Polytrauma: several lesions, of which at least one is a vital risk.
Perform immediate triage: assess severity of trauma
Ensure availability of needed teams/imaging for adequate management (neurosurgery, CT surgery, vascular surgery, orthopedics, CT, MRI, etc.)
Multidisciplinary approach, importance of having a team leader
Concurrent therapy (ABC) and diagnosis (H&P, imaging studies)
Time is of the essence (first hour = golden hour)
Stabilization/workup on arrival
After initial workup/stabilization
Secondary treatment round, depending on lesions identified
Severity criteria (Vittel, 2002): any of these require transfer to trauma center (except patient factors, which are evaluated on a case-by-case fashion):
- 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
- Lesion itself:
- Penetrating trauma of head, neck, thorax, etc
- Limb amputation or ischemia
- Pelvis fracture
- Severe burn and/or smoke inhalation
- Need for mechanical ventilation
- Fluid resuscitation >1,000 mL and/or pressors and/or military antishock trousers (MAST)
- Age >65
- CHF, CAD, respiratory insufficiency
- Pregnancy (especially second and third trimesters)
- Bleeding diathesis or anticoagulants
Major mortality criteria:
- SpO2 <80% or unobtainable (76% mortality)
- SBP <65 mm Hg (65% mortality)
- GCS = 3 (62% mortality)
- 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)
- 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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