Traumatology: Primary management of the polytraumatized patient

Primary management

Causes of polytrauma are usually

• Traffic accidents
• Falls from great heights
• Biting incidents

All can be associated with multiple, life-threatening injuries.

When a polytrauma patient presents to the doctor's office or clinic, the principle of any initial treatment is: The priority is to stabilize the patient's cardiovascular and respiratory functions.
As obvious as high-grade wounds or fractures may be, the shock and possible respiratory deficits usually represent the actual life-threatening condition.

It is important that all veterinary technicians are also familiar with this principle, so that if the worst comes to the worst, they can already begin with the appropriate primary measures before the veterinarian arrives (e.g., venous catheter, IV, ventilation).

Initial clinical examination:

The focus of the examination is usually limited to the points of cardiovascular - respiratory - body temperature (including acra), a detailed examination is often only possible in the stabilized patient.

Orthopedic emergencies are rare overall, but a possible vertebral fracture or dislocation should always be kept in mind during handling and on the basis of the medical history.

In addition, the examination includes an abbreviated neurological examination with the question: Is there a traumatic brain injury? Assessment and prognosis using, for example, the modified Glasgow Coma Scale (Leipzig, Germany).

Initial diagnostic steps:

• Radiographs of the abdomen (e.g., to show diaphragmatic rupture, hemoabdomen) and thorax (e.g., pneumothorax, pulmonary contusions) should always be taken if possible      
• Ultrasonographic examination should be performed at the latest when organ rupture or internal bleeding is suspected    
• ⇒ Diagnostic imaging should be performed as early as possible, although the timing depends greatly on the patient's condition and stability. Initial drug treatment usually takes priority.
• Check urinary bladder stability (X-ray, palpation, observation of urine output). In case of doubt, an ultrasound examination or a contrast X-ray can provide information.
• Laboratory: Minimum small hematogram. Subsequent repeat assessment of hematocrit may provide information about internal bleeding (bleeding anemia). Important to consider are possible large internal blood losses due to fractures in the pelvic region.
• Optimally, acid-base status is also obtained to detect metabolic acidosis (lactic acidosis) in an early stage. A blood chemistry profile is particularly useful for establishing the status quo and detecting changes in organ values over the course of the next few days.

First therapy steps:

Volume substitution

First and most important step. Stabilization of hypovolemic or hemorrhagic shock is done via venous access if possible.
If this is not possible, intraosseous infusion can be used as an alternative - using a spinal cannula to avoid blockage by entering bone substance. The dwell time of an intraosseous access should be kept as sterile and short as possible to reduce the risk of local infection (osteomyelitis).
Subcutaneous infusions for shock therapy are not suitable.

The use of full electrolyte solutions is recommended as a standard infusion solution; these also counteract mild metabolic acidosis at the same time.
If a traumatic brain injury is present, it may be necessary to switch to hypertonic and/or mannitol infusions (CAVE in case of a severe dehydration).

If the patient is hypothermic (cats!), a medical infusion warmer should be used if possible and the amount of infusion solution/time unit should be kept at the lower minimum.

Treatment for pneumothorax

If associated dyspnea, puncture should be performed first and the patient then placed in an oxygen box in a quiet environment.

Thoracentesis: If pneumothorax with dyspnea recurs or puncture is unsuccessful despite multiple punctures. If it is an open pneumothorax, prompt care of the wound area should be sought.

Stop severe (arterial) bleeding.

If necessary, by pressure dressings or application of a tourniquet to the extremities. If available, use of special surgical material such as Esmarch bandages.

Initial drug therapy

Antibiotics: Early administration, preferably i.v., is indicated for open fractures. Aminoglycosides should be avoided (nephrotoxicity and decrease in microcirculation).

Analgesics: In addition to pain management itself, important to control shock. In addition, good pain management also increases the patient's companionableness. Metamizol and opioids should be used preferentially. If traumatic brain injury occurs, the use of opioids must be used on an individual basis because of their respiratory depressant effect.
NSAID's are contraindicated in shock because they exacerbate preexisting decreased renal perfusion and may provoke acute renal failure if used.

After completion of initial care and stabilization of the patient, further orthopedic as well as neurological examination and further diagnostic steps are performed.

Author's note: This article is intended to give you a simple overview of the initial care of the polytrauma patient. Due to the complexity of the topic, there is no claim to completeness.

 

Bibliography: Upon request

Author of the article:

Veterinarian med. vet. Julia Brüner