diaphoretic. Bright red blood is actively spurting from a deep laceration on the volar aspect of his forearm, soaking rapidly through the towel wrapped around his arm.
Vital signs are:
Temperature: ()
Blood pressure: mm Hg
Heart rate: /min
Respiratory rate: /min
Oxygen saturation: on room air
Which of the following is the single most urgent initial step in the stabilization of this patient?
- Placement of a mechanical tourniquet proximal to the lacerationAnswer
- BDelivery of warm isotonic crystalloid fluids via two large-bore intravenous lines
- CObtaining a computed tomography angiography of the right upper limb
- DSecuring the airway with a definitive advanced airway device
- EArranging for immediate operative repair by the surgical team
Answer
Placement of a mechanical tourniquet proximal to the laceration
The correct answer emphasizes that in the setting of catastrophic, exsanguinating extremity hemorrhage, the most critical initial step in trauma resuscitation is stopping the bleeding. This adheres to the <C>ABCDE protocol, where <C> stands for catastrophic hemorrhage control. A mechanical tourniquet is the most rapid and reliable method to achieve temporary hemorrhage control for a massive arterial limb bleed, allowing the provider to then safely address the airway and initiate volume resuscitation.
Step-by-Step Solution
Key Concept
In the initial stabilization of trauma patients, catastrophic and exsanguinating hemorrhage must be controlled immediately (using a tourniquet for extremities) prior to or concurrently with airway and volume resuscitation.