Comperhensive Management

of Polytrauma
 Trauma is a Major public health problem with high disability,
INTRODUCTION death, and societal cost

50% within the first minutes of sustaining the injury

caused by massive blood loss or neurologic injury

30% within hours of arrival to hospital

most commonly from shock, hypoxia, or neurologic injury

20% within days to weeks following injury

multi system organ failure and infection are leading causes

https://www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco
 DEFINITION

Polytrauma has been defined as “a syndrome of multiple injuries exceeding an Injury

Severity Score (ISS) of 16 with sequential systemic reactions that may lead to dysfunction
or failure of remote organs and vital systems that have not been directly injured”

AO Principles of Fracture Management Third Edition

 DEFINITION
Sistolic Blood Pressure ≤ 90 mmHg

Glasgow Coma Scale score ≤ 8

The New Berlin definition of polytrauma
was defined as follows a patient with AIS ≥ 3
for two or more different body regions with Base excess ≤ 6.0
additional one or more variables from

International normalized ratio ≥ 1.4 or partial

thromboplastin time ≥ 40 s

Age ≥ 70 years

Journal of traumatology : Polytrauma Defined by the New Berlin Definition: A Validation Test Based on Propensity-Score Matching Approach 2017
PATHOPHYSIOLOGY
The pathophysiology after polytrauma represents
a complex network of interactions

Journal of traumatology : Pathophysiology in patients with polytrauma.2022 https://doi.org/10.1016/j.injury.2022.04.009

Trauma is a public health problem

 Leading cause of death and disability in people

<45 y/o
 Number of injured people increases each year
(more surviving)
 Better vehicle safety
 Better transport systems
 Better critical care

ATLS 10th edition

 ATLS principles
Treat the greatest threat to life first
• Primary survey: Resuscitation simultaneously
• Secondary survey: Provisional and definitive care
• Tertiary survey

ATLS 10th edition

 Primary Response to Severe Trauma
Local and systemic reactions are initiated in the immediate aftermath of severe trauma.
The main physiological response aims at stopping hemorrhage and maintaining blood flow to vital
organs.

Fractures
Soft-tissue injury

Organ damage (lung, liver,

bowel, etc), Hypoxia,
Acidosis

AO Principles of Fracture Management Third Edition

Management in Polytrauma
It should be cleared or secured before moving
to the rest of the ABCDE assessment

Life-Saving Management and Further Treatment:

Establishing priorities for life-saving management and further
treatment, which involves a systematic approach to the
management of polytrauma patients by an interprofessional team
Initial assessment and management pathway for polytrauma
patients. Abbreviations: ATLS, advsnced trauma life support;
CT, computed tomography; FAST, focused assessment with
sonography for trauma; ICU, intensive care unit.
 Primary survey

A Airway
B Breathing
C Circulation
D Disability/neurological
E Exposure/environmental

From : ATLS 10th edition

 AIRWAY
This rapid assessment for signs of airway obstruction
includes inspecting for foreign bodies, identifying facial,
mandibular, and/or tracheal/laryngeal fractures and other
injuries that can result in airway obstruction

Airway Problem

1. Maxillofacial Trauma
2. Neck Trauma
3. Laryngeal Trauma

From : ATLS 10th edition

 Airway Maintenance techniques
Chin-Lift Maneuver
The chin-lift maneuver is performed by placing the fingers
of one hand under the mandible and then gently lifting it
upward to bring the chin anterior.

Jaw-Thrust Maneuver
To perform a jaw thrust maneuver, grasp the angles of the
mandibles with a hand on each side and then
displace the mandible forward

Nasopharyngeal Airway
Nasopharyngeal airways are inserted in one nostril and
passed gently into the posterior oropharynx.

Oropharyngeal Airway

From : ATLS 10th edition

 Airway Maintenance techniques

Laryngeal Mask Airway and Intubating LMA

The laryngeal mask airway (LMA) and intubating
laryngeal mask airway (ILMA) have been shown to
be effective in the treatment of patients with difficult
airways, particularly if attempts at endotracheal
intubation or bag-mask ventilation have failed.

Laryngeal Tube Airway and Intubating LTA

The laryngeal tube airway (LTA) is an extraglottic
airway device with capabilities similar to those of
the LMA in providing successful patient ventilation

From : ATLS 10th edition, shock

 Definitive Airway
1. Endotracheal Intubation

2. Surgical Airway
Needle Cricothyroidotomy
Needle cricothyroidotomy involves insertion of a
needle through the cricothyroid membrane into the
trachea in an emergency situation to provide oxygen
on a short-term basis until a definitive airway can be
placed.
Surgical Cricothyroidotomy
Surgical cricothyroidotomy is performed by making
a skin incision that extends through the cricothyroid
membrane

From : ATLS 10th edition

 Breathing
 Assess breathing and oxygenation
 Identify and treat sources of reduced oxygenation:
 Tension pneumothorax  needle
decompression
 Pneumothorax  chest tube insertion
 Perform ABG
 Establish mechanical ventilation when pt unable to
breathe adequately or unable to protect airway
 e.g. vomiting, seizure, combative, severe
face/neck injury w/swelling and bleeding
 Hyperventilation for severe head injury
From : ATLS 10th edition, shock
 Circulation

The definition of shock—an abnormality of the

circulatory system that results in inadequate organ
perfusion and tissue oxygenation
 The first step in managing shock in trauma
patient is to recognize its presence
 The second step in managing shock is to identify
the probable cause of shock and adjust treatment
accordingly.
 Definitive control of hemorrhage and restoration
of adequate circulating volume are the goals of
treating hemorrhagic shock.
From : ATLS 10th edition
 Circulation
 Hemorrhagic shock is most common
type
 Assess wounds, abdomen, pelvis
stability, peripheral pulses
 CONTROL BLEEDING
 direct pressure
 compressive dressings
 tourniquets

From : ATLS 10th edition, shock

 Rescucitation
1. Begins immediately, continues during primary
and secondary surveys
2. Establish 2 large bore IVs
3. 2L lactated Ringers
4. If no improvement in hypotension, consider
transfusion

From : ATLS 10th edition, shock

 Blood Replacement
The decision to initiate blood transfusion is based on
the patient’s response. Patients who are transient responders
or nonresponders require pRBCs, plasma and platelets as an
early part of their resuscitation.

Massive Transfusion
A small subset of patients with shock will require
massive transfusion, most often defined as > 10 units of
pRBCs within the first 24 hours of admission or more than
4 units in 1 hour.

Monitoring
The goal of resuscitation is to restore organ
perfusion and tissue oxygenation. This state is identified by
appropriate urinary output, CNS function, skin color, and
return of pulse and blood pressure toward normal
From : ATLS 10th edition, shock
 Resuscitation of shock
• The goal of resuscitation is to restore organ
perfusion and tissue oxygenation
• Early resuscitation with blood and blood products
must be considered in patients with evidence of
class III and IV hemorrhage.

From : ATLS 10th edition, shock

 Management
in Polytrauma

Evolving concepts and strategies in the management of polytrauma patients 10.1016/j.jcot.2020.10.021

 Early Total Care (ETC )

ETC involves definitive surgical stabilization of all long-bone

fractures during the early phase of treatment. ETC was not
considered suitable for all polytrauma patients, since in unstable
patients it was associated with an unexpectedly high rate of
pulmonary complications

Early total care does not mean immediate total care: fractures should be temporarily splinted and time should be taken
to ensure adequate resuscitation of the patient.

https://www.hindawi.com/journals/isrn/2013/329452/
 What is DCO?
Approach:
Stabilizes orthopedic injuries Physiology improvement

 Control of hemorrhage  Avoids "second hit" of a major

 Management of soft-tissue injury orthopedic procedure
 Achievement of provisional fracture stability  Delays definitive fracture treatment
 Overall condition of the patient is
optimized.

https://www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco
 Definition
 Approach to treating polytrauma patients with the
goal of minimizing the impact of “second hit”
 Definitive treatment delayed until physiology
improved
 Initial priorities: hemorrhage control, soft tissue
management, provisional fracture stabilization

https://www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco
 Window of Oportunity

compensatory anti-inflammatory response state (CARS)

C. Roslee, H.C.L. Hinsley, N.D. Rossiter, “The swinging pendulum” the evolution of (Orthopaedic) trauma care. (An explanation of the controversies & analysis of the evidence.),
Orthopaedics and Trauma,Volume 31, Issue 2, 2017, Pages 62-67, ISSN 1877-1327, https://doi.org/10.1016/j.mporth.2016.10.006.
 FIRST HIT( After Trauma)

Systemic Inflammatory Response

We as surgeons have no control

SECOND HIT

Surgery may represent “second hit”

May exacerbate systemic inflammatory response
May lead to secondary lung injury
We as surgeons have control

https://www.orthobullets.com/trauma/1005/evaluation-resuscitation-and-dco
DCO Patient Criteria
● ISS >40 (without thoracic trauma)
● ISS >20 with thoracic trauma
● GCS of 8 or below
● multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock
● bilateral femoral fractures
● pulmonary contusion noted on radiographs
● hypothermia <35 degrees C
● head injury with AIS of 3 or greater
● IL-6 values above 500pg/dL
Following completion of the initial assessment and early interventions, patients should be stratified in terms of their physiological state
into one of four categories:
Stable, Borderline, Unstable, Extremis
 Pelvic Fractures
If the patient remains unstable, the source of
hemorrhage needs to be identified and stopped. Two
options are available: direct surgical control by pelvic
packing or interven- tional radiology and
embolization. The choice will be de- termined by
multiple factors including facilities, experience, and
the sites of hemorrhage

Severe pelvic fractures and hemorrhage control

AO Principles of Fracture Management Third Edition

 Traumatic brain injury with long-bone

Epidural or acute subdural hematomas require urgent surgical evacuation and

hemostasis. Patients with traumatic brain injury and GCS < 9 after craniotomy may
need intracranial pressure monitoring after life saving surgery. Given a good response to
resuscitation, early fracture fixation has a positive effect in brain-injured patients, as it
fa-cilitates nursing care, reduces painful stimuli (afferent input), and decreases the need
for sedation and analgesia

AO Principles of Fracture Management Third Edition

Severe chest injury with long-bone fractures

Locked IM nailing continues to be the gold standard

of treatment in both closed and open femoral shaft
fractures. How- ever, instrumentation of the IM cavity
increases the IM pressure leading to release of
mediators and intravasation of fat (emboli) in the
peripheral circulation and the lungs.

AO Principles of Fracture Management Third Edition

 Limb salvage versus amputation
• The development of microsurgical techniques for free vascularized tissue transfer has
increased the chances of saving mangled extremities or nearly amputated limbs. In
polytrauma, such salvage procedures are rarely indicated as these complex reconstructive
procedures are time consuming and result in a significant “second hit” in patients with
significant immune and physiologi- cal compromise.
• The mangled extremity severity score may assist in decision making [34]. There are only
rare indications for heroic salvage attempts

AO Principles of Fracture Management Third Edition

 Summary
• The management of polytrauma patients is evolving and improving.
• Patients treated within organized regional trauma networks are reported to have
improved outcomes.
• The physiological state of patients must be assessed quickly while performing
resuscitation and the treatment strategy for fractures is now based on the patient’s
physiological response to the injury and resuscitation.
• Damage-control orthopedics and ETC should be complementary and the key is to
select the right strategy for the right patient at the right time.

AO Principles of Fracture Management Third Edition

THANK YOU
Questions
1. A 23-year-old male arrives in the trauma bay after a motorcycle
crash caused by a drive-by shooting. The patient is awake and alert
and following commands, and vital signs and lactate levels are stable.
The patient is grossly neurovascularly intact with a 6 cm transverse
ragged wound over the medial ankle. Figures A, B and C exhibit his
orthopaedic injuries, and no other injuries are noted on exam. What is
the most appropriate management of the options below?
A. Irrigation, debridement and placement external fixator right
ankle, external fixation femur and intramedullary fixation tibia
B. Irrigation, debridement and placement external fixator right
ankle, intramedullary fixation femur and tibia
C. Irrigation, debridement and placement external fixator right
ankle, intramedullary fixation femur and external fixation tibia
D. Irrigation, debridement and placement external fixator right
ankle, femur and tibia
E. Irrigation, debridement and open fixation right ankle with
skeletal traction of the left lower extremity
Answer

The patient is relatively hemodynamically stable. In this case the femur and tibia should be definitively
fixed while the open ankle fracture can be irrigated and debrided and placed in a spanning external fixator,
temporizing for later definitive fixation.

Aside from an elevated heart rate and mildly elevated lactate (normal < 2.5 mmol/L), the patient is
relatively stable making him a good candidate for long bone stabilization and temporizing external fixation
of the right ankle. Gross contamination of the open injury also supports temporizing fixation, which can be
brought back for repeat I&D and possible fixation.

Pape et al. compared outcomes for intramedullary nailing (IMN) versus staged fixation for femur fractures
in stable versus borderline patients. Borderline patients were defined as those with multi-system injury
(especially to lungs) and exhibited higher lung complications following acute IMN when compared to
stable patients with isolated orthopaedic injuries.

O'Brien reviewed the literature regarding early total care in regards to IMN stabilization of femur fractures.
Summarized data noted isolated injuries treated with early IMN had good outcomes, whereas those with
head or lung injury had worse outcomes and pulmonary complications.
Question
2. A 36-year-old woman presents with a grade 3 open midshaft femoral shaft
fracture as the result of a high-speed motor vehicle collision. Concomitant
injuries include a high-grade splenic laceration requiring splenectomy as well
as a subdural hematoma that requires monitoring and maintenance of cerebral
perfusion pressure. After irrigation and debridement of the open fracture,
which of the following is the most appropriate management of the femoral
shaft fracture at this time?
A. Placement of antibiotic beads, wound closure and immobilization
B. Reamed antegrade intramedullary nailing
C. Unreamed antegrade intramedullary nailing
D. Wound closure and Hare traction splint placement
E. Placement of an external fixator
Answer

The clinical scenario is consistent with a femoral shaft fracture in a patient that is not stable from a
neurosurgical perspective. Therefore, the most appropriate treatment at this time is placement of an
external fixator.

When evaluating polytrauma patients with long bone fractures, timing of surgery must be
approached considering all clinical conditions. One factor most likely to adversely affect long term
outcome in polytrauma patients with severe brain injury is intra-operative hypotension; therefore,
whenever a patient has a subdural hematoma that requires close observation, definitive surgery of
long bone fractures should be delayed.

Flierl et al. review the immunopathophysiology of traumatic brain injury and the role of the
orthopaedic surgeon in avoiding a "second hit" injury to the brain by appropriately timing the
fixation of femoral shaft fractures. They recommend a multidisciplinary approach, taking individual
patient-specific factors into consideration and in general, DCO principles for severe head-injured
patients (GCS 3-13) and "early total care" principles for patients with mild head injury (GCS 14-
15).
3. All of the following indicators of resuscitation may be within normal limits for a trauma
patient that is in "compensated" shock EXCEPT:
A. Systolic blood pressure
B. Urine output
C. Heart rate
D. Serum lactate
E. Mean arterial pressure
3. All of the following indicators of resuscitation may be within normal limits for a trauma
patient that is in "compensated" shock EXCEPT:
A. Systolic blood pressure
B. Urine output
C. Heart rate
D. Serum lactate
E. Mean arterial pressure
Answer

• Historically, normal blood pressure, heart rate, and urine output have been
endpoints to signal complete resuscitation in the polytrauma patient.

The review article by Porter et al states that there is a high incidence of patients (as
much as 85%) in "compensated" shock despite normal vital signs and urine output
parameters. Compensated shock is secondary to a maldistribution of blood flow
and tissue oxygenation as splanchnic organs have less distribution of the cardiac
output compared to the heart and the brain.

The article by Elliott is also a review, and it states that serum lactate is the best
indicator of peripheral organ perfusion and tissue oxygenation. It also states that
base deficit and gastric mucosal pH are appropriate end points to determine the
complete resuscitation of trauma patients.