Management of Polytrauma in Critical Care Medicine

Initial Assessment and Prioritization

All exsanguinating patients with life-threatening hemorrhage require immediate intervention for bleeding control before addressing brain injuries 1
Urgent neurological evaluation must follow, including assessment of pupils, Glasgow Coma Scale motor score, and brain CT scan to determine brain injury severity 1
Salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention after control of life-threatening hemorrhage 1

Exsanguination is the most frequent cause of early death in polytrauma patients 2
Traumatic brain injury (TBI) is the most common cause of delayed mortality and disability 2

Secure airway control through tracheal intubation and mechanical ventilation with end-tidal CO2 monitoring is essential 1
Maintain arterial partial pressure of oxygen (PaO2) between 60-100 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1
Maintain arterial partial pressure of carbon dioxide (PaCO2) between 35-40 mmHg to prevent cerebral vasoconstriction and risk of brain ischemia 1

Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 1
Maintain cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring becomes available, adjusting based on neuromonitoring data and cerebral autoregulation status 1
Understand the conflict between "permissive hypotension" strategies for hemorrhage control and the need to maintain cerebral perfusion in TBI 3

Transfuse red blood cells for hemoglobin level <7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery 4
Maintain platelet count >50,000/mm³ for life-threatening systemic hemorrhage, with higher values (>100,000/mm³) for emergency neurosurgery including ICP probe insertion 5
Maintain prothrombin time (PT)/activated partial thromboplastin time (aPTT) <1.5 normal control during interventions 6
During massive transfusion protocol initiation, transfuse RBCs/Plasma/PLTs at a ratio of 1:1:1, with subsequent adjustments based on laboratory values 6

ICP monitoring is recommended for patients at risk for intracranial hypertension, regardless of the need for emergency extra-cranial surgery 1
Use a stepwise approach for elevated ICP, reserving more aggressive interventions with greater risks for situations when no response is observed 6
Consider external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 1

Develop protocols for simultaneous multisystem surgery in patients requiring both intervention for life-threatening hemorrhage and emergency neurosurgery 4
SMS requires established protocols and strict collaboration between different surgical teams (including interventional radiologists) 4
SMS has been associated with shorter times to initiate CT scanning/emergency surgery and fewer unfavorable outcomes at 6 months post-injury 4

Point-of-care tests (TEG, ROTEM) are recommended to assess and optimize coagulation function during interventions for life-threatening hemorrhage or emergency neurosurgery 6
These tests provide rapid assessment of hemostasis and assist in clinical decision-making, especially for patients taking novel oral anticoagulants (NOACs) 5

After the acute phase, implement a progressive rehabilitation program with gradual reintroduction of activities 7