recent advances in treatment of the polytrauma patient

1. Current
Concepts
of
Polytrau
ma
Manageme
AHMED MATTHANA

2. INTRODUCTION:
• Trauma still represents the
“major killing factor” in
young patients < 45 years
of age in industrialized
countries
• In recent years, the
implementation of
standardized protocols of
polytrauma management led
to a significant
improvement of trauma care
in European countries and
to a decrease in
posttraumatic morbidity and
mortality

3. MORTALITY IN POLYTRAUMA
• Trauma is a major public health problem with high disability,
death, and societal cost
• Three peak times of death after trauma
• 50% within the first minutes of sustaining the injury
• caused by massive blood loss or neurologic injury
• 30% within hours of arrival to hospital
• most commonly from shock, hypoxia, or neurologic injury
• 20% within days to weeks following injury
• multi system organ failure and infection are leading causes

4. ATLS
• The “Advanced Trauma Life Support” (ATLS®)
protocol for the acute management of severely
injured patients has been established as a gold
standard in most European countries since the
1990s.
• Continuative concepts to the ATLS® program
include the “Definitive Surgical Trauma Care”
(DSTC™) algorithm and the concept of “damage
control” surgery for polytraumatized patients
with immediate life-threatening injuries

5. CHANGES OF TREATMENT CONCEPTS
• Phase-oriented therapeutic strategies are in
sharp contrast to previous modalities of “early
total care” which advocate immediate definitive
surgical interventions
• “damage control” surgery takes the influence of
systemic posttraumatic inflammatory and
metabolic reactions of the organism into
account and is aimed at reducing both the
primary and the secondary – delayed – mortality
in severely injured patients.

6. DEFINITION OF POLYTRAUMA
• A syndrome of multiple injuries exceeding a
defined severity (Injury Severity Score [ISS] >
15) with consecutive systemic trauma reactions
which may lead to dysfunction or failure of
remote – primarily not injured – organs and
vital systems
“Polytrauma” – definition according to Otmar
Trentz (2000).

7. ISS:
The Injury Severity Score (ISS) is an established medical score
to assess trauma severity.
It is used to define the term major trauma.
A major trauma (or polytrauma) is defined as the Injury Severity
Score being greater than 15.
The AIS Committee of the Association for the Advancement of
Automotive Medicine (AAAM) designed and improves upon the
scale.

8. Abbreviated Injury Scale (AIS)
• The (AIS) is an anatomically based consensus-derived global
severity scoring system that classifies each injury in every body
region according to its relative severity on a six-point ordinal
scale:
1.Minor
2.Moderate
3.Serious
4.Severe
5.Critical
6.Maximal (currently untreatable).

9. ISS
• To calculate an ISS for an injured person, the body is divided
into six ISS body regions. These body regions are:
• Head or neck – including cervical spine
• Face – including the facial skeleton, nose, mouth, eyes and
ears
• Chest – thoracic spine and diaphragm
• Abdomen or pelvic contents – abdominal organs and lumbar
spine
• Extremities or pelvic girdle – pelvic skeleton
• External

10. AIS chapters corresponding to Nine body regions:
1.Head
2.Face
3.Neck
4.Thorax
5.Abdomen
6.Spine
7.Upper Extremity
8.Lower Extremity
9.External and other.

11. ISS CALCULATION
• (ISS = A2 + B2 + C2 where A, B, C are the AIS scores of the
three most injured ISS body regions).
• The ISS scores ranges from 1 to 75 (i.e. AIS scores of 5 for
each category).
• If any of the three scores is a 6, the score is automatically set
at 75.
• Since a score of 6 ("un-survivable") indicates the futility of
further medical care in preserving life, this may mean a
cessation of further care in triage for a patient with a score of 6
in any category.

12. Trauma-related mortality has
three major causes
• (1) Immediate mortality at the accident site
(“sudden death”) due to lethal injuries such as
aortic rupture with free bleeding, lacerations
of the brain stem, or decapitating injuries;

13. THE GOLDEN HOUR
• (2) Early mortality within the first few
minutes to hours (“golden hour”) due to
compromised airways, tension pneumothorax,
hemorrhagic shock of intraabdominal or
intrathoracic bleeding and pelvic ring
disruptions with massive retroperitoneal
hemorrhage, or due to severe traumatic brain
injury with acute cerebral edema or
intracranial hematoma;

14. • (3) Late mortality within days to weeks after
trauma due to septic complications, multiple
organ failure and due to untreatable increased
intracranial pressure associated with cerebral
edema.

15. RULE OF THREE
• the optimization of preclinical transportation
times and the implementation of the concept of
patient transport to the closest appropriate –
not just to the closest – hospital (rule of
“three R’s” by Donald Trunkey: “get the Right
patient to the Right hospital in the Right
time”)

16. ATLS
• The “Advanced Trauma Life Support“ (ATLS®)
protocol of the American College of Surgeons’
Committee on Trauma has been established as a
standard procedure algorithm for the initial
assessment and management of polytraumatized
patients in the past 3 decades in > 30
countries worldwide and in twelve European
countries.

18. GOLDEN HOUR CONCEPT BY ATLS:
• The principle of the “golden hour of shock”
• diagnostic algorithms and validated therapeutic
concepts according to the ATLS® guidelines
• Not restricted to management within just the
first 60 min after injury only, but can be
safely extended to the first few hours after
trauma

19. DSTC
• “Definitive Surgical Trauma Care“ (DSTC™)
course by the International Association for the
Surgery of Trauma and Surgical Intensive Care
provides the standards of emergency surgical
procedures of patients with blunt and
penetrating injuries.

20. DAMAGE CONTROL ORTHOPEDICS:
• The concept of “damage control” orthopedic
surgery has evolved based on the observation
that a prolonged early definitive treatment of
long bone fractures can be

21. SHOCK

23. LETHAL TRIAD
• the early restoration of the “lethal triad” of
persistent metabolic acidosis, hypothermia, and
coagulopathy represents the prime goal for
survival
• Thus, polytrauma patients in extremis must be
transferred to intensive care at the earliest
time point after stabilization of vital
functions for restoration of physiological
parameters, and prolonged surgical
interventions must be avoided in order to
prevent a lethal “second hit” in these patients

24. “damage control” surgery
involves four distinct phases of assessment and
management
• (1) life-saving surgery with early recognition
of those trauma patients that warrant damage
control (“ground zero” recognition phase);
• (2) salvage operation for control of hemorrhage
and contamination (“OR phase”);
• (3) intensive care management for restoration
of physiological and immunologic baseline
functions (“ICU phase”);
• (4) scheduled definitive surgery

25. DCR
• Triage rapid
assessment: DCR?
• Hemorrhage control:
STOP HGE
• Resuscitation: TREAT
REVERSED HGE SHOCK
• Medication
administration: TREAT
HYPOCACEMIA

26. ALGORITHM

27. TRIAGE ASSESSMENT
• (1) primary survey with baseline diagnostics and
immediate life-saving procedures and establishing
access to life-support systems according to the A-B-C
algorithm of the ATLS® protocol;
• (2) damage control surgery in patients who are not
responsive to the initial measures of resuscitation:
surgical control for exsanguinating hemorrhage and
decompression of body cavities (“life-saving surgery”);
• (3) secondary survey in hemodynamically stable patients
with elaborate diagnostics including a “head-to-toe”
examination and further radiologic work-up (CT scan,
conventional X-rays, angiography, etc.);
• (4) “delayed primary surgery”: decontamination,
surgical exploration and management of non-immediately
life-threatening injuries, temporary fracture fixation.

28. Life-Saving Surgery and Damage
Control
• The treatment priorities are based on the
likelihood of a patient to die within a short
time from a life-threatening injury, according
to the “A-B-C-D-E” mnemonic:
• Airway maintenance with cervical spine
protection,
• Breathing and ventilation,
• Circulation with hemorrhage control,
• Disability: brief neurologic evaluation,
• Exposure with environmental control (protection
from hypothermia).

30. CIRCULATION-HEMORRHAGE CONTROL
• hemorrhages must be recognized, and the
bleeding must be stopped, if necessary by
surgical measures.
• individual compensatory mechanisms can maintain
a normal blood pressure for a limited time
even. blood loss of up to 30% (equivalent to
1.5 l blood the systolic blood pressure can be
kept within a normal range by increasing the
peripheral resistance, thus “masking” the state
of shock.

31. CIRCULATION-HEMORRHAGE CONTROL
• However, cardiac output is reduced to up to
half the normal value which may lead to
critical LOW organ perfusion and subsequent
metabolic acidosis with elevated serum lactate
and an increased lactate : pyruvate ratio in
serum due to the anaerobic metabolic situation.
• Therefore, during the primary survey, the main
question to be addressed with regard to blood
loss

33. The clinical symptoms of shock
are the “three windows to the
microcirculation”
• which can be assessed in terms of inadequate
organ perfusion: (1) mental status/level of
consciousness (cerebral perfusion) – agitation,
confusion, somnolence or lethargy;
• (2) peripheral perfusion – cold and clammy
skin, delayed capillary refilling, tachycardia;
• (3) renal perfusion – oliguria (< 0,5 ml/kg/ h)
or anuria.

34. 3 WINDOWS:
• These clinical
findings must help
differentiate in an
early phase whether
a patient is
“hemodynamically
normal” or just
apparently
“hemodynamically
stable” with the
risk of
deterioration.

35. PROPER IV FLUIDS TRANSFUSION
• average adult (70 kg male) has an estimated 4.7 - 5 L of circulating blood
• average child (2-10 years old) has an estimated 75 - 80 ml/kg of circulating blood
• Methods of Resuscitation
• Fluids crystalloid isotonic solution
• blood options
• O negative blood (universal donor)
• Type specific blood
• Cross-matched blood
• transfuse in 1:1:1 ratio (red blood cells: platelets: plasma)

36. Indicators of adequate
resuscitation
• urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
• serum lactate levels  normal < 2.5
mmol/L, < 45 mg/dL
• most sensitive indicator as to whether
some circulatory beds remain
inadequately perfused
• gastric mucosal ph
• base deficit normal -2 to +2

37. ASSESSENT FOR HIDDEN SHOCK
• Arterial blood gas analysis can furthermore help
determine the extent of hemorrhagic shock
• lactate levels and base deficit represent highly
sensitive parameters for recognition of “hidden
shock”
• A base deficit < the cutoff at –6 mEq/l in the
initial blood gas analysis has been shown to be
associated with significantly increased
transfusion requirements
• A base deficit < –10 mEq/l has been associated
with a high mortality of 40–70%
• Mortality in patients with normal base deficit or
base excess (+2 to –2 mEq/l) was as low as about
6%

38. LACTATE MONITORING
• The time frame of normalization of lactate
levels below a cutoff at 2 mmol/l was shown to
correlate significantly with survival.
• While polytrauma patients with refractory
lactate acidosis (> 2 mmol/l) for > 48 h after
injury had a mortality of 85%, those patients
where lactate levels normalized within the
first 24 h had a low mortality of around only
1%

39. D – disability:
• brief Neurologic evaluation. After
stabilization of vital functions, a brief
evaluation of the level of consciousness (GCS)
and of pupil symmetry and reaction is
performed. The presence of traumatic brain
injury must be recognized early in order to
take preventive measures for the development of
secondary brain injury due to hypoxemia and
hypotension

40. GCS

41. GCS
• The severity of traumatic brain injury is
classified according to the GCS as
• mild (14–15 points),
• moderate (9–13 points),
• and severe (3–8 points).
• Endotracheal intubation for securing a patent
airway is mandatory at a GCS ≤ 8, since
these patients are comatose per definition

42. BRAIN INSULT
• propagation of a massive
intracerebral inflammatory
response leading to
development of brain edema
with increased intracranial
pressure and decreased
cerebral perfusion pressure,
ultimately contributing to
delayed neuronal cell death

43. CT BRAIN
• In these patients, a
craniocerebral CT
scan is mandatory due
to the significantly
increased likelihood
of intracranial
hematoma as compared
to patients with mild
head injury (GCS 14
or 15)

44. E – exposure with
environmental control.
• Every trauma patient must be
completely undressed for
thorough inspection and
examination under protection
from hypothermia by warm
blankets and preheated
infusions and heating lamps.
• A “log-roll” maneuver is
mandatory in all patients for
inspection of the back side
for potential hidden
injuries.

45. IMAGING
• Delay of fracture diagnosis is most commonly caused by failure to image extremity
• image any extremity with pain, crepitus, ecchymosis, deformity
• AP Chest
• mediastinal widening
• pneumothorax
• Lateral C-spine
• must visualize C7 on T1
• not commonly utilized in lieu of increased sensitivity with cervical spine CT
• AP Pelvis
• pelvic ring
• further CT imaging should be delayed until preliminary pelvic stabilization has been accomplished
• acetabulum
• proximal femur
• CT Scan
• C-spine, chest, abdomen, pelvis
• often used in initial evaluation of trauma patient to rule out life threatening injuries

46. The Concept of “Damage
Control”
• The rationale behind the concept of
abbreviating standard surgical procedures lies
within the aim of an early transfer of critical
patients to the intensive care unit (ICU) for
restoration of physiological “endpoints of
resuscitation”
• in recent years, the “classic” orthopedic
concept of “early total care” for the unstable
multiply injured patient has been abandoned in
favor of the new concept of “damage control
orthopedic surgery” (DCO) which has led to an
increased overall survival of polytrauma

47. DCO:
• definitive treatment delayed until physiology has improved
• popularized in 2000
• replaced the 1980s philosophy of Early Total Care (ETC), the concept of fixing
long bone fractures as soon as possible because patients were "too sick not
to operate"
• ETC led to exacerbation of the "second-hit" in a subset of patients with
hemodynamic instability, head, and/or chest injuries

48. DCO:
• Involves staging definitive management to avoid
adding trauma to patient during vulnerable
period
• the decision to operate and surgical timing on
multiple injured trauma patients remains
controversial
• intra-operative hypotension increases mortality
rate in patients with head injury

49. DCO
Parameters that help decide who should be treated
with DCO
• ISS >40 (without thoracic trauma)
• ISS >20 with thoracic trauma
• GCS of 8 or below
• multiple injuries with severe pelvic/abdominal trauma and
hemorrhagic shock
• bilateral femoral fractures
• pulmonary contusion noted on radiographs
• hypothermia <35 degrees C
• head injury with AIS of 3 or greater
• IL-6 values above 500pg/dL

50. Optimal time of surgery
• patients are at increased risk of ARDS and multisystem failure during
the acute inflammatory window (period from 2 to 5 days characterized by a
surge in inflammatory markers), THUS surgery should be avoided, if possible,
by this time temporarily.
• These measures are necessary to reduce the
overall stress to the organism through necrotic
tissue and inflammatory mediators (“antigenic
load”) and to avoid infectious complications
and the development of sepsis and organ failure

51. EXCEPTIONS:
• only potentially (LIFE/ LIMB threatening) injuries should be treated in this
period including
• unstable pelvic fracture
• compartment syndrome
• fractures with vascular injuries
• unreduced dislocations
• traumatic amputations
• unstable spine fractures
• cauda equina syndrome
• open fractures

52. Stabilization followed by staged definitive management
• to minimize trauma, initial stabilization should be performed and followed by
staged definitive management
• includes initial pelvic volume reduction via sheet, pelvic packing, skeletal
traction, binder, or external fixation
• if hemodynamically stable  proceed with further imaging including CT
chest, abdomen, pelvis
• if not hemodynamically stable  consider exploratory laparotomy and/or
pelvic angiography and embolization

53. definitive treatment delayed for
• 7-10 days for pelvic fractures
• within 3 weeks for femur fractures (conversion from Ex-Fix to IMN)
• 7-10 days for tibia fractures (conversion from external fixation to IMN)

54. EARLY APPROPRIATE CARE
• Definition/history
• identifies major trauma patients and definitively treats the most time-critical
orthopaedic injuries while minimizing the secondary inflammatory response, guided
by laboratory parameters of adequate resuscitation
• popularized in 2013
• Parameters:
1. lactate of < 4.0 mmol/L
2. pH ≥ 7.25
3. base excess ≥ -5.5 mmol/L

55. THIS IS NOT AN EARLY TOTAL
CARE!

56. Optimal time of surgery
• goal is to definitively treat spine, pelvis, femur, and acetabulum
fractures within 36 hours of injury
• Outcomes
• decreased delay to surgery
• decreased complication rates
• increased hospital revenues

57. Decompression of body cavities
• Pathologically increased pressure in body
cavities requires immediate emergency surgical
management.
• This involves the acute decompression of a
tension pneumothorax and the drainage of a
traumatic hemo-/pneumothorax, as described for the
ATLS®
• In addition, a suspected cardiac tamponade must be
immediately resolved by subxiphoideal puncture
and/or open decompression in case of required
emergency thoracotomy.
• Furthermore, the presence of a epidural hematoma
requires immediate decompression by burr hole
evacuation and/or craniotomy.
• These surgical measures have utmost priority due
to the acute life-threatening implication of these

58. Control of exsanguinating
hemorrhage.
• Volume replacement is performed according to
the 3 : 1 rule, which means that one unit of
lost blood must be replaced by three units of
fluid due to loss into the third compartment
• Significant external hemorrhages are
temporarily stopped by external compression and
sterile dressing in the emergency room followed
by surgical wound management in the operating
room.

59. Major internal bleeding
sources which require
immediate surgical control
are:
• massive hemothorax: open chest drain
placement. Requirement of urgent thoracotomy in
cases of penetrating trauma and/or after blunt
trauma with massive bleeding via chest tube (>
1,500 ml immediately or continuing hemorrhage
of > 200 ml/h in the later phase)
• intraabdominal hemorrhage: indications for
urgent laparotomy include hemodynamically
unstable patients with blunt abdominal trauma
and positive ultrasonography and patients with
penetrating abdominal injuries

60. Patients “in extremis”
• with severe multiple injuries have a
significantly increased chance of survival if
the surgical procedure is abbreviated and
definitive repair of intraabdominal injuries is
delayed in terms of a staged procedure (crash-
laparotomy, “packing”, laparostoma/ temporary
Ethizip® closure), as compared to patients with
early total care .
• Definitive surgery is followed within 24–48 h
after stabilization of vital parameters in the
ICU.

61. pelvic ring disruption
• pelvic ring disruption with massive
retroperitoneal hemorrhage: unstable pelvic
injuries with posterior pelvic ring disruption
are associated with massive uncontrolled
retroperitoneal bleeding of up to 5,000 ml due
to lacerations of the presacral and paravesical
venous plexus and cancellous bone bleeding

62. PELVIC RING DISRUPTION
• These patients require immediate closed
reduction of the pelvic ring in the emergency
room and fixation with a pelvic “C-clamp” VS
ANTISHOCK SCREWS (posterior pelvic ring) and/or
external fixator (anterior pelvic ring).

63. Packing
• If these measures – in combination with
aggressive volume resuscitation – cannot
achieve hemodynamic stability, explorative
laparotomy with pelvic “packing” is warranted
in order to achieve surgical hemorrhage
control.

64. • It is crucial to know that > 80% of hypotensive
patients due to pelvic hemorrhage are
“nonresponders” . The hallmark of these
patients’ survival is a rapid recognition and
surgical control of hemorrhage, since mortality
in pelvic fracture-associated hemorrhage is
still as high as 50–60%

65. ARTERIAL EMBOLIZATION FOR
PELVIC HEMORRHAGE IS OBSOLETE
• Interventional measures like angiography and
embolization are obsolete for the management of
these patients, since arterial bleeding sources
are present in < 10% of all cases and
successful embolization can be performed in <
2%
• TIME CONSUMING
• AGAINST GOLDEN HOUR CONCEPTS
• RISK TO TRANSFER THE CRITICAL PATIENT TO THE
CATH LAB

66. The propagated “damage
control” procedure for
• hemodynamically unstable patients with pelvic
ring disruptions includes:
• closed reduction and external fixation / rapid
SI screw fixation
• explorative laparotomy,
• pelvic “packing” and provisional closure of
the abdomen with surgical zippers (Ethizip®).

67. RESULTS
• This therapeutic modality has
been shown to lower mortality
from pelvic bleeding from 50–60%
to about 20–25%.
• Change of packings has to be
performed within 24–48 h and
definitive surgery is to follow
during the “time window of
opportunity” from the 5th to 10th
day after trauma

69. MANGLED EXTREMITY
• • penetrating and blunt vascular injuries,
“mangled extremity”: arterial injuries with
clinical signs of limb ischemia due to blunt or
penetrating trauma require immediate surgical
management without further diagnostics.
• The “Mangled Extremity Severity Score” (MESS)
has been established as a guideline for early
determination whether limb salvage is
achievable as opposed to early amputation, with
an established “cutoff” level of the MESS at 7
points

71. MESS
• MESS</= 6 LIMB
IS SALVAGEABLE

72. HOW WE DECIDE ON SALVAGE VS
AMPUTATION?
• PREDECTIVE SALVAGE INDEX PSI
• MANGLED EXTREMITY SCORE MESS
• LIMB SALVAGE INDEX LSI
• NERVE INJURY,ISCHEMIA,SOFT TISSUE INJURY,
SKELETAL INJURY, SHOCK, AND AGE NISSSA
• HANNOVER FRACTURE SCALE-97 (HFS-98)

73. HFS-98
• The HFS'98 was established,
which is characterized by eight
domains (bone loss, skin injury,
muscle injury, wound
contamination, neurology, periost
stripping, local and systemic
circulation), a total score range
from 0-22 points and a cut off point
(amputation recommended) at a
score of > or = 11.

74. Delayed Primary Surgery (“Day-
1 Surgery”)
• Surgical interventions which are not
immediately required for resolving life-
threatening conditions are performed after
further evaluation of the stabilized patients
in the secondary survey. Hereby, the term
“delayed” refers to primary surgical
interventions within the first 24 h (“day-1
surgery”).
• These operations are aimed at reducing the
“antigenic load”, saving injured limbs and
joints at risk, decompressing the spinal cord,
and optimizing the therapeutic modalities on

75. EXAMPLES:
• decompression of compartments under pressure
in non-immediately life-threatening conditions:
unstable vertebral fractures with spinal
stenosis, subdural hematoma, compartment
syndromes of the extremities;
• laparotomy for hollow viscus injuries;
• revascularization of vascular injuries;
• debridement of contaminated soft tissue and
open fractures/joint injuries;
• external fracture fixation of long bones;
• dorsal fixation of unstable vertebral
fractures by internal fixator.

76. Intensive Care & Scheduled
Definitive Surgery
• Following the operative interventions,
subsequent transfer to the ICU is aimed at the
earliest time point possible for further
stabilization of the polytrauma patient and for
restoration of the following “endpoints of
resuscitation”

77. “endpoints of resuscitation”
1. stable hemodynamics without need for
vasoactive or inotropic stimulation;
2. no hypoxemia, no hypercapnia;
3. serum lactate ≤ 2 mmol/l;
4. normal coagulation;
5. normothermia;
6. urinary output > 1 ml/kg/h.

78. window of opportunity
• The next management phase takes into account the
presence of a physiological “window of
opportunity” between days 5–10 after trauma,
which corresponds to the interval between the
early hyperinflammatory phase and the period of
immunosuppression which follows the 2nd week
after trauma

79. PHASE OF IMMUNOSUPPRESSION
• During the phase of immunosuppression, no
surgery should be performed due to the high
susceptibility to a “second-hit” injury with an
increased risk of complications such as
developing sepsis and multiple organ failure.
Only after the 3rd week should further
reconstructive operations be performed, if
required

80. SUMMARY:
• new concepts in recent years have demonstrated
that highly critical polytrauma patients in
extremis have a significantly improved overall
outcome, if surgical procedures are abbreviated
for the benefit of an early transfer to
intensive care
• The kinetics of the physiological response to
severe injury must be taken into account for
the timing and priorities of surgical
interventions in the further course after
trauma

81. REFERENCES:
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