Hit by Car — Polytrauma Triage in a 2yo Mixed Breed

This is a critical polytrauma patient in severe hypovolemic shock. Prioritization is everything. Speed kills, and speed saves.

My immediate protocol, following the primary survey:

Circulation (SBP 65mmHg is catastrophic shock):

* IV Access: Establish two large-bore IV catheters immediately.
* Fluid Resuscitation:
* Start with a LRS bolus: 20ml/kg IV over 10-15 minutes. Reassess.
* Simultaneously, administer Hypertonic Saline: 3-5ml/kg IV over 10 minutes. This will help with profound hypovolemia and potential head trauma.
* Goal-directed: After each bolus, reassess HR, pulse quality, CRT, mentation, and SBP. If still hypotensive after 30ml/kg crystalloid, consider a colloid bolus (Hetastarch 5ml/kg over 10 min) and prepare vasopressors.
* Blood Products: With a SBP of 65mmHg and positive FAST for abdominal and thoracic fluid, significant hemorrhage is assumed.
* Obtain a rapid PCV/TS, lactate, glucose, and perform a crossmatch (Type & Cross).
* Prepare for a packed red blood cell (pRBC) transfusion. Do not wait for an arbitrary PCV cutoff. This dog is bleeding out. If crossmatch isn't feasible and he's crashing, use O-type universal donor blood.
* Vasopressors: If fluid-refractory shock persists, start Norepinephrine CRI at 0.1-2µg/kg/min.
* Abdominal Counterpressure: Consider an abdominal wrap (e.g., Vetrap) as a temporizing measure for presumed intra-abdominal hemorrhage, applied snugly but not constricting respiration.

Breathing (Thoracic Fluid):

* Oxygen: Provide supplemental oxygen (flow-by, mask, or oxygen cage).
* Thoracocentesis: Bilateral thoracocentesis must be performed immediately if the patient is dyspneic or has significant tachypnea. Even if it's blood, removing it can relieve compressive atelectasis or cardiac tamponade.

Disability (Neurological):

* Head Trauma Protocol: Elevate the head 15-30 degrees. Hypertonic saline, as administered for shock, will also help reduce intracranial pressure. Monitor pupillary size and symmetry. Avoid jugular occlusion.
Pain Management: Once initial shock is being addressed and the patient is less* hypotensive, administer a pure mu-opioid like Fentanyl (2-5µg/kg IV bolus, then CRI) or Hydromorphone (0.05-0.1mg/kg IV). Avoid NSAIDs due to hypovolemia and potential renal injury/coagulopathy.

Exposure/Other:

* Femur Fracture: Temporarily stabilize the femur with a splint or heavy bandage once the patient is hemodynamically stable. Definitive repair is a secondary concern.
* Diagnostics: While aggressively stabilizing, perform a minimum database: PCV/TS, lactate, blood glucose, electrolytes. Full CBC/Chem and coagulation panel (PT/aPTT) should be run but do not delay treatment for these results.
* Monitoring: Continuous ECG, pulse oximetry, capnography, and frequent blood pressure (Doppler and ideally oscillometric). Reassess every 5-10 minutes.

My clinical philosophy applies here directly: Stabilize first, diagnose second. We address the life-threatening ABCs, aggressively resuscitate, and manage pain once stable. We do not waste time on extensive imaging (like full body radiographs or CT) until the patient is out of immediate shock. That femur fracture is important, but it will not kill him in the next 30 minutes; the shock will.

This is a critical trauma patient requiring immediate and aggressive stabilization. Prioritization is simultaneous: stop the bleeding, treat the shock, and manage pain.

Immediate Priorities:

Hemorrhage Control & Shock Management: SBP 65mmHg is severe hypovolemic shock.

* IV Access: Place 2 large-bore IV catheters immediately.
* Fluid Resuscitation:
Rapid bolus of crystalloids (e.g., LRS, Norm-R): 10-20 mL/kg over 10-15 minutes, then reassess. Do not* give full shock dose up front as this can worsen coagulopathy and "pop the clot." Titrate to effect (SBP > 90mmHg, improved mentation, HR).
* Consider hypertonic saline (4 mL/kg over 5 min) if crystalloids are not rapidly improving BP, especially if CNS signs.
* Blood Products: Essential. This patient needs red blood cells. Type and crossmatch, but if unavailable, administer packed red blood cells or fresh frozen plasma if significant coagulopathy is suspected or ongoing hemorrhage.
* Vasopressors: If crystalloids and blood products are insufficient, start a vasopressor CRI (e.g., Norepinephrine 0.05-0.5 µg/kg/min IV).
* Direct Pressure: Apply pressure to external bleeding sites (epistaxis).
* Abdominal/Thoracic Fluid: Positive FAST scan indicates hemoabdomen/hemothorax. These are major sources of blood loss. Autotransfusion may be considered if blood products are not available. Thoracocentesis is critical if there is any respiratory compromise from pleural fluid.

Pain Management: Crucial. Severe pain exacerbates shock.

* Opioid-Centric: This patient is ASA IV-V. My critical patient protocol applies.
* Fentanyl: 2-5 µg/kg IV bolus, then start a CRI at 2-5 µg/kg/hr. Fentanyl is short-acting, potent, and can be titrated quickly.
* Methadone: 0.3 mg/kg IV can be given if a longer duration of analgesia is needed and BP allows, as it has minimal cardiovascular effects.
* Avoid: NSAIDs are contraindicated due to hypovolemia and risk of acute kidney injury and coagulopathy. Avoid alpha-2 agonists (dexmedetomidine) due to profound cardiovascular depression.

Airway & Breathing:

* Oxygen Support: Provide flow-by oxygen, mask, or nasal prongs.
* Epistaxis: Monitor for airway obstruction. Keep the head elevated if possible.

Anesthetic Considerations (if proceeding to surgery for fracture repair or exploratory laparotomy):

* Pre-Anesthetic Stabilization: Do not induce anesthesia until hemodynamically stable (SBP > 90 mmHg, HR improving, normal mentation).
* Premedication: Continue fentanyl CRI. A benzodiazepine like midazolam (0.2 mg/kg IV) can provide anxiolysis with minimal cardiovascular effects.
* Induction:
* Etomidate: 1-2 mg/kg IV is my preferred induction agent for critical patients due to its minimal cardiovascular effects. Administer slowly with a co-induction agent.
* Avoid: Propofol bolus should be avoided in hemodynamically unstable patients due to dose-dependent vasodilation and myocardial depression.
* Maintenance:
* TIVA: Consider total intravenous anesthesia (TIVA) with propofol (CRI 0.1-0.2 mg/kg/min) or alfaxalone (CRI 0.1-0.2 mg/kg/min) combined with fentanyl (CRI 5-10 µg/kg/hr) to minimize inhalant use, which can further depress cardiovascular function.
* Inhalant: If using isoflurane/sevoflurane, keep MAC as low as possible (0.5-0.8 MAC) and supplement with an opioid CRI (e.g., fentanyl, sufentanil). My FLK CRI (fentanyl 2-5µg/kg/h + lidocaine 25-50µg/kg/min + ketamine 2-5µg/kg/min) can be beneficial for reducing inhalant requirements and providing multimodal analgesia if hemodynamically stable enough.
* Regional Anesthesia: A femoral nerve block (bupivacaine 0.5% at 1-2 mg/kg total dose, or ropivacaine 0.75%) for the fractured femur will provide excellent localized analgesia, reduce systemic opioid requirements, and improve hemodynamic stability. This should be performed once the patient is stable and ideally before or during surgical prep.

Continuous Monitoring: ECG, pulse oximetry, capnography, direct or indirect blood pressure (NIBP every 1-3 min, ideally direct arterial line if available), temperature, urine output. Serial PCV/TS, lactate, and blood gas analysis are essential.

This dog is in critical hemorrhagic shock from polytrauma. Prioritize circulation and breathing.

Here's my immediate approach:

* Circulation - Treat Shock & Hemorrhage:
* IV Catheters: Place two large-bore intravenous catheters immediately (18ga or 20ga). Cephalic or saphenous.
* Fluid Resuscitation: Rapidly administer a crystalloid bolus. I use LRS.
* LRS: 20 mL/kg IV over 10-15 minutes. Reassess blood pressure (Doppler), heart rate, mucous membrane color, CRT.
* Repeat boluses as needed, up to 60-90 mL/kg total. Be mindful of potential for "dilutional coagulopathy" if bleeding is severe and uncontrolled.
If I had it available (rare in my practice, but for severe shock):* A colloid like VetStarch 5-10 mL/kg IV over 15-30 minutes, then CRI. This helps maintain oncotic pressure but won't stop bleeding.
* Blood Products: If I had a compatible donor dog and equipment, I'd consider a fresh whole blood transfusion (10-20 mL/kg) for active hemorrhage and severe anemia. This is often not an option in my practice due to lack of immediate availability.
Abdominal Counter-Pressure: Consider an abdominal wrap (tightly but not excessively so) with elastic bandage material. This can* sometimes help tamponade venous hemorrhage, though it's less effective for arterial bleeds.
* Monitoring: Continuous monitoring of heart rate, respiratory rate, blood pressure (Doppler), mucous membrane color, CRT, and mentation. Perform serial PCV/TS checks every 30-60 minutes to track hemorrhage and hemodilution.

* Pain Management:
* The femur fracture is excruciating and contributing to shock.
* Opioids: Buprenorphine 0.01-0.02 mg/kg IV or IM. This is on my shelf and is a good choice for initial pain control in a critical patient. A full mu-agonist like hydromorphone (0.05-0.1 mg/kg IV/IM) would be preferred if available, but I often don't stock it. I'd avoid NSAIDs (Meloxicam) in a hypotensive patient with suspected internal bleeding.
* Sedation (if needed after pain control): If the dog remains fractious after opioids, a low dose of ketamine (1-2 mg/kg IV) could be considered for its analgesic properties, but only after initial fluid resuscitation and some improvement in blood pressure.

* Breathing & Airway:
* Oxygen: Provide supplemental oxygen via nasal prongs or mask.
* Thoracocentesis: The positive FAST in the thorax and epistaxis suggest possible pulmonary contusions, hemothorax, or pneumothorax. If respiratory effort worsens, perform a diagnostic and therapeutic thoracocentesis.
* Technique: Clip and prep the lateral thorax. Use an 18-20ga over-the-needle catheter attached to an extension set and a 3-way stopcock with a 12-20 mL syringe. Insert needle at the 7th-9th intercostal space, just dorsal to the costochondral junction, advanced craniodorsally. Aspirate fluid/air.

* Head Trauma:
* Keep the head elevated 15-30 degrees.
* Avoid jugular vein compression.
* Supportive care as outlined above (oxygen, fluids, pain control). Specific intracranial pressure-reducing drugs (mannitol, hypertonic saline) are not typically on my shelf or feasible for immediate use in the field.

* Antibiotics:
* Given the trauma and open fracture risk (even if not compound yet), prophylactic antibiotics are indicated.
* Ceftiofur (Naxcel): 2.2 mg/kg IV or IM. Broad-spectrum, good for trauma.

* Fracture Management:
* The femur fracture is NOT the immediate priority. Once the dog is hemodynamically stable, apply a temporary Robert Jones bandage for support and comfort, taking care not to exacerbate pain or further injure soft tissues. Definitive repair comes much later.

This is a critical patient. Aggressive fluid therapy and pain control are paramount to stabilize before any definitive repairs can be considered. The goal is to get the animal out of immediate danger from shock and hemorrhage.