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

2. 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.

3. Polytrauma?

4. 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

5. 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

6. 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

7. 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 Jan;44(1):12-7

8. 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

9. 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 Mar;75(3):10–15.

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

11. 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.

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

13. 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

14. 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 Apr 25;373(9673):
Ptak T, Rhea JT, Novelline RA. Radiology Dec;229(3):902-5.

15. 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

16. 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

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

18. 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.

19. 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.

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

21. Algorithms
Surgical priorities
Circulation
Brain
Bones

22. 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.

23. 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.

24. 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.

26. 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.