Motorcyclist Pinned Under a Guardrail
A 28-year-old motorcyclist has crashed on a mountain road and slid under a steel guardrail. He is lying on his back with the guardrail above his chest and the motorcycle's crash bar pinning both lower legs. He is awake, anxious, asking for water, and can answer questions; GCS is 14 (E4 V4 M6). His right thigh is deformed with a 6 cm open wound over the lateral aspect, and dark blood is pooling under him. The pelvis is tender on compression and the left arm has tingling in the fingers. Radial pulse 130, weak; RR 26; skin pale and cool. Ambient temperature 30 °C, extrication with hydraulic tools is 20 minutes away, and the ambulance is 15 minutes away. He has no allergies and takes no medication. He drank a beer an hour ago.
1. Set out the sequence of haemorrhage control and immobilisation before extrication and justify the order.
Read the worked answer
Sequence: catastrophic bleeding before splinting or extrication.
- Direct pressure and wound packing into the open thigh wound with haemostatic gauze if available; hold for at least 3 minutes.
- If bleeding is not controlled, apply a tourniquet high and tight on the right thigh, 5–7 cm above the wound, and note the time. Do not loosen it.
- Apply a pelvic binder at the level of the greater trochanters if the pelvis is unstable; this reduces pelvic volume and bleeding.
- Keep him warm; hypothermia worsens coagulopathy.
- Only then splint: a traction splint for the femur, with gentle traction, after the binder, reassessing pain and distal pulses.
- Extricate with the hydraulic tools as planned; do not delay extrication for splinting if bleeding is uncontrolled, but do not pull him by the pinned legs. This order treats the killers - haemorrhage and pelvic bleeding - before the painful but less immediately lethal fracture.
2. How do you manage spinal motion restriction and the helmet, and what is the problem with traction splinting when a pelvic fracture is suspected?
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Spinal motion restriction and helmet.
- Mechanism and neck pain warrant restriction, but rigid immobilisation is not needed if he is alert and cooperative; use manual in-line stabilisation, a collar and a vacuum mattress for transport.
- Leave the helmet on if it fits well, the airway is accessible and it does not obstruct assessment; removing it requires two trained providers with in-line stabilisation. If it must come off, remove it without allowing the head to move.
- The left arm tingling suggests a brachial plexus or cervical injury; document serial neurological findings. Traction splint and pelvis: a pelvic fracture is a relative contraindication to traction because traction can displace the pelvis. Apply the pelvic binder first, use the splint only if it clearly reduces the femur deformity, and stop if pain or neurovascular status worsens. If unsure, splint with a vacuum mattress and padded board instead.
3. State your fluid strategy, any drug considerations, and your transport destination and pre-alert.
Read the worked answer
Fluid and destination.
- He is in compensated shock: pulse 130, weak, pale. Do not pour in litres of crystalloid. Give 250 mL boluses and titrate to a palpable radial pulse and preserved consciousness - permissive hypotension, aiming for a systolic around 80–90 mmHg in the absence of head injury.
- GCS 14 with no focal deficit means traumatic brain injury is possible but not dominating; avoid hypoxia and hypotension, which worsen outcome.
- Give tranexamic acid 1 g IV over 10 minutes within 3 hours of injury if authorised.
- Destination: a trauma centre with surgical capability, not the nearest clinic. Pre-alert with mechanism, suspected pelvic and femur fractures, haemorrhage control and vital signs.
- Report the entrapment time and the tourniquet time to the receiving team; both change operative planning.