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.

Describe your initial management.

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College Answer

Initial management of trauma should be according to standard protocol.
Initial primary survey and resuscitation should address adequacy of airway (patency, need for ETT)
and breathing (eg. excluding tension pneumothorax and major haemo-thorax).
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, cross-match 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/DPL/abdominal CT if able to be kept haemo-dynamically stable. Consideration of angiography if stability maintained and expertise available.
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 haemo-dynamic state is adequately dealt with. 

Discussion

This patient has four major issues:

  • Potential high spinal injury
  • Lower left chest injuries
  • Features of shock, which may be haemorrhagic or spinal
  • A painful distending abdomen, which may be due to solid organ trauma.

A systematic approach to this answer would follow the normal ATLS pattern of the primary survey.

A) - Urgent assessment of the airway, and of the need for immediate intubation (with in-line spinal stabilisation). A very high spinal cord injury may have resulted in respiratory arrest.

B) - Evaluation of respiratory function and chest injuries. This patient can potentially have a tension or non-tension pneumothorax or haemothorax on the left side, and this diagnosis needs to be made early in the primary survey. High FiO2 should be administered. One should look for paradoxical respiration pattern due to flail chest, or diaphragmatic breathing due to high spinal cord injury.

C)

The major differentials for this shock state include the following:

  • Left haemothorax
  • Abdominal haematoma due to splenic injury
  • Cardiac tamponade
  • High spinal cord section

Features of hypovolemia (eg. cool peripheries, pallor) should be sought. In any case, volume replacement is indicated in each of the abovementioned differentials. Blood should be sampled for crossmatch, and uncrossmatched blood should be transfused if the patient is demonstrating features of anaemia. Large-bore IV access should be established.

Blood products should be preferentially used for resuscitation, with a 1:1:1 ratio of PRBCs, FFP and platelets. The MAP target for fluid resuscitation should be a MAP >50mmHg.

D) The level of consciousness should be assessed. Features of spinal cord injury should be pursued on examination

E) The patient needs to be rewarmed (presuming they are hypothermic) and a blood warmer should be connected to maintain normothermia in spite of massive resuscitation

After the completion of the primary survery, the following investigations must urgently take place:

  • CXR
  • Pelvic XR
  • FAST US of the abdomen chest and praecordium can rapidly differentiate between the abovementioned causes of shock.
  • CT trauma series, if available

This pathway of investigation should be abandoned and urgent damage control surgery should take place if any of the above assessment methods make it abundantly clear that a catastrophic intraabdominal source of bleeding is responsible for the shock state.

References

References

ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma