1.1 Course Concept:
1.2 Definition of Polytrauma
The definition implies the following parameters: Two injuries that are greater or equal to 3 on the AIS and one or more additional diagnoses (pathologic condition), that is:
- hypotension (systolic blood pressure ≤ 90 mm Hg,)
- unconsciousness (GCS score ≤ 8)
- acidosis (base deficit ≤ -6.0)
- coagulopathy (PTT ≥ 40 seconds or INR ≥ 1.4)
- age (≥70 years).
Pape et al, J Trauma Acute Care Surg. 2014; 77: 780-786.
2.1 ATLS
(Reference: https://www.facs.org/quality-programs/trauma/atls)
A: Airway Maintenance with Cervical Spine Protection
Checklist:
- Airway obstructions by foreign bodies, facial fractures.
- Glasgow Coma Scale (GCS) < 8 needs definitive airway management.
- Immobilization of the c-spine with appropriate devices
Figure 15
- Cardiac or respiratory arrest
- Airway obstruction
- Respiratory insufficiency
- Severe hypoxemia (despite supplemental oxygen)
- Severe cognitive impairment (GCS <8) requiring airway protection
- Need for deep sedation or analgesia (also preoperative management)
- Severe hemorrhagic shock
- Increased intracranial pressure (transient hyperventilation)
- Delivery of 100% oxygen to patients with carbon monoxide intoxication
- Facilitation of management (e.g., diagnostics) in combative or intoxicated patients
(Reference: Management of Musculoskeletal Injuries in the Trauma Patient; Smith, Wade R., Stahel, Philip F. (Eds.) Springer)
B: Breathing and Ventilation
Checklist:
- Clinical assessment (inspection, palpation, auscultation, and percussion).
- Radiological assessment (chest x-ray).
- Clear out: tension pneumothorax, flail chest with pulmonary contusion, massive hematothorax, and open pneumothorax.
C: Circulation with Hemorrhage Control
Checklist:
- Identify potential sources for bleeding: chest, abdomen, pelvic, and long bone.
- Bleeding signs:
- Clinical signs: (skin color, pulse, level of consciousness, capillary refill, and blood pressure).
- Radiologic signs: thoracic (chest x-ray) source, or abdominal (Focused Abdominal Sonography in Trauma (FAST)) source.
- Start resuscitation (crystalloids and/or blood products), and assess the indications for surgical intervention.
- Pelvic fractures can be stabilized by pelvic binders in trauma bay.
D: Disability (Neurologic Evaluation)
Checklist:
- In trauma victims suspected to have brain injury repeated evaluation for any change in the papillary size, and level of consciousness is a must.
- Glasgow Coma Scale is a useful score to evaluate the neurologic status.
- A decrease in level of consciousness can be due to: decreased cerebral oxygenation, decrease cerebral perfusion, direct cerebral injury, or alcohol / drugs use.
E: Exposure / Environmental Control
- Completely undress the patient.
- Avoid the development of hypothermia.
- Associated complications (impairment of coagulation, circulation, oxygenation, and appearance of cardiac arrhythmias).
2.2 Life Threatening Conditions
1. Cerebral Herniation
(Definition: Deadly side effect of high intracranial pressure)
2. Massive Hemorrhage
Gutierrez G1, Reines HD, Wulf-Gutierrez ME Clinical review: hemorrhagic shock..Crit Care. 2004 Oct;8(5):373-81.
3. Tension Pneumothorax
(Definition: abnormal collection of air or gas in the pleural space and progressive increase of pressure in the pleural space)
4. Open Pneumothorax
(Definition: Pneumothorax with associated chest wall defect)
5. Flail Chest
(Definition: Deterioration of the thoracic rib cage and detachment from the rest of the rib cage)
6. Massive Haemothorax
(Definition: massive accumulation of blood in the pleural cavity)
7. Cardiac Tamponade
(Definition: acute pericardial effusion with blood)
8. Severe Hypothermia
(Definition: Mild hypothermia (35-32 °C); severe hypothermia (< 32 °C))
GCS (Glasgow Coma Scale)
- Minor Brain Injury, GCS ≥ 13.
- Moderate Brain Injury, GCS 8 or 9–12 (controversial).
- Severe Brain Injury, with GCS < 8-9
PGCS (Pediatric Glasgow Coma Scale)
- Minor Brain Injury, GCS ≥ 13
- Moderate Brain Injury, GCS 8 or 9–12
- Severe Brain Injury, with GCS < 8-9
ISS
RTS (Revised Trauma Score)
- Physiological measurement, based on data at arrival to hospital.
- RTS is based on: Respiratory rate, Systolic blood pressure, and GCS.
Teadsdale G, Jennett B (1974) Assessment of coma and impaired consciousness – a practical scale. Lancet II: 81-83
Thoracic Trauma Score (TTS)
Pape HC, Remmers D, Rice J, Ebisch M, Krettek C, Tscherne H. Appraisal of early evaluation of blunt chest trauma: development of a standardized scoring system for initial clinical decision making. J Trauma 2000;49:496—504.
Soft Tissue Injury
- Closed Soft Tissue Injury
Oestern HJ, Tscherne H: Pathophysiology and classification of soft tissue injuries associated with fractures, in Tscherne H, Gotzen L [eds]: Fractures With Soft Tissue Injuries [German]. Telger TC [trans]. Berlin, Germany: Springer-Verlag, 1984, pp 6–7.)
- Open Soft Tissue Injury
Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–8
MESS (Mangled Extremity Severity Score)
Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990 May;30(5):568-72; discussion 572-3
Reference: Leitlinie Polytrauma / Schwerverletzten-Behandlung: http://www.awmf.org/leitlinien/detail/ll/012-019.html
5.1 Head injury
- Consciousness level, pupil function, and Glasgow Coma Scale should be recorded and documented at repeated intervals.
- Our ultimate goal to reach level of normoxia, normocapnia, and normotension. A fall in arterial oxygen saturation level below 90% must be avoided.
- A CCT scan must be performed in case of polytrauma with suspected traumatic brain injury.
- A (monitoring) CT scan must be performed in the case of neurologic deterioration.
- Glucocorticosteroids must not be administered in case of TBI.
CCT Scan Indications:
- Coma
- Clouded level of consciousness
- Amnesia
- Vomiting if there is a close time relationship to the impact of force
- Cramp seizure
- Clinical signs or radiological evidence of cranial fractures
- Suspected impression fracture and/or penetrating injuries
- Suspected cerebrospinal fluid fistula
- Evidence of a coagulation disorder (third party medical history, “marcumar pass”, continues bleeding from superficial injuries, etc.)
- Other neurologic disorders
5.2 Thoracic Injury
Indications for chest CT:
- Road traffic accident Vmax > 50 km/h
- Fall from > 3 m height
- Patient ejected from vehicle
- Rollover trauma
- Substantial vehicle deformation
- Pedestrian knocked down at > 10 km/h
- Biker knocked down at > 30 km/h
- Crush injury.
- Pedestrian hit by vehicle and flung > 3 m
- GCS < 12
- Cardio-circulatory abnormalities (respiratory rate > 30/min, pulse > 120/min, systolic blood pressure < 100 mmhg, blood loss > 500 ml; capillary refill > 4 seconds)
- Severe concomitant injuries (pelvic ring fracture, unstable spinal fracture or spinal cord compression)
- Clinically relevant or progressive pneumothorax need to be decompressed.
- Pericardial decompression should be carried out if there is evidence of pericardial tamponade and an acute deterioration in the vital signs.
- A thoracotomy can be performed if there is an initial blood loss of > 1500 ml from the chest drain or persistent blood loss of > 250 ml/h over more than 4 hours.
5.3 Abdominal Injury
- Normal abdominal exam doesn’t rule out an intra-abdominal injury.
- FAST exam usually performed to screen for free fluid.
- FAST should be repeated at intervals if a computed tomography scan cannot be performed promptly.
- Multi-slice helical CT (MSCT) has high sensitivity, and the highest specificity to identify any intra-abdominal injuries.
5.4 Pelvis Injury
- Pelvic stability should be clinically examined.
- CT scan used to assess any injury to the pelvic area.
- Emergent pelvic mechanical stabilization should be carried out if the pelvic ring is unstable and associated with hemodynamic instability.
- During the initial exploratory survey, the external urethral meatus and the transurethral bladder catheter (if the latter is already inserted) should be examined for blood.
5.5 Spine Injury
- After circulatory stabilization and before transfer to the intensive care unit, a spinal injury should be cleared by imaging diagnostic tests.
- Pathologic, suspect and non-evaluable regions in conventional radiography should be further cleared with CT.
5.6 Extremities Injury
- Malposition and dislocation in the extremities should be reduced and stabilized.
- If there is no peripheral pulse (Doppler/palpation) detected in an extremity, further diagnostic tests should be carried out.
- Depending on the finding and the condition of the patient, conventional arterial digital subtraction angiography (DSA), duplex ultrasonography or angio-CT (CTA) should be performed.
5.7 Hemorrhagic Shock
- Crystalloids are the first choice of fluid replacement in trauma patients.
- Isotonic saline solution should not be used; preference for ringer’s malate, alternatively Ringer’s acetate, or lactated Ringer’s
- If colloidal solutions are used in hypotensive trauma patients, preferences should be given to HES 130/0.4.
5.8 Coagulopathy
- Transfusion should be approach when the hemoglobin levels become below 10 g/dl or 6.2 mmol/l. Maintain hematocrit at 30% is our goal.
- In massive blood transfusions, FFP: PRBC ratio should be in the range of 1:2 and 1:1.
- Fibrinogen replacement needed if levels are at < 1.5 g/l (150 mg/dl).
6.1 Fracture Fixation
Safe Definitive Surgery
Figure 1
Description: DCO (Damage Control Orthopedics); SDS (Safe Definitive Surgery)
Secondary Surgery
Criteria for sec. surgery
- Hemodynamic stability
- Stable arterial oxygenation
- Lactate < 2 mmol/L
- Absence of coagulopathy
- Normothermia
- Urine production > 1mL/kg/h
- No needs for catecholamines
Borderline Conditions
Figure 16
Reference: Baue AE, Faist E, Fry Mods: Multiple organ failure. New York: Springer 2000
Figure 2
Tscherne, MD; G. Regel, MD; H-C Pape, MD; T. Pohlemann, MD; and C. Krettek, MD Internal Fixation of Multiple Fractures in Patients With Polytrauma CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 347, pp 62-78 1998
Fracture Fixation: Femur
Pape HC1, Tornetta P 3rd, Tarkin I, Tzioupis C, Sabeson V, Olson SA Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009 Sep;17(9):541-9.
Ipsilateral Fractures
Figure 4
Tscherne, MD; G. Regel, MD; H-C Pape, MD; T. Pohlemann, MD; and C. Krettek, MD Internal Fixation of Multiple Fractures in Patients With Polytrauma CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 347, pp 62-78 1998
Intra-operative decision making
Figure 5
Hans-Christoph Pape, MD,* Peter V. Giannoudis, MD,† Christian Krettek, MD, FRACS, and Otmar Trentz, MD‡ Timing of Fixation of Major Fractures in Blunt Polytrauma Role of Conventional Indicators in Clinical Decision Making, J Orthop Trauma 2005;19:551–562
Head Trauma
Figure 6
Ref: The Poly-Traumatized Patient with Fractures A Multi-Disciplinary ApproachEditors: Pape, Hans-Christoph, Sanders, Roy, Borrelli, Joseph (Eds.)
Thorax Trauma
Figure 7
Ref: Management of Musculoskeletal Injuries in the Trauma Patient, Smith, Wade R., Stahel, Philip F. (Eds.) Springer
Abdominal Trauma
Figure 8
GSW (Gunshot Wound), SW (Stab Wound), RUQ( Right upper Quadrant), AASW (anterior abdomen stab wound)
Ref: The Poly-Traumatized Patient with Fractures A Multi-Disciplinary ApproachEditors: Pape, Hans-Christoph, Sanders, Roy, Borrelli, Joseph (Eds.)
Pelvic Trauma
Figure 9
Ref: The Poly-Traumatized Patient with Fractures A Multi-Disciplinary ApproachEditors: Pape, Hans-Christoph, Sanders, Roy, Borrelli, Joseph (Eds.)
Figure 10
Spinal Injuries
Figure 11
Ref: The Poly-Traumatized Patient with Fractures A Multi-Disciplinary Approach Editors: Pape, Hans-Christoph, Sanders, Roy, Borrelli, Joseph (Eds.)
Urological Injuries
Figure 12
Ref: The Poly-Traumatized Patient with Fractures A Multi-Disciplinary Approach Editors: Pape, Hans-Christoph, Sanders, Roy, Borrelli, Joseph (Eds.) Heidenreich and Pfister, P 115
7.1. APACHE II (Acute Physiology and Chronic Health Evaluation)
Severity of Disease Classification System
APACHE II SCORE= Sum of A (APS points)+B(Age points)+C(Chronic Health points)Knaus WA, Draper EA, Wagner DP, Zimmerman JE,
APACHE II: a severity of disease classification system. Crit Care Med 1985; 13 (10):818-29
7.2 SOFA (Sequential Organ Failure Assessment-Score)
JL Vincent, R Moreno, J Takala; The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure; Intensive Care Medicine July 1996, Volume 22, Issue 7, pp 707-710
The Poly-Traumatized Patient with Fractures A Multi-Disciplinary Approach Editors: Pape, Hans-Christoph, Sanders, Roy, Borrelli, Joseph (Eds.); Springer 2011
Damage Control Management in the Polytrauma Patient; Hans-Christoph Pape,Andrew B. Peitzman,C. William Schwab,Peter V. Giannoudis; Springer 2010