SU17.1-10 | Trauma — Assignment

CLINICAL SCENARIO

It is a busy evening when a 24-year-old motorcyclist is brought to your district hospital emergency department after a high-speed collision with a car. He was not wearing a helmet. Bystanders report he was talking and walking at the scene but became progressively drowsy during transport. On arrival he is breathing rapidly, has bruising over the left chest, and a deep contaminated laceration over his right forearm sustained when he skidded across the road. He smells of alcohol and his tetanus status is unknown. Minutes later, the radio announces that a bus carrying 30 passengers has overturned nearby and casualties are en route — your department has two doctors and four nurses on duty.

1. Primary survey of the motorcyclist (ABCDE)

Describe how you would conduct the ATLS primary survey on this patient, stating what you assess and what immediately life-threatening problems you actively look for at each of A, B, C, D and E. Specify how you would protect the cervical spine and what you would do if you found absent breath sounds with a hyper-resonant, shocked chest.

Guidance: Structure your answer A–B–C–D–E. Name the life-threatening chest injuries (tension pneumothorax, massive haemothorax, flail chest, open pneumothorax, cardiac tamponade) and the bedside action for each. State the immediate management of a tension pneumothorax (needle decompression, then intercostal chest drain) and the threshold for thoracotomy in haemothorax (>1500 mL).

2. Neurological assessment and the deteriorating head injury

The patient was lucid at the scene but is now drowsy. Calculate and explain a GCS for a worked example (eyes to voice, confused speech, localising to pain). Explain the significance of a lucid interval, an enlarging pupil and a rising blood pressure with a falling pulse, and state your investigation and management priorities.

Guidance: Show the GCS components and arithmetic. Name the likely diagnosis (expanding extradural haematoma), explain Cushing's response and raised ICP, and state that an urgent non-contrast CT head and neurosurgical referral are required after resuscitation. Emphasise prevention of secondary brain injury (avoid hypoxia and hypotension).

3. Management of the contaminated forearm wound

Classify the forearm wound, describe how you would assess the structures deep to it, and set out your management plan including the decision on wound closure, tetanus prophylaxis and antibiotics.

Guidance: State why a contaminated wound must not be closed primarily (anaerobic pocket, tetanus risk) and describe cleaning, debridement and delayed primary closure. Address tetanus status explicitly and indications for antibiotics. Mention examining for nerve, tendon and vascular injury distal to the wound.

4. Switching to mass-casualty mode

With the bus casualties arriving, explain how your priorities and approach change. Describe the principle that now governs care, the role of command and zoning, and apply the START triage algorithm to three brief examples of your own (one RED, one YELLOW, one GREEN), justifying each category.

Guidance: State the shift from 'everything for one patient' to 'the greatest good for the greatest number'. Outline command, zones, and that only seconds-long life-saving acts are done during triage. Apply START thresholds (walking = GREEN; RR >30 or absent radial pulse or not obeying commands = RED) and justify each of your three worked examples.