ATLS primary survey — the under-triaged elderly fall

Station brief

Format. Clinical-management station, 11 minutes. You are the on-call general surgery fellow; the examiner plays the ED senior who accepted the patient as a routine consult.

Candidate instructions. Evaluate the triage decision, run your primary survey, and state your escalation plan with the evidence behind it.^[1]

Candidate scenario (first phase)

A 76-year-old woman fell 2 metres from a ladder onto her left side 90 minutes ago. She takes apixaban for atrial fibrillation and metoprolol. Observations: GCS 14 (E4 V4 M6), BP 108/66, HR 96 and regular, RR 22, SpO2 96% on air. She has left lateral chest wall bruising and a tender left hip. The triage note reads "meets no trauma team activation criteria — routine consult". (A constructed vignette; every guideline step that follows is sourced.)^[1]

Examiner: "Her blood pressure is 108 — that's fine for her age, isn't it? Why are you worried?"

Expected candidate reasoning

Why the triage missed her. The CDC field-triage guideline's Step Four special considerations state explicitly that systolic blood pressure <110 mmHg in persons aged over 65 years warrants trauma-centre care — she is 108. Anticoagulant use is a named Step Four criterion, and she is on apixaban.^[1] The undertriage literature shows this is the classic miss: severe undertriage occurs almost exclusively after blunt trauma (96% vs 71%), severe chest injuries are the injuries most likely to evade capture, and undertriaged patients still require intubation and emergent intervention at high rates with 14% mortality.^[2]

The numbers are lying, and I can prove it. Heart rate and systolic pressure often look normal in the compensatory phase of shock and are confounded by medications — she is beta-blocked. Her shock index is 96/108 = 0.89 and rising on repeat measurement is what matters; SI over 1.0 predicts mortality, massive transfusion activation and ICU admission.^[3]

The survey I run. Parallel and goal-oriented: airway with c-spine protection, breathing with early imaging of the bruised chest, circulation with blood available and tranexamic acid inside its window if she is bleeding, disability with a low threshold for CT head given anticoagulation, exposure with active warming. The survey's job is to determine disposition — resuscitation room, CT or theatre — with defined endpoints rather than a checklist.^[4]

Escalation. Upgrade to full trauma team activation now, on Step Four criteria, and I say so to the ED senior with the guideline sentence quoted.^[1]

Examiner notes

The station is failed by candidates who accept "108 is normal for 76". It is passed by candidates who quote the <110-over-65 correction, name anticoagulation as a Step Four criterion, compute the shock index, and connect the vignette to the blunt-trauma undertriage data.^[1][2][3]