Management of the Polytrauma Patient

Abstract

Trauma is the leading cause of death in the 1- to 45-year-old age group, and it is the fourth cause of death in the general population. In 2010 there were 5.2 millions of deaths by polytrauma worldwide (10.3 % of deaths). One of the most common and most serious complications in the polytrauma patient is hemorrhage. Blood loss leads to a decreased oxygen transport to the tissues. Hypoxemia triggers metabolic alterations that drive the body to a situation called lethal triad: acidosis, hypothermia, and coagulopathy. In the polytrauma patients, the defense mechanisms are activated by hypoxia, acidosis, and tissue hypoperfusion especially in the liver, kidney, and lung. The defense mechanisms activated trigger a hyper-inflammatory response that is characterized by tachycardia (>90 bpm), tachypnea (>20 bpm), body temperature >38.5 °C, and leukocytosis (Botha et al., J Trauma 39:411–417, 1995). The clinical consequences of the hyper-inflammatory response are acute respiratory distress syndrome (ARDS) and multiple organ failure syndrome (MOFS). The initial management of the polytrauma patient goes through two phases: prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) in the hospital. ATLS protocol consists of three phases: primary survey (A, B, C, D, E), secondary survey, and definitive treatment of the injuries. There are mathematical tools for scoring the severity and prognosis of the trauma patient in a numerical scale. There are two types of scales: physiological scales (RTS) and anatomic scales (NISS).

Management of the skeletal injuries in the polytrauma patient is a dynamic process that should be carried out according to the physiological situation of the patient. We must consider the impact that the treatment of the fractures can have on the patient (second hit). What we must do is clear: stabilize immediately the fractures. How we can do it depends on patient situation. We have two options: damage control surgery or early definitive surgery. Stable polytrauma patients with associated head injury require special consideration. In contrast, trauma patients with thoracic trauma, if they are stable, can be subjected to early nailing of long bone fractures without increasing the risk of respiratory distress. Spinal injury associated with multiple trauma has special characteristics. It may be undiagnosed. Furthermore, a poor handle of the patient or incorrect immobilization can trigger a neurological damage that previously did not exist. A complete and adequate exploration of the spine, including CT scan and MRI as possible, should be carried out in all trauma patients. Open fractures in multiple injured patients follow the same principles of management for fractures with soft tissue damage. In most cases damage control surgery by external fixation is the best option. The diagnosis of compartment syndrome is primarily clinical. In the multiple injured patients, the diagnosis is difficult because of the low level of awareness that masks the pain and low blood pressure that affects the calculation of the differential pressure. In these cases the alert level should be over and we have to react to the slightest suspicion.