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A 28-year-old man arrives 40 minutes after a high-speed RTC. He is confused and pale. BP 80/50, pulse 130, RR 32, SpO2 94% on 15 L O2. Seatbelt mark across the abdomen. Breath sounds equal; pelvis appears clinically stable. eFAST shows free intraperitoneal fluid. No external haemorrhage.
Questions
a) Structure the primary survey actions and the key disposition decision. (4 marks)
A: airway with C-spine protection; talk/inspect/suction/adjuncts; prepare for definitive airway if GCS falls or course demands.
B: oxygen, expose chest, exclude tension pneumothorax/massive haemothorax clinically.
C: two large-bore IV/IO, bloods including VBG/lactate/crossmatch, activate MTP, control any external bleed, pelvic binder if mechanism/exam warrants.
D/E: GCS/pupils/glucose; full exposure; prevent hypothermia.
Disposition: haemodynamically unstable + positive eFAST → emergency laparotomy / damage-control surgery. Do not send to CT.
b) Prescribe tranexamic acid and state the evidence time window. (3 marks)
Tranexamic acid 1 g IV over 10 minutes, then 1 g IV infusion over 8 hours, if within 3 hours of injury (CRASH-2). Benefit is time-critical; late administration loses efficacy and may harm.
c) Approximate ATLS class of shock and blood-product philosophy. (4 marks)
BP fall with marked tachycardia and confusion fits class III haemorrhagic shock (~30–40% blood volume loss).
Use damage-control resuscitation: early balanced blood products approaching 1:1:1 RBC:plasma:platelets, limit large crystalloid volumes, correct hypocalcaemia, warm the patient, reverse anticoagulants if relevant, and achieve surgical/IR haemorrhage control.
d) Define the lethal triad and one countermeasure for each component. (4 marks)
Hypothermia — acidosis — coagulopathy.
Warming/warm products; restore perfusion and avoid excessive saline/hyperchloraemic worsening; balanced MTP + haemorrhage control + calcium. Damage-control laparotomy packs/controls contamination quickly, temporary closure, ICU rewarming/correction, planned relook.
Additional teaching points (mark-scoring phrases)
ATMIST handover skeleton: Age, Time of injury, Mechanism, Injuries found, Signs (vitals), Treatment given.
eFAST windows (name four): perihepatic (Morison), perisplenic, pelvic, pericardial (± pleural views). Limitation: cannot exclude hollow-viscus injury or retroperitoneal bleed.
Pelvic binder: applied at the level of the greater trochanters, not iliac crests; do not repeatedly “spring” an unstable pelvis.
Hard signs of vascular injury (limb): active haemorrhage, expanding haematoma, bruit/thrill, absent distal pulses, distal ischaemia — go to theatre/IR, not prolonged observation.
When CT is allowed: only after primary survey complete and haemodynamic stability (responders); unstable non-responders go to theatre/IR suite pathways.