John Smith is brought into A&E having sustained a comminuted fracture of his right tibia/fibula after a stone wall fell on top of his leg. He is complaining of severe pain in his calf.

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How would you manage him?


A patient involved in this severity of trauma will require an urgent and full ATLS and team based approach to their initial management.

I would start by securing the airway with cervical spine control. The C-spine should be immobilised with all three of a hard collar, sandbags and tape, in addition to assessing their airway.

Initially this can be done by speaking to the patient and if they can chat back to you their airway is secure. If not, it must be formally assessed with the look/listen/feel approach 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.

I would assess breathing and ventilation, starting by providing high flow oxygen through a non-rebreathe mask as other members of the team are attaching monitoring. I'd look for any obvious chest injuries such as open wounds or flail segments, for respiratory distress, symmetrical chest wall movement and I'd measure the respiratory rate. I'd palpate for a central trachea and any subcutaneous emphysema. I'd percuss for obvious pneumothorax or haemothrorax, and finish by auscultating the lung fields.

Moving on to circulation with haemorrhage control, I would gain IV access with 2 large bore cannulae into the antecubital fossas, taking blood for FBC, U&Es, LFTs, glucose, lactate, coag and X-match for at least 4 units of bloods. I would then commence fluid resuscitation with 2L of warmed crystalloid and move on to looking for any obvious source of bleeding in the chest, abdomen, pelvis, long bones or floor (the 5 areas discussed in ATLS). If there was any question of a pelvic injury I would put on a pelvic binder and it would be appropriate to ask for a trauma series of c-spine, chest and pelvic XR at this stage, as long as they don’t get in the way of resuscitation. Other investigations at this stage could include ECG and ABG depending on the staffing levels available.

Moving on to Disability, I would assess the pupils, perform an AVPU or GCS score measure blood glucose.

I'd assess the environment/exposure completely undressing the patient, taking care to prevent hypothermia and respect privacy, and performing a logroll to look for any other obvious injury at the end of the primary survey. I would consider urinary catheterisation and NG tubes.

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