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Difficulty: MediumInitial Stabilization and Triage

A 31-year-old man is brought to the trauma bay by helicopter emergency medical services following a motorcycle crash. He was thrown approximately 30 feet into a ditch. On arrival, he is confused, agitated, and diaphoretic. His airway is intact, and breath sounds are present and equal bilaterally. Vital signs show a temperature of 36.2°C (97.2°F), heart rate of 148/min, blood pressure of 68/38 mm Hg, respiratory rate of 28/min, and oxygen saturation of 95% on 15 L/min of oxygen via a non-rebreather mask. Physical examination reveals extensive ecchymosis over the lower abdomen and perineum, a mechanically unstable pelvis to lateral compression, and a visibly deformed right thigh. Two 16-gauge peripheral intravenous catheters are rapidly established. Which of the following interventions should be ordered simultaneously as the immediate next steps in the patient's stabilization? (Select 3)

  1. Activate the massive transfusion protocol to administer uncrossmatched blood productsAnswer
  2. Apply a noninvasive circumferential pelvic compression deviceAnswer
  3. Administer intravenous tranexamic acidAnswer
  4. D
    Transport the patient for an urgent whole-body computed tomography scan
  5. E
    Establish a definitive airway via rapid sequence intubation
  6. F
    Transfer the patient to the intensive care unit for central venous catheter placement

Answer

The correct simultaneous interventions are to activate the massive transfusion protocol, apply a circumferential pelvic compression device, and administer intravenous tranexamic acid.
The patient is presenting with class IV hemorrhagic shock due to polytrauma, complicated by a suspected open-book pelvic fracture. Immediate survival depends on rapid intravascular volume expansion using balanced blood products (massive transfusion protocol) to prevent trauma-induced coagulopathy. Concurrently, applying a pelvic binder decreases pelvic volume to tamponade venous retroperitoneal bleeding, and administering tranexamic acid limits fibrinolysis. These three steps represent the gold standard for simultaneous initial resuscitation in severe traumatic shock.

Step-by-Step Solution

1
Assess the patient's airway, breathing, and circulation (ABCs).
The airway is intact and breathing is adequate (SpO2 95%), but the patient has class IV hemorrhagic shock (HR 148/min, BP 68/38 mm Hg, confusion) driven by massive blood loss.
Prioritizing ABCs identifies the most immediate life-threatening physiological derangement, which is circulatory collapse.
2
Identify the likely sources of hemorrhage based on the physical examination.
The mechanically unstable pelvis and deformed thigh point to massive retroperitoneal and extremity bleeding.
Recognizing the source guides specific stabilization interventions beyond general fluid administration.
3
Select interventions that simultaneously treat hypovolemia, prevent coagulopathy, and control the anatomical source of bleeding.
Uncrossmatched blood products replace volume and clotting factors, tranexamic acid prevents clot breakdown, and a pelvic binder provides mechanical tamponade.
Modern trauma resuscitation requires a multimodal approach to halt the lethal triad of coagulopathy, hypothermia, and acidosis.

Key Concept

In severe polytrauma with hemorrhagic shock, initial stabilization prioritizes hemostatic resuscitation (blood products, tranexamic acid) and mechanical hemorrhage control (pelvic binding) over definitive imaging or isolated orthopedic repairs.
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Topics

Initial Stabilization and Triage

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