Polytrauma Course (PTC)

1.1 Course Concept:   

       polytraumacourse.com

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 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 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 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 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