Polytrauma refers to multiple severe injuries that affect multiple body systems. It requires a team-based approach involving multiple specialties. The document discusses the definition of polytrauma, the pathophysiology involving an immune and inflammatory response, pre-hospital and in-hospital management priorities, and the concept of damage control orthopedics to stabilize injuries without worsening the patient's condition. Scoring systems like ISS, NISS, and TRISS are used to quantify injuries and predict outcomes. Managing both the injuries and the patient's physiological response is important to prevent late complications like multiple organ dysfunction syndrome.

1. Surg Lt Cdr Anup Maurya
Resident Orthopaedics
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2. References
• Rock wood and green’s
• Campbells Operative Orthopedics
• Current concepts of polytrauma management; PF Stahel, CE Heyde, W
Ertel - European Journal of Trauma, 2005 - Springer
• Early Total Care versus Damage Control: Current Concepts in the
Orthopedic Care of Polytrauma Patients; ISRN Orthopedics Vol 2013
(http://dx.doi.org/10.1155/2013/329452)
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3. CONTENTS
• Definition
• Introduction
• Pathophysiology
• Pre-Hospital Management
• In Hospital Care
• Damage Control Orthopedics
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4. Definition
“A syndrome of multiple injuries exceeding a defined severity
(ISS ≥ 17)
with sequential systemic reactions
{systemic inflammatory response syndrome(SIRS)
for at least 1 day}
that may lead to
dysfunction or failure of remote organs and vital systems (MODS),
which have not themselves been directly injured.”
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5. Team Effort
• Polytrauma needs management by a team of surgeons,
Physicians, Anaesthetist & Radiologist
Orthopaedic surgeon is one of the team member of
trauma unit
• Orthopaedic injuries are generally not life-threatening
unless they result in significant hemodynamic instability
• Team leader is a General Surgeon
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6. Death Toll
• World wide No.1 cause of deaths amongst the younger
age group (18-44 yrs).
• Third most common cause of death in all age groups
Current concepts of polytrauma management; PF Stahel, CE Heyde, W Ertel - European
Journal of Trauma, 2005 - Springer
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7. POLYTRAUMA Vs MULTIPLE
FRACTURES
• Polytrauma is not a synonym of multiple fractures.
• Multiple fractures are purely Orthopaedic problem as
there is involvement of skeletal system only.
• While in polytrauma there is involvement of more than
one system like associated head injury/ chest
injury/spinal injury/ abdominal or pelvic injury
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8. Death in polytrauma
• Immediate trauma death/First peak of death.
• Early trauma death /Second peak of death .
• Late death /Third peak of death .
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9. FIRST PEAK OF DEATH/IMMEDIATE TRAUMA DEATH
• Severe head injury
• Brain stem injury
• High spinal cord injury
• Heart and major vessel injury
• Massive blood loss
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10. Second peak of death / Early trauma death
• Intracranial bleed
• Chest injury
• Abdominal bleeding
• Pelvic bleeding
• Multiple limb injury
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11. Third peak of death / Late death
• It occurs after several days or weeks due to
– Sepsis
– Organ failure
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12. Non-salvagable deaths
• 50% deaths due to trauma occurs before the patient
reaches hospital.
• 30% occurs within 4 hrs of reaching the hospital.
• 20% occurs within next 3 weeks in the hospital.
• If preventive measures are taken, 70% deaths can be
prevented meaning 30% deaths are non-salvagable
deaths.
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13. PATHOPHYSIOLOGY AND IMMUNE
RESPONSE TO TRAUMA
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14. Physiologic response to injury
(Earlier Hypothesis)
• 3 phases:
(a) a hypo dynamic phase (shock) where our body initially
attempts to limit the blood loss and to maintain perfusion to
the vital organs
(b) a hyper dynamic flow phase lasting for up to 2 weeks,
characterized by increased blood flow, in order to remove
waste products and to allow nutrients to reach the site of
injury for repair
(c) a recuperation phase, lasting for months, to allow the
human body to attempt to return to its pre-injury level.
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15. Physiologic response to injury
(Present Theory)
• The first physiologic reaction after injury involves the
neuroendocrine system leading to an adrenocortical
response characterized by the increased release of
adrenocorticosteroids and catecholamines.
• This is involved in what is called “the general
adaptation syndrome.” This is considered as a
forerunner to the SIRS.
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16. • This activation of the neuroendocrine system is
responsible for the incr in HR, RR, fever and leukocytosis
observed in trauma patients after major injury
• SIRS is defined as being present when two or more of the
criteria apply
(a) body temperature: >38 or <36°C;
(b) heart rate: >90/min;
(c) RR: >20/min or PaCO2 < 32 mm Hg;
(d) white blood cell count>12,000 or <4,000/mm3 or
>10% band forms
(e) Lactate <2 mmol/L
SIRS
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17. • The activation of the immune system following a traumatic
insult is necessary for
• hemostasis
• protection against invading microorganisms
• initiation of tissue repair and tissue healing.
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20. GENOMIC STORM
• The analysis of the genomic response to trauma has shown a
“genomic storm” with activation of more than 5,136 genes.
• Trauma has stimulated the expression of genes involved in innate
immunity, microbial recognition, or inflammation.
• In contrast, the expression was decreased in genes for T-cell
function and antigen presentation.
• Patients with uncomplicated recovery were associated with a
down regulation of genes within 7 to 14 days after trauma
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21. Interleukin-6
• Interleukin-6 (IL-6) has perhaps been the most useful
and widely employed of these mediators, partly due to
its more consistent pattern of expression and plasma
half life.
• A measurement of >500 pg/dL in combination with
early surgery has been associated with adverse
outcome.
• A cut-off value of 200 pg/dL was shown to be
significantly diagnostic of an “SIRS state.”
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23. Alarmins
• The alarmins are endogenous molecules capable of activating innate
immune responses as a signal of tissue damage and cell injury.
• In this group of endogenous triggers belong molecules such as
(a) high mobility group box 1 (HMGB1),
(b) heat shock proteins (HSPs),
(c) defensins, cathelicidin, eosinophil-derived neurotoxin
• These structurally diverse proteins function as
(a) Endogenous mediators of innate immunity
(b) chemoattractants
(c) Activators of antigen presenting cells (APCs).
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24. PAMPs
• In contrast to alarmins, the so-called pathogen-associated
molecular patterns (PAMPs) represent inflammatory
molecules of a microbial nature being recognised by the
immune system as foreign due to their peculiar molecular
patterns
• Both PAMPS and alarmins are currently considered to belong
to the larger family of Damage associated molecular proteins
(DAMPs)
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27. 34

28. simultaneous induction of pro- and anti-inflammatory genes and
suppression of adaptive immune system following trauma -A genomic storm
in critically injured humans
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29. Current paradigm shows initial pro-inflammatory response associated with the development
of systemic inflammatory response syndrome and delayed immunosuppression also known
as compensatory anti-inflammatory response syndrome (CARS).
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32. Multiple Organ Dysfunction
Syndrome(MODS)
• The clinical appearance of a seemingly poorly controlled
severe systemic inflammatory reaction, following a
triggering event such as infection,inflammation or
trauma.
• It represents the net result of altered host defence and
deregulation of the inflammatory response and the
immune system.
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33. Physiological effects of MODS
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34. PRE-HOSPITAL CARE
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35. PRE-HOSPITAL PHASE
• Starts soon as the EMS arrives the site of injury
• 1. Maintenance of Airway
• 2. Cardiopulmonary resuscitation
• 3. Fluid replacement with isotonic solution
• 4. Reduction and splintage of fractures
• 5. Perform primary survey of patient and report findings
to destination centre
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36. TRIAGE
• Triage is usually used in a scene of an accident or
"mass-casualty incident”.
• To sort patients into those who need critical attention
and immediate transport to the hospital and those with
less serious injuries.
Priority 1 Immediate
Priority 2 Urgent
Priority 3 Delayed
Priority 4 Dead
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37. Current concepts of polytrauma
management; PF Stahel, CE Heyde,
W Ertel - European Journal of
Trauma, 2005 - Springer 45

38. Golden Hour
• Rapid transport of severely injured patient to a trauma
center with in one hour
• Chances of survival diminishes after one hour
• Platinum 10 minutes: Only 10 minutes of the Golden hour
may be used for on-scene activities
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39. PRIMARY SURVEY
• A – Air way maintenance with control of cervical spine
• B – Breathing & Oxygenation
• C – Circulation & Control of bleeding
• D - Disability Limitation (Neurological Evaluation)
• E - Exposure/ Environmental Control
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40. • Life threatening conditions are identified and
management is instituted simultaneously
• Airway obstruction
• Tension pneumothorax
• Haemothorax
• Open thoracic injury and flail chest
• Cardiac tamponade
• Massive internal or external hemorrhage
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41. SIGNS OF AIRWAY OBSTRUCTION
• LOOK
• AGITATION
• RIB RETRACTION
• DEFORMITY
• FOREIGN MATERIAL.
• LISTEN
• SPEECH?
• HOARSENESS.
• NOISY BREATHING
• GURGLE.
• STRIDOR.
• FEEL
• CREPITUS
• TRACHEAL DEVIATION
• HEMATOMA
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42. MAINTANENCE OF AIRWAY
• Mask O2
• Endo Tracheal-Intubation
• Ambu Bag
– Protection of the spine is very important while giving
airway maintanence.
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43. CAUSES OF MAJOR BLEEDING
• External bleeding(Inspect and apply local pressure)
• Thoracic bleeding
• Pelvic bleeding
• Intra-abdominal bleeding
• Long bones fracture bleeding (Splintage and transport)
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47. Trauma scoring systems
• Used to quantify the injuries in consideration with other parameters like
comorbidities, age, and mechanism of injury
• based on conversion of many independent factors into a one-dimensional numeric
value that ideally represents the patient’s degree of critical illness.
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48. RTSc - 0.9368 GCS + 0.208 RR +0.7326 SBP
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49. Injury Severity Score
• AIS codes are allotted and grouped into six ISS-body regions: head and neck,
face, chest,abdomen, extremities and pelvis, and external
• The ISS is the sum of the squared AIS scores from the three most severely
injured ISS-body regions.
• It can take values from 1 to 75
• If AIS is 6 in any of the body region ISS becomes 75 independent of any other
injuries
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51. NISS
• Osler et al described NISS in 1997
• Calculated as the sum of highest three AIS severity scores
regardless of the ISS body regions
• Disadvantage - requires an accurate injury diagnosis
before a precise calculation can be made
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52. TRISS
• The TRISS uses both the ISS and the RTS as well as the
patient’s age to predict survival
Ps = 1/(1 + e-b)
where e is a constant (approximately 2.718282) and
b = b0 + b1(RTS) + b2(ISS) + b3(age factor)
b constant is derived from MOTS database
• Scores range from 0 to 1
• Its predictive value of survival or death approximates75% to 90%
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53. IN HOSPITAL MANAGEMENT
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54. Staging of the Patient’s Physiologic
Status
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55. Staging of Patient Management
Periods
• Acute “Reanimation” period - 1-3hrs
• Primary “stabilisation” period- 1-48hrs
• Secondary “regeneration” period - 2-10 days
• Tertiary “reconstruction and rehabilitation” period
(weeks)
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56. Imaging
• Conventional Radiography
• Chest Xray AP View
• Cervical spine lateral view
• Xray pelvis AP view
• USG- eFAST
To be done bedside with a mobile
Xray machine
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57. • CT Scan
• Gold standard for head, spinal, chest and abdomen
imaging
• Angiography
• Best method for detecting traumatic vascular
injuries
• Especially useful in intra pelvic and abdominal solid
organ injuries
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58. Priorities for life saving Surgeries
• Hemothorax
• Mediastinal Hemorrhage and thoracic Aortic injuries
• Abdominal Trauma vs expanding ICH
• Pelvic Trauma
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59. Priorities for life saving Surgeries
• Hemothorax
• Mediastinal Hemorrhage and thoracic Aortic injuries
• Abdominal Trauma vs expanding ICH
• Pelvic Trauma
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60. Damage Control Orthopedics
• Early stabilisation of the femoral fractures reduces the
incidence of Fat embolism, ARDS and post op
complications
• In 1980s the rationale of Early Total Care was
developed. Surgeries were done within 24hrs of
admission
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61. What is Damage Control?
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64. Damage Control Orthopedics
• Early rapid containment and stabilisation of orthopedic
injuries without worsening the patient general
condition
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65. Damage Control Orthopedics
• Early rapid containment and stabilisation of orthopedic
injuries without worsening the patient general
condition
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72. CONCLUSION
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