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Trauma·CA-3 / Fellow

Splenic Laceration & C-Collar

High-acuity trauma logic involving cervical spine instability, full-stomach Rapid Sequence Induction (RSI), and massive transfusion priorities.

The stem

A 53 y.o. woman is brought to the OR for exploratory laparotomy after a car crash. BP 110/70, HR 115. EXAM: Soft cervical collar in place (not cleared). Mallampati 2. CT shows splenic laceration and active internal bleeding.

Focus

Management of the unstable patient with a potential difficult airway and C-spine instability. Massive Transfusion Protocol (MTP) logic.

Examination relevance

Defend your intubation plan: Fiberoptic vs. Video-Laryngoscopy vs. Direct with MLI. Examiners look for your ability to protect the spinal cord while securing a life-threatening airway.

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Expert sample response

This patient is hemodynamically unstable with a presumed full stomach and a potential C-spine injury. My goal is to secure the airway while maintaining Manual In-Line Stabilization (MILS). I will perform a Rapid Sequence Induction using etomidate to preserve its cardiovascular stability and succinylcholine for its rapid onset and favorable conditions.

I will use a Video-Laryngoscope as my primary device to minimize cervical neck movement during intubation. I'll have the Level-1 Rapid Infuser ready with O-negative blood as her tachycardia and soft blood pressure suggest significant internal bleeding. I will prioritize volume resuscitation over vasopressors in this trauma setting, aiming for a MAP that balances organ perfusion with the risk of 'popping the clot' from her splenic injury.

Full walkthrough

What the Examiner Is Testing

This case tests your ability to protect the cervical spine while securing an emergency airway in an unstable patient. The examiner wants to hear a specific intubation technique — video laryngoscopy with manual in-line stabilization — and a clear explanation of why fiberoptic is not appropriate in this context.

The Board Trap

The trap is either ignoring the C-collar (and just doing direct laryngoscopy) or delaying the airway for an awake fiberoptic because "she has a C-spine injury." She's bleeding internally and deteriorating — a prolonged awake fiberoptic in a hemodynamically unstable trauma patient is not the answer. The board answer is RSI with MILS and video laryngoscopy.

Walk-Through: How This Case Plays Out

Examiner: She has a soft collar in place and hasn't been cleared. How do you intubate?

Me: I would perform a rapid sequence induction with manual in-line stabilization. I'd remove the anterior portion of the collar to open the mouth, have an assistant maintain MILS throughout the intubation, and use a video laryngoscope as my primary device — it minimizes neck extension compared to direct laryngoscopy. I'd use etomidate and succinylcholine, modified RSI with cricoid pressure applied during the intubation.

Examiner: Why etomidate and succinylcholine specifically?

Me: Etomidate preserves hemodynamics — she's already tachycardic with a soft BP, and I can't afford to drop her MAP further on induction. Succinylcholine gives me the fastest intubating conditions and the shortest duration of action if I need to rescue the airway quickly. Yes, etomidate has the cortisol suppression concern in prolonged use, but one dose for induction is acceptable in trauma.

Examiner: Her BP drops to 75/40 after induction. What do you do?

Me: I would push phenylephrine boluses initially to restore SVR, but I'm also thinking about hemorrhagic shock resuscitation now. She's tachycardic and hypotensive — this is hemorrhagic shock until proven otherwise. I'd activate the massive transfusion protocol: O-negative pRBCs, FFP, and platelets in a 1:1:1 ratio. I'd pull the Level-1 rapid infuser. Pressors are a bridge, not a solution — she needs volume in the form of blood products.

Examiner: When do you use vasopressors vs. blood products in trauma hemorrhage?

Me: Blood products are the definitive resuscitation. Vasopressors can temporarily support the MAP while the Level-1 is running or while the surgeon controls the bleeding, but they don't replace intravascular volume. If I'm squeezing down vasoconstricted vessels that are already volume-depleted, I risk end-organ ischemia. I use pressors as a bridge, not a treatment.

Key Phrases That Score Points

  • "Manual in-line stabilization plus video laryngoscope — that's how I protect the C-spine during RSI in trauma."
  • "Remove the anterior collar to open the mouth — MILS replaces the immobilization during intubation."
  • "Etomidate for induction — I cannot afford to drop her MAP in hemorrhagic shock."
  • "Massive transfusion protocol: 1:1:1 ratio of pRBCs, FFP, platelets — not just saline."
  • "Vasopressors are a bridge to surgical hemorrhage control, not a substitute for volume."

Why This Case Appears on the Boards

Trauma with C-spine instability tests your ability to perform two competing priorities simultaneously — spinal protection and rapid airway control — and make a defensible decision about intubation technique under time pressure.