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SU17.1-10 | Trauma — PBL Case

CLINICAL SETTING

A 47-year-old construction-site supervisor, Mr R, is brought to a peripheral hospital after a heavy steel beam swung loose and struck him across the chest and right side of the head. His colleagues placed him on the back of a pickup truck and drove him in. On arrival he is restless, breathing fast and shallow, and clutching the right side of his chest. There is a graze over his right temple. You are the surgical team on call. This is a single complex trauma patient — but the local police warn that the same site has had a scaffold collapse and more injured workers may follow.

Trigger 1: The first minutes — primary survey and a deteriorating chest

On primary survey Mr R is maintaining his own airway but is in marked respiratory distress. The right side of the chest is barely moving and is hyper-resonant to percussion with absent breath sounds; his neck veins are distended and his trachea is deviated to the left. His radial pulse is thready and fast, and his blood pressure is falling. No chest X-ray has been done yet.

DISCUSSION POINTS

  • Walk through the ATLS primary survey (ABCDE). At which step does this patient declare himself, and why?
  • What is the diagnosis from these clinical signs alone, and why must you NOT wait for a chest X-ray?
  • What is the immediate life-saving intervention, and what definitive procedure follows it?
  • How does cervical-spine protection fit into your airway management given the head strike?
Click to reveal Trigger 2: The head injury and the falling conscious level (discuss previous trigger first!)

Trigger 2: The head injury and the falling conscious level

After decompression Mr R's breathing improves and his blood pressure recovers. Over the next 45 minutes, however, he becomes increasingly drowsy. His right pupil is now larger than the left and sluggish to react; his blood pressure is climbing while his pulse slows. You recall that he was reportedly talking to his colleagues immediately after the beam struck him.

DISCUSSION POINTS

  • Score a GCS for a patient who opens eyes to speech, is confused, and localises to pain — and explain what each component means.
  • What is the significance of the 'lucid interval' followed by deterioration, the unequal pupil, and the rising-BP/falling-pulse pattern?
  • What is the most likely intracranial pathology and which artery is classically involved?
  • What investigation and definitive management does he now need, and how do you prevent secondary brain injury in the meantime?
Click to reveal Trigger 3: The scaffold collapse — many casualties, few hands (discuss previous trigger first!)

Trigger 3: The scaffold collapse — many casualties, few hands

As Mr R is stabilised and referred for neurosurgery, six more injured workers arrive together from the scaffold collapse. You now have two doctors, three nurses and limited equipment. One man walks in holding a bleeding scalp wound and shouting in pain; another lies silent and is not breathing until you tilt his head; a third has a respiratory rate of 38 and cannot follow commands.

DISCUSSION POINTS

  • How does your overall aim change when casualties overwhelm your resources, and what single principle now governs your decisions?
  • Apply START triage to each of the three described casualties and justify the colour category you assign to each.
  • What organisational structures (command, zones) make a disaster response effective, and what interventions are permitted during triage itself?
  • Why are the loudest, walking casualties usually the lowest priority, and which casualties demand your immediate attention?

Group Task Assignments

  • Produce a one-page ABCDE primary-survey aide-memoire that lists each immediately life-threatening chest injury alongside its single bedside management step.
  • Build a GCS scoring card with worked examples and a flowchart for the deteriorating head injury, ending in 'urgent CT + neurosurgical referral'.
  • Draft a START triage poster with the decision thresholds and colour categories, and rehearse triaging ten hypothetical casualties as a group.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU17.9] What are the five immediately life-threatening chest injuries identified in the ATLS primary survey, and what is the bedside management of each?
  2. [SU17.10] How do the clinical features and emergency management of tension pneumothorax, massive haemothorax and flail chest differ from one another?
  3. [SU17.5] How is the Glasgow Coma Scale scored, and what GCS and clinical signs indicate raised intracranial pressure and the need for urgent neurosurgery?
  4. [SU17.3] How does the START triage algorithm sort casualties, and what principle governs care when resources are overwhelmed?