Treatment algorithms for the polytrauma patient Published: July 2013 Thorsten Hammer, DE AOT Basic Principles Course

Learning outcomes Identify the priorities of saving life, saving limb, and disability-limiting surgery Outline the general and local factors affecting decision making Discuss the role of the different trauma team members Teaching points: Include emergency management of the cervical spine or give separate lecture on this.

Polytrauma?

Definition Two or more severe injuries At least one injury or the sum of all injuries being life threatening Injury severity score (ISS) ≥ 16 There is a lack of consensus and a validated definition of the term polytrauma References: Trentz O, et al. [Criteria for the operability of patients with multiple injuries (author’s transl.)]. Unfallheilkunde 1978; 81: 451–458. German. Baker SP, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187–196 Butscher N, et al. The definition of polytrauma: The need for international consensus. Injury 2009 Nov;40 Suppl 4:S12-22

Distribution There are three peaks of death from trauma: First peak, immediate—unsurvivable injuries, impacted by trauma prevention Second peak, early—golden hour of care, impacted by Advanced Trauma Life Support (ATLS) and early hospital care Third peak, late—caused by sepsis and multiple organ dysfunction syndrome (MODS), impacted by optimal early care and trauma center management

Incidence Trauma is the leading cause of death in the first four decades of life in developed countries There are more than 5 million trauma-related deaths each year worldwide Motor vehicle crashes cause over 1 million deaths per year Injury accounts for 12% of the world’s burden of disease

Algorithms Treatment of multiple trauma requires: Knowledge of the common injury patterns Incidence Mortality Consequences Main differences between these injuries References: Butcher NE, Balogh ZJ. The practicality of including the systemic inflammatory response syndrome in the definition of polytrauma: experience of a level one trauma centre. Injury. 2013 Jan;44(1):12-7

Algorithms—index of suspicion Fall from high (> 3 m) Ejection from car Death of a passenger Pedestrian or cyclist struck by car Motorcycle or car crash Entrapment or burying Explosion injuries High energy

Algorithms Get the right patient to the right hospital in the right time References: Trunkey DD. What's wrong with trauma care? Bull Am Coll Surg. 1990 Mar;75(3):10–15.

Algorithms Assessment of the patient: Cranium and facial bones Chest and neck Abdomen Spine Pelvis Extremities

Roles of the team members Aim of the trauma team is a safe and efficient evaluation of the patient Identify all injuries and instigate definitive management Golden hour starts at the time of injury Vital that everyone knows their place and tasks, and has the skills, equipment, and support to accomplish these. Trauma room should be quiet so that the team leader can be heard and assessments from team members can be relayed back Vital signs should be called out every five minutes and heard by everyone The aim of the trauma team is to provide a safe and efficient evaluation of the patient. Identify all injuries and instigate definitive management of such injuries. The golden hour starts at the time of injury. It is vital that everyone knows their place and their tasks, and has the skills, equipment and support to accomplish these. The trauma room should be quiet so that the voice of the team leader can be heard and assessments from team members can be relayed back to him Vital signs should be called out every five minutes and these must be heard by everyone.

Advanced Trauma Life Support (ATLS) ATLS provides a common language © 2012 American College of Surgeons, ATLS Manual, 9th Edition

Advanced Trauma Life Support (ATLS) Airway with C-spine protection Breathing with adequate oxygenation Circulation with hemorrhage control Disability Exposure / Environment © 2012 American College of Surgeons, ATLS Manual, 9th Edition

Algorithms Whole-body CT significantly increases the probability of survival Whole-body CT is recommended as a standard diagnostic method during early resuscitation Radiation dose is reduced with a single-pass, whole-body multidetector row CT trauma protocol Integration of whole-body CT into trauma care significantly increases the probability of survival in patients with polytrauma. Whole-body CT is recommended as a standard diagnostic method during the early resuscitation phase for patients with polytrauma. Radiation dose is reduced with a single-pass whole-body multi-detector row CT trauma protocol compared with a conventional segmented method References: Huber-Wagner S et al. Lancet. 2009 Apr 25;373(9673):1455-61 Ptak T, Rhea JT, Novelline RA. Radiology. 2003 Dec;229(3):902-5.

Pathophysiology Central part of the pathophysiological changes is the trauma-induced: Coagulopathy (TIC) Hypothermia Acidosis References: Gebhard F. Polytrauma—pathophysiology and management principles; Langenbecks Arch Surg (2008) 393:825–831

Pathophysiology Complex pathophysiological interactions of damaged and dysfunctional molecules, cells, and organs with the defense systems Results in a systemic inflammatory response and severe complications such as Sepsis Multi-organ dysfunction (MODS) Multi-organ failure (MOF) The complex pathophysiological interactions of damaged and dysfunctional molecules, cells, and organs with the defense systems result in a systemic inflammatory response and severe complications such as sepsis, multi-organ dysfunction (MODS) multi-organ failure (MOF) References: Gebhard F. Polytrauma—pathophysiology and management principles; Langenbecks Arch Surg (2008) 393:825–831

Pathophysiology References: Gebhard F. Polytrauma—pathophysiology and management principles; Langenbecks Arch Surg (2008) 393:825–831

Pathophysiology—Systemic Inflammatory Response Syndrome (SIRS) SIRS can be diagnosed when any two of the following criteria exist: Body temperature < 36°C or > 38°C Heart rate > 90 beats/min Respiratory rate > 20 breaths/min or pCO2 < 4.3 kPa (32mm Hg) White cell count < 4 or > 12 x 109 /l or the presence of > 10% immature neutrophils References: Russell JA. Management of sepsis [published erratum appears in N Engl J Med 2006;355:2267]. N Engl J Med 2006;355:1699–713.

Pathophysiology—Systemic Inflammatory Response Syndrome (SIRS) Early key components of therapy: Adequate fluid resuscitation Antibiotic therapy (IV) Mechanical ventilation Source control Vasopressors (Low dose IV corticosteroids) References: Russell JA. Management of sepsis [published erratum appears in N Engl J Med 2006;355:2267]. N Engl J Med 2006;355:1699–713.

Algorithms Early Total Care (ETC) Damage Control Orthopedics (DCO)

Algorithms Surgical priorities Circulation Brain Bones

Algorithms First, at the same time as the clinical assessment, life-saving procedures need to be performed rapidly: Control of massive intrathoracic abdominal bleeding Decompression of the chest and brain ATLS guidelines First, at the same times as the clinical assessment, lifesaving procedures need to be performed rapidly. Control of massive intra-thoracic abdominal bleeding Decompression of the chest and brain As standardized by ATLS guidelines.

Algorithms Second, damage-control interventions are needed: Debridement Decompression Temporary fracture stabilization Trauma-adjusted surgical techniques are crucial to limiting the systemic response known to put remote organs at risk In the “vulnerable phase”, only “second look” debridement to minimize a “second hit” is recommended During the second phase of “day-one-surgery” damage-control interventions (such as debridement, decompression, and temporary fracture stabilization) are needed to avoid an excessive molecular and cellular danger response. Trauma-adjusted surgical techniques are crucial to limiting the systemic response known to put remote organs at risk. In the “vulnerable phase” when the patient’s defense is rather uncontrolled, only “second look” debridement to minimize a “second hit” is recommended.

Algorithms Third, reconstructive surgery can be applied after stabilization of the patient After stabilization of the patient as indicated by improvement of tissue oxygenation, coagulation, and decreased inflammatory mediators, reconstructive surgery can be applied.

Take-home messages Timely and effective management to prevent severe systemic complications Successful treatment requires comprehensive knowledge of: Underlying pathophysiological mechanisms Corresponding principles of surgical management The complex pathophysiology of the polytraumatized patient requires a timely and effective management in order to protect the trauma victim from the deathly spiral of severe systemic complications. Comprehensive knowledge of the underlying pathophysiological mechanisms and the corresponding principles of surgical management are indispensable for the successful treatment of multiple injured patients.