All polytrauma patients and trauma patients with high-energy injuries should be assessed according to advanced trauma life support (ATLS) principles. You may be asked to describe a detailed ATLS assessment of a patient prior to moving onto a specific orthopaedic or extremity injury. It is absolutely essential that you are confident with this routine system for assessment.

You are called to the emergency department as part of the trauma team to see a patient who was involved in a high-speed RTA. He was the restrained driver in a head-on collision with a tree. He was immobilised at the scene and taken straight to the emergency department. He is talking, but confused, tachycardic and hypotensive.

         1. How would you manage this injury?

 I would manage this injury in the emergency department according to ATLS principles with concurrent assessment and resuscitation undertaken by the whole trauma team. I would start by assessing the airway with cervical spine control. The cervical spine must be immobilised with all three of a hard collar, sandbags and tape. If the patient is talking, he has a patent airway; if not, it must be formally assessed with the look/listen/feel approach. This is done by looking in the mouth for foreign bodies or trauma, attempting suction if appropriate, listening for abnormal breath sounds such as stridor or hoarseness of the voice and feeling for breath on your cheek as you look for chest wall movements.

  Moving onto breathing and ventilation, I would administer high-flow oxygen using a non-rebreathe mask as other members of the team are attaching monitoring at this stage to determine pulse from a three-lead ECG, blood pressure, oxygen saturations, respiratory rate and temperature. An inspection/palpation/percussion/ auscultation approach is taken, looking for any obvious chest injuries such as open wounds or flail segments. One would also look for respiratory distress and symmetrical chest wall movement. I would look for symmetrical chest wall movement and any evidence of respiratory distress. I would palpate to assess for the central position of the trachea and any subcutaneous emphysema. I would percussion and auscultate to confirm good bilateral air entry and to identify an obvious pneumothorax or haemothorax.

  Moving on to circulation with haemorrhage control, I would gain IV access with two large-bore cannulae into the antecubital fossas, taking blood for FBC, U&Es, LFTs, glucose, lactate, coagulation and cross-match for at least four units of bloods. I would then commence appropriate resuscitation as per my hospital’s major haemorrhage protocol* before moving on to look for any obvious source of bleeding in the chest, abdomen, pelvis, long bones or floor. I would apply a pelvic binder (although

* Traditional ATLS teaching at this stage is to administer 2L of warmed Ringer’s lactate (Hartmann’s). Modern teaching has moved on from this, with targeted resuscitation and a move towards the replacement of ‘like with like’, replacing lost blood with O-negative blood products prior to group specific and, later, fully cross-matched blood. For the exam, it would be advisable to have an example from your own hospital/local trauma unit, with most units moving towards a 1:1:1 protocol (1 unit red cell concentrate (RCC), 1 unit of fresh frozen plasma (FFP) and 1 unit of pooled platelets). The local fixed ratio protocol should be changed to a protocol guided by laboratory results as soon as possible (see below for an example).

ideally this would have been done pre-hospital for any polytrauma patient with evidence of hypovolaemic shock) and I would request a trauma series of c-spine, chest and pelvic radiographs at this stage, as long as they don’t get in the way of resuscitation.

  Moving onto disability, I would assess the pupils, perform an AVPU and GCS score and D (don’t ever forget blood glucose).

  Environment/exposure is next, where the patient is completely undressed, taking care to prevent hypothermia and respect privacy, and they are then logrolled to allow for inspection of the patient’s back and to remove the spinal board. Consideration can be given at this stage to urinary catheterisation/need for further imaging/surgery and ultimate location of the patient, that is, ward/HDU/ITU, prior to moving onto the secondary survey. Imaging in the form of a CT scan (from the vertex of the skull to the symphysis pubic) with intravenous contrast is obtained if the patient is stable enough to be transferred to CT.

  Should the patient deteriorate at any stage I would return to reassess the airway with cervical spine control and assess the patient again in a logical order.

  In my hospital, patients with active or severe bleeding have their resuscitation managed in line with a major haemorrhage protocol, which is summarised here.

  The major haemorrhage protocol should be activated in the context of ongoing severe bleeding or haemorrhagic shock:

• Activate major haemorrhage protocol.
• Use O-negative blood as necessary (this is usually present in A&E and theatre recovery). Group-specific blood (ABO + RhD grouping) generally takes 15 –20 minutes; fully cross-matched blood 30–40 minutes.
• Where no results are available, order six units of RCC and four units of FFP. If bleeding persists and still no blood results, order a further four units of RCC and four units of FFP, in addition to one unit of platelets and two pools of cryoprecipitate.
• Rotational thromboelastometry (ROTEM) should be used where available to guide resuscitation.
• Tranexamic acid has been shown to reduce the risk of death in bleeding trauma patients (CRASH 2 trial). It is given as a 1 g bolus over 10 minutes followed by a 1  g infusion over 8 hours.
• Once results are available, target driven resuscitation should be performed as follows.

     2. What are signpost injuries?

 There are injuries which should alert the clinician to the possibility of other associated injuries. Examples include:

• Spinal fractures: Where a spinal fracture is present, there is a 10% possibility of a spinal fracture at another level.
• Scapular fractures: These rare injuries represent a high-energy injury and one should be mindful of potential injury to the thorax, for example lung contusion/ haemothorax/pneumothorax.
• Sternal fractures: Similar to scapular fractures, these are rare and are indicative of a high-energy injury. Care must be taken to rule out associated thoracic injuries.
• Calcaneal fractures: These are generally sustained from an axial load injury. This should alert the clinician to the possibility of other axial load injuries, for example, pilon, tibial plateau, femur, hip, acetabulum/pelvis and spine. The most frequent associated injury with one calcaneal fracture however is a contralateral calcaneal fracture.
• Knee dislocation: These are frequently associated with a common peroneal nerve injury. There is also a risk of damage to the popliteal artery.
• Hip dislocation (posterior): This may be associated with a sciatic nerve injury or a posterior wall acetabular fracture. If sustained following a ‘dashboard’ injury, there is a risk of knee ligamentous injury, patella fracture or a femoral fracture.

Femoral shaft: In the young, there is an 8–10% rate of concurrent femoral neck fractures