Skip to main content
SpringerLink
Log in

Polytrauma—pathophysiology and management principles

  • Current Concepts in Clinical Surgery
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Background

Multiple injury results in a complex pathophysiological and immunological response. Depending on the individual injury pattern, the time elapsed after injury, and the systemic “danger response”, the surgical treatment has to be modified.

Objectives

This overview provides new insights in the pathophysiology of the early danger response after polytrauma and outlines the main resulting consequences for surgical management.

Results

First, synchronically to the clinical assessment, life-saving procedures need to be performed rapidly, such as control of massive intra-thoracic or abdominal bleeding and decompression of the chest and brain, as standardized by advanced trauma life support guidelines. During the second phase of “day-one-surgery” damage-control interventions such as debridement, decompression and temporary fracture stabilization are needed to avoid an excessive molecular and cellular danger response. Trauma-adjusted surgical techniques are crucial to limit the systemic response known to put remote organs at risk. In the “vulnerable phase” when the patient’s defense is rather uncontrolled, only “second look” debridement to minimize a “second hit” is recommended. After stabilization of the patient as indicated by improvement of tissue oxygenation, coagulation, and decreased inflammatory mediators, “reconstructive surgery” can be applied.

Conclusion

Individually adjusted surgical “damage control” and “immune control” are important interactive concepts in polytrauma management.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Matthes G, Seifert J, Ostermann PA, Wuerfel S, Ekkernkamp A, Wich M (2001) Early death of the severely injured patient—a retrospective analysis. Zentralbl Chir 126:995–999

    Article  PubMed  CAS  Google Scholar 

  2. Ertel W, Trentz O (1994) Polytrauma and multiple organ failure syndrome. Definition–pathophysiology–therapy. Zentralbl Chir 119:159–167

    PubMed  CAS  Google Scholar 

  3. Kohl J (2006) The role of complement in danger sensing and transmission. Immunol Res 34:157–176

    Article  PubMed  CAS  Google Scholar 

  4. Cohen J (2002) The immunopathogenesis of sepsis. Nature 420:885–891

    Article  PubMed  CAS  Google Scholar 

  5. Matzinger P (2002) The danger model: a renewed sense of self. Science 296:301–305

    Article  PubMed  CAS  Google Scholar 

  6. Keel M, Trentz O (2005) Pathophysiology of polytrauma. Injury 36:691–709

    Article  PubMed  Google Scholar 

  7. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee (1992) American college of chest physicians/society of critical care medicine consensus conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 20:864–874

    Article  Google Scholar 

  8. Albers S, Burk AM, Rittisch D, Amara U, Helm M, Lampl L, Bruckner UB, Beck A, Gebhard F, Huber-Lang M (2006) Impairment of the complement function after multiple trauma in humans. Shock 26(Suppl. 1):44

    Google Scholar 

  9. Hecke F, Schmidt U, Kola A, Bautsch W, Klos A, Köhl J (1997) Circulating complement proteins in multiple trauma patients-correlation with injury severity, development of sepsis, and outcome. Crit Care Med 25:2015–24

    Article  PubMed  CAS  Google Scholar 

  10. Huber-Lang M, Sarma JV, Zetoune FS, Rittirsch D, Neff TA, McGuire SR, Lambris JD, Warner RL, Flierl MA, Hoesel LM, Gebhard F, Younger JG, Drouin SM, Wetsel RA, Ward PA (2006) Generation of C5a in the absence of C3: a new complement activation pathway. Nature Med 12:682–687

    Article  PubMed  CAS  Google Scholar 

  11. Brohi K, Singh J, Heron M, Coats T (2003) Acute traumatic coagulopathy. J Trauma 54:1127–30

    PubMed  Google Scholar 

  12. Stahel PF, Heyde CE, Wyrwich W, Ertel W (2005) Current concepts of polytrauma management: from ATLS to “damage control”. Orthopade 34:823–836

    Article  PubMed  CAS  Google Scholar 

  13. Lampl L, Helm M, Specht A, Bock KH, Hartel W, Seifried E (1994) Blood coagulation parameters as prognostic factors in multiple trauma: can clinical values be an early diagnostic aid? Zentralbl Chir 119:683–689

    PubMed  CAS  Google Scholar 

  14. Toh CH, Hoots WK (2006) The scoring system of the scientific standardization committee on disseminated intravascular coagulation of the International Society on Thrombosis and Haemostasis: a 5-year overview. J Thromb Haemost 5:604–606

    Article  PubMed  Google Scholar 

  15. Cohen MJ, Brohi K, Ganter MT, Manley GT, Mackersie RC, Pittet JF (2007) Early coagulopathy after traumatic brain injury: the role of hypoperfusion and the protein C pathway. J Trauma 63:1254–1261

    PubMed  CAS  Google Scholar 

  16. Nast-Kolb D, Ruchholtz S, Waydhas C, Schmidt B, Taeger G (2005) Damage control orthopedics. Unfallchirurg 108:804–811

    Article  PubMed  CAS  Google Scholar 

  17. Schmidt OL, Heyde CE, Ertel W, Stahel PF (2005) Closed head injury—an inflammatory disease? Brain Res Brain Res Rev 48:388–399

    Article  PubMed  Google Scholar 

  18. Leinhase I, Rozanski M, Harhausen D, Thurman JM, Schmidt OL, Hossini AM, Taha ME, Rittirsch D, Ward PA, Holers VM, Ertel W, Stahel PF (2007) Inhibition of the alternative complement activation pathway in traumatic brain injury by a monoclonal anti-factor B antibody: a randomized placebo-controlled study in mice. J Neuroinflammation 2:1–13

    Google Scholar 

  19. Stahel PF, Smith WR, Moore EE (2008) Hypoxia and hypotension, the “lethal duo” in traumatic brain injury: implication for prehospital care. Intensive Care Med 34:402–404

    Article  PubMed  Google Scholar 

  20. Stahel PF, Ertel W, Heyde CE (2005) Traumatic brain injury: impact on timing and modality of fracture care. Orthopade 34:852–864

    Article  PubMed  CAS  Google Scholar 

  21. Tracey KJ (2002) The inflammatory reflex. Nature 421:384–388

    PubMed  Google Scholar 

  22. Flierl MA, Rittirsch D, Nadeau BA, Chen AJ, Sarma JV, Zetoune FS, McGuire SR, List RP, Day DE, Hoesel LM, Gao H, Van Rooijen N, Huber-Lang MS, Neubig RR, Ward PA (2007) Phagocyte-derived catecholamines enhance acute inflammatory injury. Nature 449:721–725

    Article  PubMed  CAS  Google Scholar 

  23. Flohe S, Flohe SB, Schade FU, Waydhas C (2007) Immune response of severely injured patients-influence of surgical intervention and therapeutic impact. Langenbecks Arch Surg 392:639–648

    Article  PubMed  CAS  Google Scholar 

  24. Gebhard F, Bruckner UB, Strecker W, Kinzl L (2000) Untersuchungen zur systemischen posttraumatischen Inflammation in der Frühphase nach Trauma. Hefte zu der Unfallchirurg 276. Springer, Berlin Heidelberg New York

    Google Scholar 

  25. Biffl WL, Moore EE, Zallen G, Johnson JL, Gabriel J, Offner PJ, Silliman CC (1999) Neutrophils are primed for cytotoxicity and resist apoptosis in injured patients at risk for multiple organ failure. Surgery 126:198–202

    PubMed  CAS  Google Scholar 

  26. Köller M, Wick M, Muhr G (2001) Decreased leukotriene release from neutrophils after severe trauma: role of immature cells. Inflammation 25:53–59

    Article  PubMed  Google Scholar 

  27. Huber-Lang M, Younkin EM, Sarma VJ, McGuire SR, Lu KT, Guo RF, Padgoankar VA, Curnutte JT, Erickson R, Ward PA (2002) Complement-induced impairment of innate immunity during sepsis. J Immunol 169:3223–3231

    PubMed  CAS  Google Scholar 

  28. Walz CR, Zedler S, Schneider CP, Mayr S, Loehe F, Bruns CJ, Faist E, Jauch KW, Angele MK (2007) Depressed T cell-derived INF-g following trauma-hemorrhage: a potential mechanism for diminished APC response. Langebecks Arch Surg 392:339–343

    Article  CAS  Google Scholar 

  29. Haas NP (1997) Recommendations for structure, organization and outfitting preclinical and clinical patient care in trauma surgery departments of German hospitals. Unfallchirurg 100:2–7

    Article  PubMed  CAS  Google Scholar 

  30. Franz J, Marzi I, Mutschler W (1996) Shock room management of polytrauma. Zentralbl Chir 121:943–949

    Google Scholar 

  31. Kienlen J, de La Coussaye JE (1999) Management of multiple trauma in the emergency room. J Chir (Paris) 136:240–251

    CAS  Google Scholar 

  32. Maghsudi M, Nerlich M (1998) Management of polytrauma. Preclinical handling and shock unit management. Chirurg 69:313–322

    Article  PubMed  CAS  Google Scholar 

  33. Ruchhotlz S, Zintl B, Nast-Kolb D, Waydhas C, Schwender D, Pfeifer KJ, Schweiberer L (1997) Quality mangagement in early clinical polytrauma management. II. Optimizing therapy by treatment guidlines. Unfallchirurg 100:859–866

    Article  Google Scholar 

  34. Siebert H (2006) White book of severely injured-care of the DGU. Recommendations on structure, organization and provision of hospital equipment for care of severely injured in the Federal Republic of Germany. Unfallchirurg 109:815–820

    Article  PubMed  CAS  Google Scholar 

  35. Weber U, Ertel W (2005) Introduction to the topic: the golden hour is decisive. Standard procedures in polytrauma. Orthopade 34:821–822

    Article  PubMed  CAS  Google Scholar 

  36. Hessmann MH, Hofmann A, Kreitner KF, Lott C, Rommens RM (2006) The benefit of multislice CT in the emergency room management of polytraumatized patients. Acta Chir Belg 106:500–507

    PubMed  CAS  Google Scholar 

  37. Pape HC, Hildebrand F, Krettek C (2004) Decision making and priorities for surgical treatment during and after shock trauma room treatment. Unfallchirurg 107:927–936

    Article  PubMed  CAS  Google Scholar 

  38. Moore EE, Burch JM, Franciose RJ, Offner PJ, Biffl WL (1998) Staged physiologic restoration and damage control surgery. Worl J Surg 22:1184–1191

    Article  CAS  Google Scholar 

  39. Pape HC, Tscherne H (2000) Early definitive fracture fixation, and systemic effects. In: Baue AE, Faist E, Fry M (eds) Multiple organ failure. Springer, Berlin, pp 279–290

    Google Scholar 

  40. Pape HC, Stalp M, Dahlweid M, Regel G, Tscherne H, Arbeitsgemeinschaft “Polytrauma” der Deutschen Gesellschaft für Unfallchirurgie (1999) Welche primäre Operationsdauer ist hinsichtlich eines “Borderline-Zustandes”polytraumatisierter Patienten vertretbar? Unallchirurg 102:861–869

    Article  CAS  Google Scholar 

  41. Sauerland S, Waydhas C, Raum MR, Neugebauer E (2002) Systematic literature searches for clinical guideline development in the field of out-of-hospital and early in-hospital care of multiply injured patients. Unfallchirurg 105:1022–1026

    Article  PubMed  CAS  Google Scholar 

  42. Sauerland S, Neugebauer EA (2004) Evidence of shock trauma room care. Unfallchirurg 107:833–834

    Article  PubMed  CAS  Google Scholar 

  43. Heinzelmann M, Imhof HG, Trentz O (2004) Shock trauma room management of the multiple-traumatized patient with skull–brain injuries. A systematic review of the literature. Unfallchirurg 107:871–880

    Article  PubMed  CAS  Google Scholar 

  44. Woltmann A, Bühren V (2004) Shock trauma room management of spinal injuries in the framework of multiple trauma. A systematic review of the literature. Unfallchirurg 107:911–918

    Article  PubMed  CAS  Google Scholar 

  45. Platzer P, Jaindl M, Thalhammer G, Dittrich S, Wieland T, Vescei V, Gaebler C (2006) Clearing the cervical spine in critically injured patients: a comprehensive C-spine protocol to avoid unnecessary delays in diagnosis. Eur Spine J 15:1801–1810

    Article  PubMed  Google Scholar 

  46. Voggenreiter G, Eisold C, Sauerland S, Obertacke U (2004) Diagnosis and immediate therapeutic management of chest trauma. A systematic review of the literature. Unfallchirurg 107:881–891

    Article  PubMed  CAS  Google Scholar 

  47. Liener UC, Sauerland S, Knoeferl MW, Bartl C, Riepl C, Kinzl L, Gebhard F (2006) Emergency surgery for chest injuries in the multiply injured: a systemic review. Unfallchirurg 109:447–452

    Article  PubMed  CAS  Google Scholar 

  48. Staib L, Aschoff AJ, Henne-Bruns D (2004) Abdominal trauma. Tailoring its management to injury. Chirurg 75:447–467

    Article  PubMed  CAS  Google Scholar 

  49. Lindner T, Bail HJ, Manegold S, Stöckle U, Haas NP (2004) Shock trauma room diagnosis: initial diagnosis after blunt abdominal trauma. A review of the literature. Unfallchirurg 107:892–902

    Article  PubMed  CAS  Google Scholar 

  50. Seekamp A, Burkhardt M, Pohlemann T (2004) Shock trauma room management of pelvic injuries. A systematic review of the literature. Unfallchirurg 107:903–910

    Article  PubMed  CAS  Google Scholar 

  51. Burkhardt M, Culemann U, Seekamp A, Pohlemann T (2005) Strategies for surgical treatment of multiple trauma including pelvic fracture. Review of the literature. Unfallchirurg 108:812–820

    Article  PubMed  CAS  Google Scholar 

  52. Kobbe P, Frink M, Zelle BA, Pape HC (2007) Complex knee injury in polytraumatized patients. Unfallchirurg 110:235–244

    Article  PubMed  CAS  Google Scholar 

  53. Delire M (1988) Immune disorders after severe injury. Ann Biol Clin 46:272–275

    CAS  Google Scholar 

  54. Beck A, Bischoff M, Gebhard F, Huber-Lang M, Kinzl L, Schmelz A (2004) Diagnostic apparatus in the shock trauma room. Unfallchirurg 107:862–870

    Article  PubMed  CAS  Google Scholar 

  55. Kühne CA, Ruchholtz S, Sauerland S, Waydhas C, Nast-Kolb D (2004) Personnel and structural requirements for the shock trauma room management of multiple trauma. A systematic review of the literature. Unfallchirurg 107:851–861

    Article  PubMed  Google Scholar 

  56. Mutschler W, Kanz KG (2002) Interdisciplinary shock room management: responsibilities of the radiologist from the trauma surgery viewpoint. Radiologe 42:506–514

    Article  PubMed  CAS  Google Scholar 

  57. Nast-Kolb D, Ruchholtz S, Waydhas C, Taeger G (2006) Management of polytrauma. Chirurg 77:861–872

    Article  PubMed  CAS  Google Scholar 

  58. Wurb T, Frühwald P, Brederlau J, Steinhübel B, Frommer M, Kuhnigk H, Kredel M, Knüpffer J, Hopfner W, Maroske J, Moll R, Wagner R, Thiede A, Schindler G, Roewer N (2005) The Würzburg polytrauma algorithm. Concept and first results of a sliding-gantry-based computer tomography diagnostic system. Anaesthesist 54:763–768 770–772

    Article  Google Scholar 

  59. Westhoff J, Hildebrand F, Grotz M, Richter M, Pape HC, Krettek C (2003) Trauma care in Germany. Injury 34:674–683

    Article  PubMed  CAS  Google Scholar 

  60. Haas NP, Hoffmann RF, Mauch C, von Foumier C, Südkamp NP (1995) The management of polytraumatized patients in Germany. Clin Orthop Relat Res 318:25–35

    PubMed  Google Scholar 

  61. Celso B, Tepas J, Langland-Orban B, Pracht E, Papa L, Lottenberg L, Flint L (2006) A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma 60:371–8

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Trauma, Hand-, Plastic-, and Reconstructive Surgery, University Hospital Ulm, Steinhoevelstr. 9, 89075, Ulm, Germany

    F. Gebhard & M. Huber-Lang

Authors
  1. F. Gebhard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. Huber-Lang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to F. Gebhard.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gebhard, F., Huber-Lang, M. Polytrauma—pathophysiology and management principles. Langenbecks Arch Surg 393, 825–831 (2008). https://doi.org/10.1007/s00423-008-0334-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-008-0334-2

Keywords

Search

Navigation