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)
2
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.”
4
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
5
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
6
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
7
8. Death in polytrauma
• Immediate trauma death/First peak of death.
• Early trauma death /Second peak of death .
• Late death /Third peak of death .
8
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
9
10. Second peak of death / Early trauma death
• Intracranial bleed
• Chest injury
• Abdominal bleeding
• Pelvic bleeding
• Multiple limb injury
10
11. Third peak of death / Late death
• It occurs after several days or weeks due to
– Sepsis
– Organ failure
11
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.
12
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.
15
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.
16
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
17
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.
18
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
27
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.”
28
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).
30
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)
31
28. simultaneous induction of pro- and anti-inflammatory genes and
suppression of adaptive immune system following trauma -A genomic storm
in critically injured humans
35
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).
36
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.
39
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
42
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
44
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
46
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
47
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
48
42. MAINTANENCE OF AIRWAY
• Mask O2
• Endo Tracheal-Intubation
• Ambu Bag
– Protection of the spine is very important while giving
airway maintanence.
50
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)
51
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.
58
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
61
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
63
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%
64
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)
67
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
68
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
69
58. Priorities for life saving Surgeries
• Hemothorax
• Mediastinal Hemorrhage and thoracic Aortic injuries
• Abdominal Trauma vs expanding ICH
• Pelvic Trauma
70
59. Priorities for life saving Surgeries
• Hemothorax
• Mediastinal Hemorrhage and thoracic Aortic injuries
• Abdominal Trauma vs expanding ICH
• Pelvic Trauma
71
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
72
2 of the 4 parameteres satisfied to call it as SIRS
- Target Hb concentration is between 7-9g/L (superior outcomes than Hb of 1g/L)
- Young and indl with adequate physiologic reserve tolerate Hb as low as 5g/L
D/D of Shock
Neurogenic Shock - Relative hypovolemia . Due to spinal injury. Loss of autonomic supply leads to decrease in vascular tone without significant blood loss
Cardiogenic Shock - Cardiac temponade, tension pneumothorax or hemothorax
Damage control using Hypotensive resuscitation is a new concept
Accomplished by using transfusion of RBCs, plasma and Platelets in ratio of 1:1:1 together wit coagulation factors
More than 600 patients of poly trauma across 12 level 1 centres in North America’s were followed up between Aug 12 and Dec 13
APACHE - Acute Physiology and Chronic Health evaluation
SOFA - Sequential Oran Failure Assessment
PATI - Penetrating Abdominal Trauma Index
SIRS-
TRISS- RTS + ISS + Pt Age Index
ASCOT- A Severity Characterisation of Trauma
AIS
Uses 7 digits to describe an injury
1- Body Region
2- Type of anatomical structure
3-4 - specific anatomical structure
5,6- level of injury
7- severity of score
MANGLED EXTREMITY SEVERITY SCORE
Described by Johansen et al (1990)
Components include:
• Skeletal / soft-tissue injury
• Limb ischemia
• Shock
• Age
• Interpretation: a MESS score of greater than or equal to 7 had a 100% predictable value for amputation
Threshold of 11 was used as a decision tool to transfer the patient to a dedicated trauma centre
In RTSc the threshold for transfer is 4
AIS
Uses 7 digits to describe an injury
1- Body Region
2- Type of anatomical structure
3-4 - specific anatomical structure
5,6- level of injury
7- severity of score
Body regions
1- Head
2- Face
3- Neck
4- Thorax
5- abdomen
6- Spine
7- UL
8- LL
9- Unspecified
Example
MOTS- Major Trauma Outcome Study
Ps- probability of survival
Borderline Pts
ISS >40
Hypothermia below 35 deg
Mean Pulm Art pr >24mm Hg
ISS > 2 with thoracic Trauma
Multiple injuries in assoc with abdominal or pelvic injury and hemorrhagic shock at presentation (SBP <90 mmHg)
Radiographic Pulm Contusion
Bilateral Femoral fractures
Mod to severe head injury (AIS >3)
AIS
1- Minor
2- Moderate
3- Severe
4- Serious
5- Critical
6- Unsurvivable
In a study of almost 50,000 trauma patients 70% of deaths were attributed to the head injury alone and only 7% to extracranial trauma
Evacuating an intracranial hematoma if the patient exsanguinates is obviously futile. However, there is equally little, and some would say less, benefit in saving a patients life if the result is profoundly disabling brain injury or death from tentorial herniation. Once compensatory autoregulatory mechanisms are overwhelmed, intracranial pressure rapidly increases
Decisions must be made and clinical experience
In a study of almost 50,000 trauma patients 70% of deaths were attributed to the head injury alone and only 7% to extracranial trauma
Evacuating an intracranial hematoma if the patient exsanguinates is obviously futile. However, there is equally little, and some would say less, benefit in saving a patients life if the result is profoundly disabling brain injury or death from tentorial herniation. Once compensatory autoregulatory mechanisms are overwhelmed, intracranial pressure rapidly increases
Decisions must be made and clinical experience
In 1960s the philosophy prevailed that the polytrauma pt was too sick to operate on
Development of fat embolism and pulmonary dysfunction was feared
Defensive surgical treatment was often delayed up to 10-14days
A variety of unexpected complications related to the early stabilization of fractures of long bones was described. These complications mainly developed in patients with severe chest injuries, severe hemodynamic shock post reamed intramedullary nailing without thoracic trauma.
This led to the conclusion that the method of stabilization and the timing of surgery may have played a major role in the development of such complications
Aims
Contains and stabilises Orthopedic Injuries so that the patient general physiologic conditions improve
Avoid worsening of the patient by a major Orthopedic procedure
Delay definitive fracture repair in unstable patient
Aims
Contains and stabilises Orthopedic Injuries so that the patient general physiologic conditions improve
Avoid worsening of the patient by a major Orthopedic procedure
Delay definitive fracture repair in unstable patient