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European Journal of Trauma Focus on Polytrauma

Current Concepts of Polytrauma Management


Philip F. Stahel*, Christoph E. Heyde*, Wolfgang Ertel1

Abstract Introduction
In recent years, the implementation of standardized Trauma still represents the “major killing factor” in
protocols of polytrauma management led to a sig- young patients < 45 years of age in industrialized coun-
nificant improvement of trauma care in European tries [1, 2]. In Germany alone, 4–5 million people suffer
countries and to a decrease in posttraumatic mor- traumatic injuries each year and > 20,000 severely injured
bidity and mortality. As such, the “Advanced Trauma patients die every year [1, 3–5]. Trauma-related mortality
Life Support” (ATLS®) protocol for the acute man- has three major causes [6]: (1) the immediate mortality at
agement of severely injured patients has been es- the accident site (“sudden death”) due to lethal injuries
tablished as a gold standard in most European such as aortic rupture with free bleeding, lacerations of
countries since the 1990s. Continuative concepts to the brain stem, or decapitating injuries; (2) early mortal-
the ATLS® program include the “Definitive Surgical ity within the first few minutes to hours (“golden hour”)
Trauma Care” (DSTC™) algorithm and the concept of due to compromised airways, tension pneumothorax,
“damage control” surgery for polytraumatized pa- hemorrhagic shock as a consequence of intraabdominal
tients with immediate life-threatening injuries. or intrathoracic bleeding and pelvic ring disruptions with
These phase-oriented therapeutic strategies ap- massive retroperitoneal hemorrhage, or due to severe
praise the injured patient in the whole extent of the traumatic brain injury with acute cerebral edema or in-
sustained injuries and are in sharp contrast to pre- tracranial hematoma; (3) late mortality within days to
vious modalities of “early total care” which advo- weeks after trauma due to septic complications, multiple
cate immediate definitive surgical interventions. organ failure and due to untreatable increased intracra-
The approach of “damage control” surgery takes the nial pressure associated with cerebral edema.
influence of systemic posttraumatic inflammatory Major improvements in the management strategies of
and metabolic reactions of the organism into ac- severely injured patients in the past decades have led to a
count and is aimed at reducing both the primary significant reduction of polytrauma-associated mortality
and the secondary – delayed – mortality in severely from about 40% in the 1970s to around 10% in the year
injured patients. The present paper shall provide an 2000 [7]. This achievement is mainly owed to improved
overview on the current state of management algo- standards of trauma care due to defined algorithms of pre-
rithms for polytrauma patients. and in-hospital trauma care which have been broadly
propagated and established in most industrialized and de-
Key Words veloping countries [6, 8–15]. Since the patients’ outcome is
Polytrauma · Management · ATLS® · Damage con- directly related to the time interval from injury to properly
trol · Multiorgan failure · Mortality delivered definitive care, the optimization of preclinical
transportation times and the implementation of the con-
Eur J Trauma 2005;31:200–11 cept of patient transport to the closest appropriate – not
DOI 10.1007/s00068-005-2028-6 just to the closest – hospital (rule of “three R’s” by Donald

* Both authors contributed equally to this paper.


1
Department of Trauma and Reconstructive Surgery, Charité –
University Medical School Berlin, Campus Benjamin Franklin, Berlin,
Germany.
Received: February 27, 2005; accepted: March 7, 2005.

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Stahel PF, et al. Polytrauma Management

Trunkey: “get the Right patient to the Right hospital in the Figure 1. The “lethal triad” in the
Right time”) [16, 17], have led to minimized transportation pathophysiology of severely in-
jured patients leading to a vicious
times and to shorter therapy-free intervals with overall im- circle and adverse outcome. This
proved outcome of polytrauma patients [1, 4, 7, 13]. Fur- implication constitutes the un-
thermore, the vast propagation of the “damage control” derlying rationale for the concept
of “damage control” surgery [30].
concept for severely injured patients with immediate
life-threatening injuries, as well as the improvement of in-
tensive care strategies for polytraumatized patients have
further contributed to an increased level of trauma care
with reduced trauma-associated mortality [18–24].
Successful primary care of polytraumatized patients detrimental for severely injured patients who are in a per-
(Box 1) is characterized by the demands of both therapeu- sisting unstable physiological state despite adequate resus-
tic and diagnostic measures. Since the time factor is of cru- citative measures during the initial management phase [18,
cial essence, validated concepts and algorithms have been 19, 28–30]. In these patients, the early restoration of the
established in the past few years for the initial diagnosis “lethal triad” of persistent metabolic acidosis, hypother-
and treatment of severely injured patients. The updated mia, and coagulopathy represents the prime goal for sur-
“Guidelines of the German Society of Trauma Surgery” vival [28–30] (Figure 1). Thus, polytrauma patients in ex-
(DGU) for the diagnostics and treatment of polytrauma- tremis must be transferred to intensive care at the earliest
tized patients have recently been outlined in a compre- time point after stabilization of vital functions for restora-
hensive review article [25]. The “Advanced Trauma Life tion of physiological parameters, and prolonged surgical
Support“ (ATLS®) protocol of the American College of interventions must be avoided in order to prevent a lethal
Surgeons’ Committee on Trauma has been established as “second hit” in these patients [24, 31–33]. The current un-
a standard procedure algorithm for the initial assessment derstanding of “damage control” surgery involves four dis-
and management of polytraumatized patients in the past 3 tinct phases of assessment and management [18, 34]: (1)
decades in > 30 countries worldwide and in twelve Euro- life-saving surgery with early recognition of those trauma
pean countries [6, 14]. Based on the principle of the “gold- patients that warrant damage control (“ground zero” rec-
en hour of shock”, injuries which would take a lethal ognition phase); (2) salvage operation for control of hem-
course if left untreated within the first minutes to few orrhage and contamination (“OR phase”); (3) intensive
hours after trauma are being cared for using standardized care management for restoration of physiological and im-
diagnostic algorithms and validated therapeutic concepts munologic baseline functions (“ICU phase”); (4) sched-
according to the ATLS® guidelines [6, 14, 26]. In blunt uled definitive surgery (“reconstructive phase”).
polytrauma patients, this early phase of the “golden hour” The present review shall provide an up-to-date
is not restricted to management within just the first 60 min overview on established diagnostic and therapeutic al-
after injury only, but can be safely extended to the first gorithms of preclinical and clinical management of poly-
few hours after trauma [27]. Beyond the ATLS® concept, traumatized patients.
the “Definitive Surgical Trauma Care“ (DSTC™) course
by the International Association for the Surgery of Trau- Preclinical Management
ma and Surgical Intensive Care provides the standards of During the prehospital period, emphasis in the manage-
emergency surgical procedures of patients with blunt and ment of polytrauma patients should be placed on airway
penetrating injuries. maintenance, control of external bleeding, fluid resusci-
The concept of “damage control” orthopedic surgery tation, immobilization of the spine, and immediate trans-
has evolved based on the observation that a prolonged port to the closest appropriate clinic. Different algorithms
early definitive treatment of long bone fractures can be have been established to narrow the time window from
injury to definitive care and to optimize the preclinical
Box 1. “Polytrauma” – definition according to Otmar Trentz (2000). therapeutic strategies and determine the adequate target
A syndrome of multiple injuries exceeding a defined severity (Injury facility for the individual trauma patients [6, 13, 35–37].
Severity Score [ISS] > 17) with consecutive systemic trauma reactions These defined algorithms should help prevent the under-
which may lead to dysfunction or failure of remote – primarily not
triage of trauma victims – a phenomenon which has been
injured – organs and vital systems [24].
shown to occur mainly in elderly patients [16, 17]. Thus,

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Stahel PF, et al. Polytrauma Management

the prime philosophy in the decision scheme suggested tion devices must be applied for stabilization of the entire
by the American College of Surgeons’ Committee on vertebral column during transport, since spinal injuries
Trauma is: “When in doubt, take the patient to a trauma must be assumed in all polytrauma patients until proven
center” [6]. The initial assessment of trauma victims at the otherwise. Based on the principle of “do no further harm”,
accident site is performed on the basis of vital functions patients are immobilized with a cervical collar and evacu-
and a rough overview of the overall injury pattern. In the ated on a long spine board or a vacuum mattress. Based
case of a trapped person inside a car, the temporal course on the National Acute Spinal Cord Injury Study (NAS-
of rescue and life-saving procedures must be coordinated CIS) guidelines, high-dose methylprednisolone therapy
[6, 35]. According to established algorithms, the mea- (30 mg/kg bolus i.v.) should be initiated as early as possi-
sures of extrication of trapped victims are in secondary ble in the case of neurologic impairment due to suspected
priority to securing the airway and protecting the cervical spinal cord injury, ideally at the accident site and impera-
spine [6, 35, 36]. Ensuring vital function according to the tively within a time window of 8 h after trauma [43, 44].
A-B-C priorities of the ATLS® protocol comprises clear- Steroid therapy is continued in the clinic for further 24 h
ing and securing the airway or establishing a patent air- with a maintenance dose of 5.4 mg/kg/h [43, 44]. In con-
way by endotracheal intubation in the case of acute air- trast to blunt spinal trauma, steroids are not recommend-
way compromise [6, 13]. Supplemental oxygen is provided ed for penetrating spinal cord injury, such as gunshot in-
to every trauma patient by an oxygen mask. The indica- juries [45, 46]. In the latter case, the use of steroids has not
tion for endotracheal intubation at the accident site is es- been shown to improve the neurologic outcome, but was
tablished liberally in cases of risk of airway obstruction or associated with a greater frequency of nonspinal compli-
aspiration (unconscious patients with Glasgow Coma cations [45, 46].
Scale [GCS] score ≤ 8, insufficient respiration with hyp- In parallel to airway management with cervical spine
oxemia due to severe thoracic trauma or flail chest), and protection, resuscitative measures for shock therapy are
to prevent hypoxemia-induced secondary injury in severe initiated by fluid replacement via at least two large-cali-
head trauma [6, 38]. In intubated patients, adequate anal- ber peripheral venous accesses. An initial infusion vol-
gesia and sedation/relaxation are mandatory to prevent ume of 2,000 ml crystalline solution or alternatively crys-
pain and systemic secondary stress reactions leading to talloids and colloids at a ratio of 3 : 1 are recommended
increased intracranial pressure and adverse outcome as a standard [6, 13]. External bleeding sources are con-
[39]. While assessing and managing the patient’s airway, trolled by local compression and sterile dressing in addi-
great care must be taken to prevent excessive movement tion to fluid resuscitation. The use of surgical clamps and
of the – potentially injured – cervical spine. During resus- tourniquets is obsolete and contraindicated due to iatro-
citative measures, the C-spine must be protected by genic additional tissue damage. In the case of hemorrhag-
in-line immobilization to prevent hyperextension, hyper- ic shock associated with massive internal bleeding due to
flexion, and rotation [6, 40]. Endotracheal intubation is pelvic ring disruptions, initial hemorrhage control is es-
performed by standardized two-person maneuver ac- tablished by reduction of the pelvic ring by internal rota-
cording to the ATLS® criteria with the helper holding the tion of both thighs and wrapping with wide bandages or
cervical spine in slight axial in-line position while the sec- sheets [47, 48]. This simple technique can significantly de-
ond person performs intubation [6, 40]. Although fiber- crease retroperitoneal bleeding associated with pelvic
scope-guided nasotracheal intubation has been shown to ring disruptions – by diminishing the pelvic volume – dur-
be the safest measure with regard to limited cervical spine ing the transportation phase.
motion during establishment of a patent airway [41], this Soft-tissue wounds and open fractures need to be
technique is not suited for intubation in an emergency documented at the accident site and are covered by a
situation. For rapid-sequence induction, the use of an in- sterile dressing. No further inspection of the wound is
tubating laryngeal mask (Fastrach) has been postulated warranted until surgical exploration in the clinic [6]. At
as a safe maneuver with limited cervical spine excursion no time should the wound be probed. If a fracture and an
[42], however, the use of a laryngeal mask is not regarded open wound exist in the same limb segment, the fracture
as a safe standard for establishing a patent airway in trau- has to be considered open until proven otherwise by the
ma patients, according to the ATLS® criteria [6]. Thus, surgical exploration. Concordantly, a wound over a joint
these additional measures are not suited for emergency implies an open joint injury. In these cases, administra-
intubation at the accident site. Appropriate immobiliza- tion of tetanus prophylaxis and antibiotics by a sec-

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Stahel PF, et al. Polytrauma Management

prove the overall outcome of severely injured patients


(Figure 2) [4, 6, 18, 23–26, 50]. The established time-de-
pendent management phases for trauma patients in the
first 24 h (“day-1 surgery”) comprise:
(1) primary survey with baseline diagnostics and imme-
diate life-saving procedures and establishing access
to life-support systems according to the A-B-C algo-
rithm of the ATLS® protocol;
(2) damage control surgery in patients who are not re-
sponsive to the initial measures of resuscitation: surgi-
cal control for exsanguinating hemorrhage and de-
compression 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, surgi-
cal exploration and management of non-immediately
life-threatening injuries, temporary fracture fixation.

Life-Saving Surgery and Damage Control


During the primary survey, the injured patient is rapidly
assessed according to the algorithm of the ATLS® pro-
tocol and life-preserving therapy is instituted simultane-
ously. The treatment priorities are based on the likeli-
Figure 2. Proposed algorithm for the initial assessment and manage- hood of a patient to die within a short time from a
ment of polytrauma patients.
life-threatening injury, according to the “A-B-C-D-E”
mnemonic [6] (Table 1):
ond-generation cephalosporin are warranted upon ar- • Airway maintenance with cervical spine protection,
rival in the clinic [49]. Fracture-dislocations are reduced • Breathing and ventilation,
in-line and fixed by temporary devices. Immediate trans- • Circulation with hemorrhage control,
fer to definitive care should not be retarded by any of • Disability: brief neurologic evaluation,
these additional measures [6]. When available, the rescue • Exposure with environmental control (protection
helicopter should be used for fast and careful transport of from hypothermia).
seriously injured patients to a verified level I trauma cen- Using this algorithm during the primary survey, poten-
ter. Hereby, early notification of the receiving doctor at tial life-threatening conditions are identified and man-
the target hospital is of essential importance. All avail- aged simultaneously with a frequent reassessment of
able information on the overall condition and estimated the patient’s physiological status and response to re-
injury pattern of the accident victim must be transmitted suscitative measures [6]. The key point of any success-
ahead of time so that adequate equipment and manpow- ful management of a severely injured patient concerns
er can be arranged at the receiving hospital until admis- the clear priority of “damage control” ahead of any
sion of the patient to the emergency room [6]. time-consuming diagnostic procedure. It has to be
pointed out, however, that the concept of “damage
Initial Assessment and Management control” – as outlined later in the paper – does not rep-
Upon arrival in the emergency room, the primary objec- resent an integrated part of the original ATLS® proto-
tive of the initial assessment and management of poly- col [6].
traumatized patients is survival. Thus, timing and pri-
orities have to be followed in tight adherence to defined A – airway maintenance with cervical spine protection.
established algorithms which have been shown to im- The first priority in the care of trauma victims is to ensu-

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Stahel PF, et al. Polytrauma Management

Table 1. Initial assessment and management principles according to the Advanced Trauma Life Support (ATLS®) algorithm [6]. FAST: focused
assessment sonography for trauma.

Assessment of vital functions Management

A Airway maintenance with cervical spine protection


• Inspection of upper airways, recognition of upper airway obstruction • Clearance of upper airways, suction, jaw-thrust or chin-lift maneuver,
(stridor, hoarseness, laryngeal hematoma/emphysema/dislocation, oropharyngeal tube, “patent airway“ establishment by endotracheal
dyspnea, tachypnea) intubation with rapid-sequence induction or surgical airway by cri-
cothyroidotomy. Deliver supplemental oxygen. All measures must be
performed under C-spine protection (C-collar, in-line immobilization)!
B Breathing and ventilation
• Clinical recognition of tension pneumothorax (!), massive hemothorax, • Puncture of second intercostal space in midclavicular line for acute
rib fractures, flail chest, subcutaneous emphysema decompression of tension pneumothorax, open placement of a chest
drain for hemo-/pneumothorax, flail chest, rib fractures in intubated
patients
C Circulation with hemorrhage control
• Recognize clinical signs of shock (“three windows to the microcircu- • Aggressive volume resuscitation (3 : 1 rule of replacement)
lation”): cerebral, peripheral and renal perfusion, tachycardia • Surgical control of external and internal bleedings
(> 100/min). Hypotension only in advanced state of shock with blood • “Damage control“ procedure for patients in extremis
loss of > 30–40%
• Recognize external and internal hemorrhage sources (clinical
examination, “FAST“, chest and pelvic X-ray)
D Disability: brief neurologic evaluation
• Glasgow Coma Scale (GCS) score and pupil evaluation • GCS ≤ 8: endotracheal intubation!
E Exposure with environmental control
• Completely undress the patient and “log-roll“ for posterior injuries • Protection from hypothermia by warmed blankets, heating lamps and
application of preheated infusions

re an adequate airway. This implies the maintenance B – breathing and ventilation. In second priority to en-
of patent upper airways, if necessary by endotracheal suring an adequate airway, a tension pneumothorax
intubation or, in exceptional situations, by establishing must be excluded based on clinical findings due to the
a surgical airway through cricothyroidotomy. Correct immediate threat to life [6]. The clinical symptoms in-
positioning of the tube must be confirmed by ausculta- clude acute dyspnea with ipsilaterally decreased respi-
tion, end-tidal CO2 monitoring, and a chest X-ray. In ratory sounds and hypersonoric percussion sound with
addition, every trauma patient must receive supplemen- congested jugular veins. The clinical sign of congested
tal oxygen (4–10 l/min via oxygen mask in nonintubated jugular veins may be absent in patients with hemorrhag-
patients and 50–100% FiO2 in intubated patients). The ic-traumatic shock due to hypovolemia and circulatory
need for exogenous oxygen in the trauma patient is il- centralization. A tracheal deviation to the contralateral
lustrated in the formula established by Nunn & Free- side represents a late sign and may be detected by clini-
man in 1964 [51]: cal inspection of the neck. A tension pneumothorax
O2av = CO × SaO2 × Hb × 1.34. compromises ventilation and circulation dramatically
This formula specifies that the oxygen available in the and acutely. Thus, if suspected by clinical findings, chest
tissue (O2av) is equal to the product of cardiac output decompression by puncture of the second intercostal
(CO in ml/min), arterial O2 saturation (SaO2 in %) space in the midclavicular line with a large-bore needle
and hemoglobin concentration (Hb in g%), whereby must be accomplished immediately without further im-
1.34 represents the O2-binding capacity of hemoglobin aging diagnostics [6]. This life-saving maneuver converts
(in ml/g). While the oxygen demand is satisfied under the injury into a simple pneumothorax and must imme-
physiological conditions, several of these variables may diately be followed by an open placement of a chest
be significantly compromised in seriously injured pa- drain in the fourth to fifth intercostal space in anterior
tients due to acute blood loss (Hb), pulmonary contu- axillary line. The most frequent cause of tension pneu-
sion (SaO2) and myocardial contusion or pericardial mothorax is mechanical positive pressure ventilation in
tamponade (CO), thus resulting in a severe deficit of a patient with visceral pleural injury. Thus, insertion of
oxygen supply for the trauma patient [52]. a chest drain is mandatory in every intubated trauma

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patient with rib fractures due to thoracic trauma even in sion, somnolence or lethargy; (2) peripheral perfusion
absence of radiologic signs of a traumatic hemo-/pneu- – cold and clammy skin, delayed capillary refilling,
mothorax [6]. tachycardia; (3) renal perfusion – oliguria (< 0,5 ml/kg/
Aside from a tension pneumothorax, additional criti- h) or anuria. These clinical findings must help differen-
cal thoracic injuries include a flail chest with pulmonary tiate in an early phase whether a patient is “hemody-
contusion, a massive hemothorax, and an open pneumo- namically normal” or just apparently “hemodynamical-
thorax, also referred to as a “sucking chest wound” [6, 53, ly stable” with the risk of deterioration. Based on the
54]. The latter injury is treated by initial sterile occlusive response to initial resuscitative measures, the latter
dressing which is left open on one side to allow a flut- group of patients are defined as either “transient re-
ter-type valve effect for prevention of aggravation into a sponders” or “nonresponders” and are likely to require
tension pneumothorax. The injury is then treated by a surgical intervention for hemorrhage control [6]. Ar-
chest tube insertion and by surgical exploration of the terial blood gas analysis can furthermore help deter-
wound in the operating room after stabilization of vital mine the extent of hemorrhagic shock in polytrauma
functions. Patients with a flail chest may be candidates for patients. In this regard, clinical studies have demon-
early intubation and mechanical ventilation due to respi- strated that lactate levels and base deficit represent
ratory distress and hypoxemia [6]. A traumatic hemotho- highly sensitive parameters for recognition of “hidden
rax is treated by chest tube drainage. This simple maneu- shock” in traumatic hemorrhage [56–59]. A base deficit
ver resolves the problem in most cases of blunt thoracic below the cutoff at –6 mEq/l in the initial blood gas anal-
trauma [6, 53, 54]. However, the presence of a massive ysis has been shown to be associated with significantly
hemothorax with continuous bleeding and/or the pres- increased transfusion requirements, posttraumatic com-
ence of a cardiac tamponade – both entities mainly due to plications and increased mortality [58, 59]. A base defi-
penetrating injuries – require surgical management by cit < –10 mEq/l has been associated with a high mortal-
resuscitative thoracotomy [6, 53–55]. ity of 40–70% [58, 59]. By contrast, mortality in patients
with normal base deficit or base excess (+2 to –2 mEq/l)
C – circulation with hemorrhage control. In third prior- was as low as about 6% [58, 59]. In addition, the lactate
ity, internal and external hemorrhages must be recog- level on admission represents a sensitive parameter re-
nized and the bleeding must be stopped, if necessary by flecting the extent of traumatic-hemorrhagic shock [57].
surgical measures. When assessing the extent of hemor- The time frame of normalization of lactate levels below
rhage, attention should be paid to the fact that the indi- a cutoff at 2 mmol/l was shown to correlate significantly
vidual compensatory mechanisms can maintain a nor- with survival [57]. While polytrauma patients with re-
mal blood pressure for a limited time even in a critical fractory lactate acidosis (> 2 mmol/l) for > 48 h after in-
hypovolemic situation. In this regard, in case of an acute jury had a mortality of 85%, those patients where lac-
blood loss of up to 30% (equivalent to 1.5 l blood loss in tate levels normalized within the first 24 h had a low
a 70-kg patient), the systolic blood pressure can be kept mortality of around only 1% [57].
within a normal range by increasing the peripheral resis- In parallel to aggressive volume resuscitation, the
tance, thus “masking” the state of shock [6]. However, main bleeding sources must be screened according to
cardiac output is reduced to up to half the normal value standardized protocols during the primary survey [6].
which may lead to critical organ perfusion and subse- This includes a focused assessment sonography for trau-
quent metabolic acidosis with elevated serum lactate ma (“FAST”) and anteroposterior radiographs of chest
and an increased lactate : pyruvate ratio in serum due to and pelvis as a gold standard. The further algorithms for
the anaerobic metabolic situation [56]. Therefore, dur- diagnosis and management of intrathoracic and intraab-
ing the primary survey, the main question to be ad- dominal bleedings and of retroperitoneal hemorrhage
dressed with regard to blood loss – “Is the patient in associated with pelvic ring disruptions are provided in
shock?” – needs to be immediately resolved by clinical the paragraph on damage control (see below).
findings of compromised tissue oxygenation [6]. The
clinical symptoms of shock are the “three windows to D – disability: brief neurologic evaluation. After stabili-
the microcirculation” which can be assessed in terms of zation of vital functions, a brief evaluation of the level of
inadequate organ perfusion [6]: (1) mental status/level consciousness (GCS) and of pupil symmetry and reac-
of consciousness (cerebral perfusion) – agitation, confu- tion is performed. The presence of traumatic brain in-

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Stahel PF, et al. Polytrauma Management

jury must be recognized early in order to take preven- (Figure 1) represents a major risk factor for deteriora-
tive measures for the development of secondary brain tion and adverse outcome of polytrauma patients [29,
injury due to hypoxemia and hypotension [38, 39]. These 30]. The underestimation of the extent of traumatic
parameters are crucial for the outcome after head injury hemorrhage and of the patient’s physiological condition
due to propagation of a massive intracerebral inflam- and reserves may be detrimental due to prolonged sur-
matory response leading to development of brain ede- gical interventions which exacerbate this vicious circle
ma with increased intracranial pressure and decreased and contribute to increased posttraumatic mortality [18,
cerebral perfusion pressure, ultimately contributing to 28–30]. Thus, in recent years, the “classic” orthopedic
delayed neuronal cell death [60, 61]. For this reason, an concept of “early total care” for the unstable multiply
appropriate resuscitation of the “A-B-C” parameters injured patient has been abandoned in favor of the new
represents the crucial basis for avoidance of secondary concept of “damage control orthopedic surgery” (DCO)
brain injuries after trauma [38]. The severity of traumat- which has led to an increased overall survival of poly-
ic brain injury is classified according to the GCS as mild trauma patients [20, 31, 33, 48, 63, 64].
(14–15 points), moderate (9–13 points), and severe (3–8 According to the “damage control” concept, life-pre-
points). Endotracheal intubation for securing a patent serving measures are first priority while other prolonged
airway is mandatory at a GCS ≤ 8, since these patients surgical interventions must be avoided at all costs in or-
are comatose per definition [6, 39]. Patients with a GCS der to decrease the systemic pathophysiological “load” to
≤ 13 must be admitted to a trauma center with available the injured organism and to breach the vicious circle of
neurosurgical capabilities. In these patients, a cranioce- the “lethal triad” (Figure 1). The two major surgical steps
rebral CT scan is mandatory due to the significantly in- of damage control procedures include the acute decom-
creased likelihood of intracranial hematoma as com- pression of body cavities and the control of exsanguinat-
pared to patients with mild head injury (GCS 14 or 15) ing hemorrhage, as outlined below.
[39].
Decompression of body cavities. Pathologically in-
E – exposure with environmental control. Every trauma creased pressure in body cavities requires immediate
patient must be completely undressed for thorough in- emergency surgical management. This involves the
spection and examination under protection from hypo- acute decompression of a tension pneumothorax and
thermia by warm blankets and preheated infusions and the drainage of a traumatic hemo-/pneumothorax, as
heating lamps. A “log-roll” maneuver is mandatory in described for the ATLS® protocol above [6]. In addi-
all patients for inspection of the back side for potential tion, a suspected cardiac tamponade must be immedi-
hidden injuries. A continuous reassessment of vital pa- ately resolved by subxiphoideal puncture and/or open
rameters must be performed in order to recognize dete- decompression in case of required emergency thoracot-
rioration and to initiate according resuscitative mea- omy [6, 53–55]. Furthermore, the presence of a peracute
sures [6]. epidural hematoma requires immediate decompression
by burr hole evacuation and/or craniotomy [39, 65].
The Concept of “Damage Control” These surgical measures have utmost priority due to the
Since the first description of the concept of abbreviated acute life-threatening implication of these injury pat-
laparotomy with intraabdominal packing in patients terns.
with massive hemorrhage more than 2 decades ago [62],
this concept of “damage control” surgery has had a Control of exsanguinating hemorrhage. During the pri-
worldwide dispersion in all major surgical disciplines mary survey, the presence of hemorrhagic shock must be
[18]. The rationale behind the concept of abbreviating diagnosed and treated simultaneously. The basic man-
standard surgical procedures lies within the aim of an agement principle is to stop the bleeding and to replace
early transfer of critical patients to the intensive care the volume loss. Volume replacement is performed ac-
unit (ICU) for restoration of physiological “endpoints cording to the 3 : 1 rule, which means that one unit of lost
of resuscitation” [24] in order to improve the overall blood must be replaced by three units of fluid due to loss
outcome of critically injured patients in severe traumat- into the third compartment [6]. Thus, for illustration, the
ic-hemorrhagic shock [22, 28]. The presence of the “le- management of a simple femoral shaft fracture associat-
thal triad” of hypothermia, coagulopathy, and acidosis ed with up to 1,500 ml blood loss requires about 4,500 ml

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Stahel PF, et al. Polytrauma Management

fluid replacement for adequate resus-


citation. The potential requirement
of surgical hemorrhage control must
be determined during the early resus-
citative phase. Significant external
hemorrhages are temporarily stopped
by external compression and sterile
dressing in the emergency room fol-
lowed by surgical wound manage-
ment in the operating room.
Major internal bleeding sources
which require immediate surgical
control are:
• massive hemothorax: initial man-
agement by open chest drain place-
ment. Requirement of urgent tho-
racotomy in cases of penetrating
trauma and/or after blunt trauma
with massive bleeding via chest tube
(> 1,500 ml immediately or continu- Figures 3A to 3D. Case example of a 21-year-old female patient involved in a motorcycle crash
ing hemorrhage of > 200 ml/h in the with applied “damage control” procedure due to severe polytrauma with central liver lacera-
later phase) [6, 53–55]. tion, intracranial hematoma and multiple long bone fractures (A). The Injury Severity Score
• intraabdominal hemorrhage: indi- (ISS) was 50 points. Damage control surgery was performed by “crash”-laparotomy, Pringle ma-
neuver and intraabdominal packing (B) and external fracture fixation. The abdominal wall was
cations for urgent laparotomy in- not closed – in terms of a provisional laparostoma (C) – for avoidance of abdominal compart-
clude hemodynamically unstable ment syndrome and further staged procedures including changes of packings within 24–48 h.
patients with blunt abdominal trau- The postoperative CT scan (D) shows the “packed” liver with the central laceration (arrow).
ma and positive ultrasonography
and patients with penetrating abdominal injuries [6]. explorative laparotomy with pelvic “packing” is war-
Patients “in extremis” with severe multiple injuries ranted in order to achieve surgical hemorrhage control
have a significantly increased chance of survival if the [20, 33, 47, 48, 68]. It is crucial to know that > 80% of
surgical procedure is abbreviated and definitive repair hypotensive patients due to pelvic hemorrhage are
of intraabdominal injuries is delayed in terms of a staged “nonresponders” [69]. The hallmark of these patients’
procedure (crash-laparotomy, “packing”, laparostoma/ survival is a rapid recognition and surgical control of
temporary Ethizip® closure), as compared to patients hemorrhage, since mortality in pelvic fracture-associat-
with early total care [28–30, 66, 67] (Figure 3). Defini- ed hemorrhage is still as high as 50–60% [70]. Interven-
tive surgery is followed within 24–48 h after stabiliza- tional measures like angiography and embolization are
tion of vital parameters in the ICU. obsolete for the management of these patients, since
• pelvic ring disruption with massive retroperitoneal hem- arterial bleeding sources are present in < 10% of all
orrhage: unstable pelvic injuries with posterior pelvic cases and successful embolization can be performed in
ring disruption are associated with massive uncon- < 2% [69, 71]. In addition, angiography has several dis-
trolled retroperitoneal bleeding of up to 5,000 ml due to advantages due to the necessity of transporting a hemo-
lacerations of the presacral and paravesical venous dynamically unstable patient and the average time of
plexus and cancellous bone bleeding [47]. These pa- about 2.5 h until angiography is performed in a level I
tients require immediate closed reduction of the pelvic trauma center, which extends way beyond the “golden
ring in the emergency room and fixation with a pelvic hour” [69, 71]. According to the ATLS® algorithm, per-
“C-clamp” (posterior pelvic ring) and/or external fix- forming extended diagnostics, such as angiography, is
ator (anterior pelvic ring) [20, 33, 47, 48, 68]. If these part of the secondary survey and is therefore obsolete
measures – in combination with aggressive volume re- for early hemorrhage control in the initial phase [6].
suscitation – cannot achieve hemodynamic stability, The propagated “damage control” procedure for he-

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Stahel PF, et al. Polytrauma Management

modynamically unstable patients Table 2. Timing and priorities of operative interventions in polytrauma patients depending on
with pelvic ring disruptions includes the physiological status [24].
closed reduction and external fixa- Physiological status Operative procedures Timing
tion with explorative laparotomy,
pelvic “packing” and provisional Compromised vital functions 씮 Life-saving surgery
closure of the abdomen with surgi- Stable vital functions 씮 Delayed primary surgery Day 1
®
cal zippers (Ethizip ) [20, 33, 47, 48, Highly unstable/in extremis 씮 Damage control surgery
68]. This therapeutic modality has Hyperinflammation “Second looks” only! Day 2–4
”Window of opportunity“ Scheduled definitive surgery Day 5–10
been shown to lower mortality from
Immunosuppression No surgery!
pelvic bleeding from 50–60% [70]
Recovery Secondary reconstructive surgery After 3 weeks
to about 20–25% [20, 33]. Change
of packings has to be performed
within 24–48 h and definitive surgery is to follow during was shown to unequivocally exclude an aortic rupture
the “time window of opportunity” from the 5th to 10th [80–84]. An aortography or transesophageal echocar-
day after trauma (Table 2). diography are nowadays only indicated in rare cases
• intracranial bleeding sources: aside from acute epidu- with equivocal findings in the CT scan [80, 82]. Conven-
ral hematoma from arterial bleeding sources (see tional X-rays of extremities and spine series are per-
above), dural sinus bleeding may represent a major formed during the secondary survey according to the
source of intracranial hemorrhage requiring immedi- individual injury pattern [6].
ate surgical intervention by trepanation and cranioto-
my [65]. Delayed Primary Surgery (“Day-1 Surgery”)
• penetrating and blunt vascular injuries, “mangled ex- Surgical interventions which are not immediately re-
tremity”: arterial injuries with clinical signs of limb quired for resolving life-threatening conditions are per-
ischemia due to blunt or penetrating trauma require formed after further evaluation of the stabilized patients
immediate surgical management without further di- in the secondary survey. Hereby, the term “delayed” re-
agnostics [72–74]. The “Mangled Extremity Severity fers to primary surgical interventions within the first
Score” (MESS) has been established as a guideline 24 h (“day-1 surgery”). These operations are aimed at
for early determination whether limb salvage is reducing the “antigenic load”, saving injured limbs and
achievable as opposed to early amputation, with an joints at risk, decompressing the spinal cord, and opti-
established “cutoff” level of the MESS at 7 points mizing the therapeutic modalities on the ICU [21, 22,
[75–79]. 24, 85].
Such interventions in the context of “day-1 surgery”
Secondary Survey include:
The phase of the secondary survey can only begin after • decompression of compartments under pressure in
the resuscitative measures of the primary survey are non-immediately life-threatening conditions: unstable
completed according to the A-B-C-D-E algorithm and vertebral fractures with spinal stenosis, subdural he-
the patient has been hemodynamically stabilized and matoma, compartment syndromes of the extremities;
demonstrates normal vital functions [6]. The secondary • laparotomy for hollow viscus injuries;
survey comprises an extended anamnestic evaluation of • revascularization of vascular injuries;
concomitant diseases and events associated with the • debridement of contaminated soft tissue and open
mechanism of injury and a complete and thorough fractures/joint injuries;
“head-to-toe” examination including a full neurologic • external fracture fixation of long bones;
status. Diagnostic adjuncts to the secondary survey in- • dorsal fixation of unstable vertebral fractures by inter-
clude a multislice polytrauma CT scan which nowadays nal fixator.
represents a fast and highly sensitive “gold standard” These operative measures should take as little time as
for further evaluation of hemodynamically stable poly- possible to avoid an iatrogenic “second hit” [86] which is
trauma patients [80, 81]. The multislice CT has been associated with adverse outcome in polytrauma pa-
shown to be a highly sensitive tool also for detecting tients, particularly in the presence of concomitant head
aortic rupture, whereby a normal CT scan of the aorta injury [31, 64, 65, 87, 88].

208 European Journal of Trauma 2005 · No. 3 © Urban & Vogel


Stahel PF, et al. Polytrauma Management

Intensive Care and Scheduled Definitive Surgery grafting and definitive orthopedic reconstructive inter-
Following the operative interventions, subsequent ventions aimed at restoring a good functional long-term
transfer to the ICU is aimed at the earliest time point result.
possible for further stabilization of the polytrauma pa-
tient and for restoration of the following “endpoints of Conclusion
resuscitation” [21, 22, 24]: The complex management of polytraumatized patients
• stable hemodynamics without need for vasoactive or can be optimized by standardized and validated ap-
inotropic stimulation; proaches using well-established algorithms, such as the
• no hypoxemia, no hypercapnia; ATLS® program. In addition, new concepts in recent
• serum lactate ≤ 2 mmol/l; years have demonstrated that highly critical polytrauma
• normal coagulation; patients in extremis have a significantly improved overall
• normothermia; outcome, if surgical procedures are abbreviated for the
• urinary output > 1 ml/kg/h. benefit of an early transfer to intensive care. This notion
The pathophysiological phase of hyperinflammation – which is in sharp contrast to the classic concept of “ear-
between days 2–4 after trauma (Table 2) is a time period ly total care” – has been defined as ”damage control” sur-
of enhanced susceptibility to a “second-hit” injury and gery. The kinetics of the physiological response to severe
thus does not allow any surgical intervention [24, 86]. injury must be taken into account for the timing and pri-
Exceptions are short operations such as sterile change orities of surgical interventions in the further course after
of dressing, exchange of tamponades and “second-look” trauma. As such, the “time window of opportunity” for
operations for further debridement of necrotic tissue scheduled definitive surgical interventions lies between
and avoidance of bacterial contamination [24, 89]. These the 5th to 10th day after injury, whereas the time of hy-
measures are necessary to reduce the overall stress to perinflammation (day 2–4) and immunosuppression
the organism through necrotic tissue and inflammatory (2nd–3rd week) are associated with a high susceptibility
mediators (“antigenic load”) and to avoid infectious to iatrogenic “second hits” induced by prolonged surgical
complications and the development of sepsis and organ interventions, leading to adverse outcome due to devel-
failure [90, 91]. opment of sepsis and multiorgan failure. This golden bal-
The next management phase takes into account ance between mandatory primary and secondary mea-
the presence of a physiological “window of opportu- sures and the knowledge of the pathophysiological
nity” between days 5–10 after trauma, which corre- reactions in adherence with established diagnostic and
sponds to the interval between the early hyperinflam- therapeutic algorithms will help improve the overall out-
matory phase and the period of immunosuppression come of polytrauma patients.
which follows the 2nd week after trauma (Table 2)
[24]. Thus, during the “time window of opportunity”, Acknowledgment
the fully resuscitated patient is a candidate for changes Dr. Stahel is supported by grants from the German Research Founda
in operative strategies and definitive scheduled surgi- Ztion (DFG) No. STA 635/1-1, 635/1-2, and 635/2-1.
cal procedures. These include the change from exter-
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