A  24-year-old   male   mountain  bike   rider  crashes   into   a   tree,  resulting  in   a   severe hyperextension neck injury, and  fractured lower left ribs. He now presents to hospital  with shock and a painful distending  abdomen.

a) Describe your initial management.

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College Answer

a) Describe your initial management.

Initial management of trauma should be according to standard protocol.  Initial primary survey and resuscitation would address adequacy of airway (patency, need for ETT) and breathing (eg. excluding tension pneumothorax and major haemothorax). At the review of “circulation” phase, the presence of shock with obvious abdominal signs means urgent surgery is required (with simultaneous insertion of 2 wide bore IVs if not already present, removal of blood for Hb/platelets, crossmatch and clotting profile, rapid infusion of 2 litres of fluid [blood if significant previous non- blood resuscitation].  In the time until surgery is organised, it may be possible to perform a supine CXR, pelvic X-ray and/or a FAST (ultrasound) examination.   He must be treated with spinal precautions (including for intubation) as it must be assumed that there is an unstable cervical spine, with possible thoraco-lumbar spine injuries.  Attempts should be made to maintain his temperature stable (eg. >35-36°C).  Full secondary survey and specific investigations must be deferred until the haemodynamic state is adequately dealt with.

Discussion

This question is identical to Question 12 from the second paper of 2005.