EM Cases · Primary survey
Blunt polytrauma primary survey — <C>ABCDE resus station
ACEM Fellowship OSCE resus station testing catastrophic haemorrhage control before airway, tension/breathing threats, damage-control circulation with TXA, and iterative primary survey discipline.
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Target exams
Station brief
Format. Clinical-management (resus) station, 11 minutes. You are the trauma team leader.
[1]Candidate instructions. Run the primary survey from end-of-trolley handover. Treat life threats in order. Examiner plays the team.
[1]Candidate scenario (first phase)
A 35-year-old motorcyclist, helmeted, hit a car at ~60 km/h. Prehospital: pelvic binder not yet applied; spurting wound right mid-thigh packed loosely.
[1]- HR 130 · BP 88/54 · RR 32 · SpO₂ 90% on 15 L · GCS 13
- Visible arterial bleeding from right thigh; pelvis feels unstable; trachea midline; decreased air entry left
- Finger-prick glucose not yet done
Nurse: "Shall we go straight to CT?"
[1]The deterioration (second phase)
After tourniquet and oxygen, BP remains 90/55; left chest becomes silent and hyperresonant with worsening hypotension.
[1] [1]Reveal the expected management (assessor key)
Phase 1 — <C> then ABCDE.
[1]- Team roles, MILS/C-spine, simultaneous actions.[1]
- <C> catastrophic haemorrhage: windlass tourniquet proximal to thigh wound; time marked; firm packing if needed.
- Pelvic binder at greater trochanters for unstable pelvis suspicion.
- A: oxygenate/assess airway; prepare RSI if threatened; C-spine protection.
- B: high-flow O₂; examine chest — if tension physiology develops, decompress then drain.
- C: two large-bore IV/IO; bloods including VBG/lactate; activate MHP; TXA 1 g IV within 3 hours; minimise crystalloid; permissive hypotension until control if isolated haemorrhage without TBI concern.
- D: GCS, pupils, bedside glucose.
- E: full exposure with active warming (lethal triad).
Phase 2 — evolving left tension.
[1]- Recognise left tension → needle decompress 5th ICS AAL → definitive chest drain.
- eFAST as adjunct; disposition: theatre/IR for haemorrhage control, not CT-first while unstable.
Assessor marking grid
- Applies catastrophic haemorrhage control before prolonged airway focus
- Correct primary-survey order and concurrent resuscitation
- TXA + blood-product-first mindset
- Treats tension clinically
- Leadership/CRM
Common candidate errors
- CT-first
- Missing tourniquet/binder
- Crystalloid megadoses
- Skipping glucose at D
Examiner teaching points
- Treat first what kills first; primary survey is iterative.[1]
References
- [1]Polmear MM, Moed BR, Mousavi-Ideh M, et al. Early care of polytraumatized patients: a framework for orthopaedic surgeons. Journal of the American Academy of Orthopaedic Surgeons, 2025.PMID 39739953