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Polytrauma: several lesions, of which at least one is a vital risk.

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Perform immediate triage: assess severity of trauma

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Ensure availability of needed teams/imaging for adequate management (neurosurgery, CT surgery, vascular surgery, orthopedics, CT, MRI, etc.)

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Multidisciplinary approach, importance of having a team leader

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Concurrent therapy (ABC) and diagnosis (H&P, imaging studies)

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Time is of the essence (first hour = golden hour)

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Triage

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Stabilization/workup on arrival

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Airway, breathing

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Circulation/heme

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Neurological

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After initial workup/stabilization

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Secondary treatment round, depending on lesions identified

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Severity criteria (Vittel, 2002): any of these require transfer to trauma center (except patient factors, which are evaluated on a case-by-case fashion):

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  • Vital signs:
    • GCS <13
    • SBP <90 mm Hg
    • SpO2 <90%
  • High-energy trauma:
    • Ejection from vehicle
    • Another person died in the same vehicle
    • Fall >6 m (about 20 ft)
    • Patient thrown or crushed
    • No helmet/seatbelt
    • Blast
  • Lesion itself:
    • Penetrating trauma of head, neck, thorax, etc
    • Limb amputation or ischemia
    • Pelvis fracture
    • Severe burn and/or smoke inhalation
  • Management:
    • Need for mechanical ventilation
    • Fluid resuscitation >1,000 mL and/or pressors and/or military antishock trousers (MAST)
  • Patient:
    • Age >65
    • CHF, CAD, respiratory insufficiency
    • Pregnancy (especially second and third trimesters)
    • Bleeding diathesis or anticoagulants

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Major mortality criteria:

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  • SpO2 <80% or unobtainable (76% mortality)
  • SBP <65 mm Hg (65% mortality)
  • GCS = 3 (62% mortality)

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  • Document basic information:
    • NIBP, HR, SpO2, EtCO2 if intubated, temperature
    • GCS, pupil size and reactivity, moving lower extremities; full neuro exam before any sedative given
    • Finger stick for blood glucose, point-of-care Hct
  • At least two large-bore IVs
  • Consider CVL and/or A-line; prefer femoral access unless abdominal trauma or B/L LE trauma; insert both lines side-by-side; use 5 Fr arterial catheter (can be used for arteriogram); draw labs when inserting lines:
    • Chem 7, CBC, coags, LFTs, troponin, alcohol/drugs, β-HCG (if female), ABO-Rh for blood bank
  • Give tetanus booster shot
  • If open fracture, start Abx, for example, cefazolin 2 g IV, and then 1 g q8 hours (if allergy, clindamycin 600 mg IV, and then 600 mg q6–8 hours); add 5 mg/kg per day of gentamycin if Gustilo grade III open fracture (crushed tissue and contamination, with or without vascular compromise)
  • Consider analgesia; however, no sedation without intubation
  • Portable CXR and pelvic AP film (if pelvic Fx, do not insert Foley)
  • Focused Assessment with Sonography in Trauma (FAST: rule out intraperitoneal fluid) and thoracic U/S to r/o hemothorax and/or pneumothorax
  • B/L transcranial Doppler if available: Vd on MCA <20 cm/s, pulsatility index >1.2 suggest increased ICP
  • Consider OGT to avoid further aspiration of gastric contents/blood (no NGT until skull base fracture ruled out)

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  • Do not blindly trust ETT in situ; check position and B/L breath sounds, CXR
  • Assess airway for difficult intubation: LEMON:
    • Look: obesity, micrognathia, evidence of previous head and neck ...

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