Abstract
Introduction: Classical trauma teaching involves attending to airway issues first, followed by breathing and then circulation – the Advance Trauma Life Support (ATLS) algorithm. Although this provides a robust framework for most trauma presentations, there are times when this approach needs to be altered. This case report describes a patient who sustained chest trauma where it was necessary to attend to circulatory issues before the breathing issues.
Case report: A 63-year-old male, whilst on anticoagulation sustained an extrapleural hematoma (EH) with active bleeding from intercostal arteries. He presented with features of circulatory shock but was also compromised from a respiratory point of view. His circulatory issues were attended first with embolisation. The respiratory issues continued and venous bleeding from the chest did not settle and he ultimately required a thoracotomy to evacuate the extrapleural haematoma. Although trauma teaching would state his respiratory issues should have been managed before his circulatory issues, EH occur in a space where there is a natural tamponading effect, and there was concern that opening chest before addressing intercostal bleeding would have led to catastrophic uncontained haemorrhage and circulatory collapse.
Conclusion: Although a useful guide, the ATLS algorithm cannot be applied blindly to all trauma presentations. Trauma clinicians need to analyse a patient’s injury with the resulting physiology to determine what approach needs to be undertaken. An EH is one such example where early decompression without thought could lead to uncontrolled intercostal bleeding resulting in a fatal outcome.

Key words: trauma, thoracic, extrapleural, thoracotomy, emobolisation