Current Concepts of Polytrauma Management - Springer Link

Focus on Polytrauma

European Journal of Trauma

Current Concepts of Polytrauma Management Philip F. Stahel*, Christoph E. Heyde*, Wolfgang Ertel1

Abstract In recent years, the implementation of standardized protocols of polytrauma management led to a significant improvement of trauma care in European countries and to a decrease in posttraumatic morbidity and mortality. As such, the “Advanced Trauma Life Support” (ATLS®) protocol for the acute management of severely injured patients has been established as a gold standard in most European countries since the 1990s. Continuative concepts to the ATLS® program include the “Definitive Surgical Trauma Care” (DSTC™) algorithm and the concept of “damage control” surgery for polytraumatized patients with immediate life-threatening injuries. These phase-oriented therapeutic strategies appraise the injured patient in the whole extent of the sustained injuries and are in sharp contrast to previous modalities of “early total care” which advocate immediate definitive surgical interventions. The approach of “damage control” surgery takes the influence of systemic posttraumatic inflammatory and metabolic reactions of the organism into account and is aimed at reducing both the primary and the secondary – delayed – mortality in severely injured patients. The present paper shall provide an overview on the current state of management algorithms for polytrauma patients. Key Words Polytrauma · Management · ATLS® · Damage control · Multiorgan failure · Mortality Eur J Trauma 2005;31:200–11 DOI 10.1007/s00068-005-2028-6

Introduction Trauma still represents the “major killing factor” in young patients < 45 years of age in industrialized countries [1, 2]. In Germany alone, 4–5 million people suffer traumatic injuries each year and > 20,000 severely injured patients die every year [1, 3–5]. Trauma-related mortality has three major causes [6]: (1) the immediate mortality at the accident site (“sudden death”) due to lethal injuries such as aortic rupture with free bleeding, lacerations of the brain stem, or decapitating injuries; (2) early mortality within the first few minutes to hours (“golden hour”) due to compromised airways, tension pneumothorax, hemorrhagic shock as a consequence of intraabdominal or intrathoracic bleeding and pelvic ring disruptions with massive retroperitoneal hemorrhage, or due to severe traumatic brain injury with acute cerebral edema or intracranial hematoma; (3) late mortality within days to weeks after trauma due to septic complications, multiple organ failure and due to untreatable increased intracranial pressure associated with cerebral edema. Major improvements in the management strategies of severely injured patients in the past decades have led to a significant reduction of polytrauma-associated mortality from about 40% in the 1970s to around 10% in the year 2000 [7]. This achievement is mainly owed to improved standards of trauma care due to defined algorithms of preand in-hospital trauma care which have been broadly propagated and established in most industrialized and developing countries [6, 8–15]. Since the patients’ outcome is directly related to the time interval from injury to properly delivered definitive care, the optimization of preclinical transportation times and the implementation of the concept of patient transport to the closest appropriate – not 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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European Journal of Trauma 2005 · No. 3 © Urban & Vogel

Stahel PF, et al. Polytrauma Management

Trunkey: “get the Right patient to the Right hospital in the Right time”) [16, 17], have led to minimized transportation times and to shorter therapy-free intervals with overall improved outcome of polytrauma patients [1, 4, 7, 13]. Furthermore, the vast propagation of the “damage control” concept for severely injured patients with immediate life-threatening injuries, as well as the improvement of intensive 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 (Box 1) is characterized by the demands of both therapeutic and diagnostic measures. Since the time factor is of crucial essence, validated concepts and algorithms have been established in the past few years for the initial diagnosis and treatment of severely injured patients. The updated “Guidelines of the German Society of Trauma Surgery” (DGU) for the diagnostics and treatment of polytraumatized patients have recently been outlined in a comprehensive review article [25]. The “Advanced Trauma Life Support“ (ATLS®) protocol of the American College of Surgeons’ Committee on Trauma has been established as a standard procedure algorithm for the initial assessment and management of polytraumatized patients in the past 3 decades in > 30 countries worldwide and in twelve European countries [6, 14]. Based on the principle of the “golden hour of shock”, injuries which would take a lethal course if left untreated within the first minutes to few hours after trauma are being cared for using standardized diagnostic algorithms and validated therapeutic concepts according to the ATLS® guidelines [6, 14, 26]. In blunt polytrauma patients, this early phase of the “golden hour” is not restricted to management within just the first 60 min after injury only, but can be safely extended to the first few hours after trauma [27]. Beyond the ATLS® concept, the “Definitive Surgical Trauma Care“ (DSTC™) course by the International Association for the Surgery of Trauma and Surgical Intensive Care provides the standards of emergency surgical procedures of patients with blunt and penetrating injuries. The concept of “damage control” orthopedic surgery has evolved based on the observation that a prolonged early definitive treatment of long bone fractures can be Box 1. “Polytrauma” – definition according to Otmar Trentz (2000). A syndrome of multiple injuries exceeding a defined severity (Injury Severity Score [ISS] > 17) with consecutive systemic trauma reactions which may lead to dysfunction or failure of remote – primarily not injured – organs and vital systems [24].


Figure 1. The “lethal triad” in the pathophysiology of severely injured patients leading to a vicious circle and adverse outcome. This implication constitutes the underlying rationale for the concept of “damage control” surgery [30].

detrimental for severely injured patients who are in a persisting unstable physiological state despite adequate resuscitative measures during the initial management phase [18, 19, 28–30]. In these patients, the early restoration of the “lethal triad” of persistent metabolic acidosis, hypothermia, and coagulopathy represents the prime goal for survival [28–30] (Figure 1). Thus, polytrauma patients in extremis must be transferred to intensive care at the earliest time point after stabilization of vital functions for restoration of physiological parameters, and prolonged surgical interventions must be avoided in order to prevent a lethal “second hit” in these patients [24, 31–33]. The current understanding of “damage control” surgery involves four distinct phases of assessment and management [18, 34]: (1) life-saving surgery with early recognition of those trauma patients that warrant damage control (“ground zero” recognition phase); (2) salvage operation for control of hemorrhage and contamination (“OR phase”); (3) intensive care management for restoration of physiological and immunologic baseline functions (“ICU phase”); (4) scheduled definitive surgery (“reconstructive phase”). The present review shall provide an up-to-date overview on established diagnostic and therapeutic algorithms of preclinical and clinical management of polytraumatized patients. Preclinical Management During the prehospital period, emphasis in the management of polytrauma patients should be placed on airway maintenance, control of external bleeding, fluid resuscitation, immobilization of the spine, and immediate transport to the closest appropriate clinic. Different algorithms have been established to narrow the time window from injury to definitive care and to optimize the preclinical therapeutic strategies and determine the adequate target facility for the individual trauma patients [6, 13, 35–37]. These defined algorithms should help prevent the undertriage of trauma victims – a phenomenon which has been shown to occur mainly in elderly patients [16, 17]. Thus,

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the prime philosophy in the decision scheme suggested by the American College of Surgeons’ Committee on Trauma is: “When in doubt, take the patient to a trauma center” [6]. The initial assessment of trauma victims at the accident site is performed on the basis of vital functions and a rough overview of the overall injury pattern. In the case of a trapped person inside a car, the temporal course of rescue and life-saving procedures must be coordinated [6, 35]. According to established algorithms, the measures of extrication of trapped victims are in secondary priority to securing the airway and protecting the cervical spine [6, 35, 36]. Ensuring vital function according to the A-B-C priorities of the ATLS® protocol comprises clearing and securing the airway or establishing a patent airway by endotracheal intubation in the case of acute airway compromise [6, 13]. Supplemental oxygen is provided to every trauma patient by an oxygen mask. The indication for endotracheal intubation at the accident site is established liberally in cases of risk of airway obstruction or aspiration (unconscious patients with Glasgow Coma Scale [GCS] score ≤ 8, insufficient respiration with hypoxemia due to severe thoracic trauma or flail chest), and to prevent hypoxemia-induced secondary injury in severe head trauma [6, 38]. In intubated patients, adequate analgesia and sedation/relaxation are mandatory to prevent pain and systemic secondary stress reactions leading to increased intracranial pressure and adverse outcome [39]. While assessing and managing the patient’s airway, great care must be taken to prevent excessive movement of the – potentially injured – cervical spine. During resuscitative measures, the C-spine must be protected by in-line immobilization to prevent hyperextension, hyperflexion, and rotation [6, 40]. Endotracheal intubation is performed by standardized two-person maneuver according to the ATLS® criteria with the helper holding the cervical spine in slight axial in-line position while the second person performs intubation [6, 40]. Although fiberscope-guided nasotracheal intubation has been shown to be the safest measure with regard to limited cervical spine motion during establishment of a patent airway [41], this technique is not suited for intubation in an emergency situation. For rapid-sequence induction, the use of an intubating laryngeal mask (Fastrach) has been postulated as a safe maneuver with limited cervical spine excursion [42], however, the use of a laryngeal mask is not regarded as a safe standard for establishing a patent airway in trauma patients, according to the ATLS® criteria [6]. Thus, these additional measures are not suited for emergency intubation at the accident site. Appropriate immobiliza-

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tion devices must be applied for stabilization of the entire vertebral column during transport, since spinal injuries must be assumed in all polytrauma patients until proven otherwise. Based on the principle of “do no further harm”, patients are immobilized with a cervical collar and evacuated on a long spine board or a vacuum mattress. Based on the National Acute Spinal Cord Injury Study (NASCIS) guidelines, high-dose methylprednisolone therapy (30 mg/kg bolus i.v.) should be initiated as early as possible in the case of neurologic impairment due to suspected spinal cord injury, ideally at the accident site and imperatively within a time window of 8 h after trauma [43, 44]. Steroid therapy is continued in the clinic for further 24 h with a maintenance dose of 5.4 mg/kg/h [43, 44]. In contrast to blunt spinal trauma, steroids are not recommended for penetrating spinal cord injury, such as gunshot injuries [45, 46]. In the latter case, the use of steroids has not been shown to improve the neurologic outcome, but was associated with a greater frequency of nonspinal complications [45, 46]. In parallel to airway management with cervical spine protection, resuscitative measures for shock therapy are initiated by fluid replacement via at least two large-caliber peripheral venous accesses. An initial infusion volume of 2,000 ml crystalline solution or alternatively crystalloids and colloids at a ratio of 3 : 1 are recommended as a standard [6, 13]. External bleeding sources are controlled by local compression and sterile dressing in addition to fluid resuscitation. The use of surgical clamps and tourniquets is obsolete and contraindicated due to iatrogenic additional tissue damage. In the case of hemorrhagic shock associated with massive internal bleeding due to pelvic ring disruptions, initial hemorrhage control is established by reduction of the pelvic ring by internal rotation of both thighs and wrapping with wide bandages or sheets [47, 48]. This simple technique can significantly decrease retroperitoneal bleeding associated with pelvic ring disruptions – by diminishing the pelvic volume – during the transportation phase. Soft-tissue wounds and open fractures need to be documented at the accident site and are covered by a sterile dressing. No further inspection of the wound is warranted until surgical exploration in the clinic [6]. At no time should the wound be probed. If a fracture and an open wound exist in the same limb segment, the fracture has to be considered open until proven otherwise by the surgical exploration. Concordantly, a wound over a joint implies an open joint injury. In these cases, administration of tetanus prophylaxis and antibiotics by a sec-



prove the overall outcome of severely injured patients (Figure 2) [4, 6, 18, 23–26, 50]. The established time-dependent management phases for trauma patients in the first 24 h (“day-1 surgery”) comprise: (1) primary survey with baseline diagnostics and immediate life-saving procedures and establishing access to life-support systems according to the A-B-C algorithm of the ATLS® protocol; (2) damage control surgery in patients who are not responsive to the initial measures of resuscitation: surgical control for exsanguinating hemorrhage and decompression 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, surgical exploration and management of non-immediately life-threatening injuries, temporary fracture fixation.

Figure 2. Proposed algorithm for the initial assessment and management of polytrauma patients.

ond-generation cephalosporin are warranted upon arrival in the clinic [49]. Fracture-dislocations are reduced in-line and fixed by temporary devices. Immediate transfer to definitive care should not be retarded by any of these additional measures [6]. When available, the rescue helicopter should be used for fast and careful transport of seriously injured patients to a verified level I trauma center. Hereby, early notification of the receiving doctor at the target hospital is of essential importance. All available information on the overall condition and estimated injury pattern of the accident victim must be transmitted ahead of time so that adequate equipment and manpower can be arranged at the receiving hospital until admission of the patient to the emergency room [6]. Initial Assessment and Management Upon arrival in the emergency room, the primary objective of the initial assessment and management of polytraumatized patients is survival. Thus, timing and priorities have to be followed in tight adherence to defined established algorithms which have been shown to im-


Life-Saving Surgery and Damage Control During the primary survey, the injured patient is rapidly assessed according to the algorithm of the ATLS® protocol and life-preserving therapy is instituted simultaneously. The treatment priorities are based on the likelihood of a patient to die within a short time from a life-threatening injury, according to the “A-B-C-D-E” mnemonic [6] (Table 1): • Airway maintenance with cervical spine protection, • Breathing and ventilation, • Circulation with hemorrhage control, • Disability: brief neurologic evaluation, • Exposure with environmental control (protection from hypothermia). Using this algorithm during the primary survey, potential life-threatening conditions are identified and managed simultaneously with a frequent reassessment of the patient’s physiological status and response to resuscitative measures [6]. The key point of any successful management of a severely injured patient concerns the clear priority of “damage control” ahead of any time-consuming diagnostic procedure. It has to be pointed out, however, that the concept of “damage control” – as outlined later in the paper – does not represent an integrated part of the original ATLS® protocol [6]. A – airway maintenance with cervical spine protection. The first priority in the care of trauma victims is to ensu-

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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 A

B

C

Airway maintenance with cervical spine protection • Inspection of upper airways, recognition of upper airway obstruction (stridor, hoarseness, laryngeal hematoma/emphysema/dislocation, dyspnea, tachypnea)

Management

• Clearance of upper airways, suction, jaw-thrust or chin-lift maneuver, oropharyngeal tube, “patent airway“ establishment by endotracheal intubation with rapid-sequence induction or surgical airway by cricothyroidotomy. Deliver supplemental oxygen. All measures must be performed under C-spine protection (C-collar, in-line immobilization)!

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 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

E

Exposure with environmental control • Completely undress the patient and “log-roll“ for posterior injuries

re an adequate airway. This implies the maintenance of patent upper airways, if necessary by endotracheal intubation or, in exceptional situations, by establishing a surgical airway through cricothyroidotomy. Correct positioning of the tube must be confirmed by auscultation, end-tidal CO2 monitoring, and a chest X-ray. In addition, every trauma patient must receive supplemental oxygen (4–10 l/min via oxygen mask in nonintubated patients and 50–100% FiO2 in intubated patients). The need for exogenous oxygen in the trauma patient is illustrated in the formula established by Nunn & Freeman in 1964 [51]: O2av = CO × SaO2 × Hb × 1.34. This formula specifies that the oxygen available in the tissue (O2av) is equal to the product of cardiac output (CO in ml/min), arterial O2 saturation (SaO2 in %) and hemoglobin concentration (Hb in g%), whereby 1.34 represents the O2-binding capacity of hemoglobin (in ml/g). While the oxygen demand is satisfied under physiological conditions, several of these variables may be significantly compromised in seriously injured patients due to acute blood loss (Hb), pulmonary contusion (SaO2) and myocardial contusion or pericardial tamponade (CO), thus resulting in a severe deficit of oxygen supply for the trauma patient [52].

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• GCS ≤ 8: endotracheal intubation! • Protection from hypothermia by warmed blankets, heating lamps and application of preheated infusions

B – breathing and ventilation. In second priority to ensuring an adequate airway, a tension pneumothorax must be excluded based on clinical findings due to the immediate threat to life [6]. The clinical symptoms include acute dyspnea with ipsilaterally decreased respiratory sounds and hypersonoric percussion sound with congested jugular veins. The clinical sign of congested jugular veins may be absent in patients with hemorrhagic-traumatic shock due to hypovolemia and circulatory centralization. A tracheal deviation to the contralateral side represents a late sign and may be detected by clinical inspection of the neck. A tension pneumothorax compromises ventilation and circulation dramatically and acutely. Thus, if suspected by clinical findings, chest decompression by puncture of the second intercostal space in the midclavicular line with a large-bore needle must be accomplished immediately without further imaging diagnostics [6]. This life-saving maneuver converts the injury into a simple pneumothorax and must immediately be followed by an open placement of a chest drain in the fourth to fifth intercostal space in anterior axillary line. The most frequent cause of tension pneumothorax is mechanical positive pressure ventilation in a patient with visceral pleural injury. Thus, insertion of a chest drain is mandatory in every intubated trauma



patient with rib fractures due to thoracic trauma even in absence of radiologic signs of a traumatic hemo-/pneumothorax [6]. Aside from a tension pneumothorax, additional critical thoracic injuries include a flail chest with pulmonary contusion, a massive hemothorax, and an open pneumothorax, also referred to as a “sucking chest wound” [6, 53, 54]. The latter injury is treated by initial sterile occlusive dressing which is left open on one side to allow a flutter-type valve effect for prevention of aggravation into a tension pneumothorax. The injury is then treated by chest tube insertion and by surgical exploration of the wound in the operating room after stabilization of vital functions. Patients with a flail chest may be candidates for early intubation and mechanical ventilation due to respiratory distress and hypoxemia [6]. A traumatic hemothorax is treated by chest tube drainage. This simple maneuver resolves the problem in most cases of blunt thoracic trauma [6, 53, 54]. However, the presence of a massive hemothorax with continuous bleeding and/or the presence of a cardiac tamponade – both entities mainly due to penetrating injuries – require surgical management by resuscitative thoracotomy [6, 53–55]. C – circulation with hemorrhage control. In third priority, internal and external hemorrhages must be recognized and the bleeding must be stopped, if necessary by surgical measures. When assessing the extent of hemorrhage, attention should be paid to the fact that the individual compensatory mechanisms can maintain a normal blood pressure for a limited time even in a critical hypovolemic situation. In this regard, in case of an acute blood loss of up to 30% (equivalent to 1.5 l blood loss in a 70-kg patient), the systolic blood pressure can be kept within a normal range by increasing the peripheral resistance, thus “masking” the state of shock [6]. However, cardiac output is reduced to up to half the normal value which may lead to critical organ perfusion and subsequent metabolic acidosis with elevated serum lactate and an increased lactate : pyruvate ratio in serum due to the anaerobic metabolic situation [56]. Therefore, during the primary survey, the main question to be addressed with regard to blood loss – “Is the patient in shock?” – needs to be immediately resolved by clinical findings of compromised tissue oxygenation [6]. The clinical symptoms of shock are the “three windows to the microcirculation” which can be assessed in terms of inadequate organ perfusion [6]: (1) mental status/level of consciousness (cerebral perfusion) – agitation, confu-


sion, somnolence or lethargy; (2) peripheral perfusion – cold and clammy skin, delayed capillary refilling, tachycardia; (3) renal perfusion – oliguria (< 0,5 ml/kg/ h) or anuria. These clinical findings must help differentiate in an early phase whether a patient is “hemodynamically normal” or just apparently “hemodynamically stable” with the risk of deterioration. Based on the response to initial resuscitative measures, the latter group of patients are defined as either “transient responders” or “nonresponders” and are likely to require a surgical intervention for hemorrhage control [6]. Arterial blood gas analysis can furthermore help determine the extent of hemorrhagic shock in polytrauma patients. In this regard, clinical studies have demonstrated that lactate levels and base deficit represent highly sensitive parameters for recognition of “hidden shock” in traumatic hemorrhage [56–59]. A base deficit below the cutoff at –6 mEq/l in the initial blood gas analysis has been shown to be associated with significantly increased transfusion requirements, posttraumatic complications and increased mortality [58, 59]. A base deficit < –10 mEq/l has been associated with a high mortality of 40–70% [58, 59]. By contrast, mortality in patients with normal base deficit or base excess (+2 to –2 mEq/l) was as low as about 6% [58, 59]. In addition, the lactate level on admission represents a sensitive parameter reflecting the extent of traumatic-hemorrhagic shock [57]. The time frame of normalization of lactate levels below a cutoff at 2 mmol/l was shown to correlate significantly with survival [57]. While polytrauma patients with refractory lactate acidosis (> 2 mmol/l) for > 48 h after injury had a mortality of 85%, those patients where lactate levels normalized within the first 24 h had a low mortality of around only 1% [57]. In parallel to aggressive volume resuscitation, the main bleeding sources must be screened according to standardized protocols during the primary survey [6]. This includes a focused assessment sonography for trauma (“FAST”) and anteroposterior radiographs of chest and pelvis as a gold standard. The further algorithms for diagnosis and management of intrathoracic and intraabdominal bleedings and of retroperitoneal hemorrhage associated with pelvic ring disruptions are provided in the paragraph on damage control (see below). D – disability: brief neurologic evaluation. After stabilization of vital functions, a brief evaluation of the level of consciousness (GCS) and of pupil symmetry and reaction is performed. The presence of traumatic brain in-

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jury must be recognized early in order to take preventive measures for the development of secondary brain injury due to hypoxemia and hypotension [38, 39]. These parameters are crucial for the outcome after head injury due to propagation of a massive intracerebral inflammatory response leading to development of brain edema with increased intracranial pressure and decreased cerebral perfusion pressure, ultimately contributing to delayed neuronal cell death [60, 61]. For this reason, an appropriate resuscitation of the “A-B-C” parameters represents the crucial basis for avoidance of secondary brain injuries after trauma [38]. The severity of traumatic brain injury is classified according to the GCS as mild (14–15 points), moderate (9–13 points), and severe (3–8 points). Endotracheal intubation for securing a patent airway is mandatory at a GCS ≤ 8, since these patients are comatose per definition [6, 39]. Patients with a GCS ≤ 13 must be admitted to a trauma center with available neurosurgical capabilities. In these patients, a craniocerebral CT scan is mandatory due to the significantly increased likelihood of intracranial hematoma as compared to patients with mild head injury (GCS 14 or 15) [39]. E – exposure with environmental control. Every trauma patient must be completely undressed for thorough inspection and examination under protection from hypothermia by warm blankets and preheated infusions and heating lamps. A “log-roll” maneuver is mandatory in all patients for inspection of the back side for potential hidden injuries. A continuous reassessment of vital parameters must be performed in order to recognize deterioration and to initiate according resuscitative measures [6]. The Concept of “Damage Control” Since the first description of the concept of abbreviated laparotomy with intraabdominal packing in patients with massive hemorrhage more than 2 decades ago [62], this concept of “damage control” surgery has had a worldwide dispersion in all major surgical disciplines [18]. The rationale behind the concept of abbreviating standard surgical procedures lies within the aim of an early transfer of critical patients to the intensive care unit (ICU) for restoration of physiological “endpoints of resuscitation” [24] in order to improve the overall outcome of critically injured patients in severe traumatic-hemorrhagic shock [22, 28]. The presence of the “lethal triad” of hypothermia, coagulopathy, and acidosis

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(Figure 1) represents a major risk factor for deterioration and adverse outcome of polytrauma patients [29, 30]. The underestimation of the extent of traumatic hemorrhage and of the patient’s physiological condition and reserves may be detrimental due to prolonged surgical interventions which exacerbate this vicious circle and contribute to increased posttraumatic mortality [18, 28–30]. Thus, in recent years, the “classic” orthopedic concept of “early total care” for the unstable multiply injured patient has been abandoned in favor of the new concept of “damage control orthopedic surgery” (DCO) which has led to an increased overall survival of polytrauma patients [20, 31, 33, 48, 63, 64]. According to the “damage control” concept, life-preserving measures are first priority while other prolonged surgical interventions must be avoided at all costs in order to decrease the systemic pathophysiological “load” to the injured organism and to breach the vicious circle of the “lethal triad” (Figure 1). The two major surgical steps of damage control procedures include the acute decompression of body cavities and the control of exsanguinating hemorrhage, as outlined below. Decompression of body cavities. Pathologically increased pressure in body cavities requires immediate emergency surgical management. This involves the acute decompression of a tension pneumothorax and the drainage of a traumatic hemo-/pneumothorax, as described for the ATLS® protocol above [6]. In addition, a suspected cardiac tamponade must be immediately resolved by subxiphoideal puncture and/or open decompression in case of required emergency thoracotomy [6, 53–55]. Furthermore, the presence of a peracute epidural hematoma requires immediate decompression by burr hole evacuation and/or craniotomy [39, 65]. These surgical measures have utmost priority due to the acute life-threatening implication of these injury patterns. Control of exsanguinating hemorrhage. During the primary survey, the presence of hemorrhagic shock must be diagnosed and treated simultaneously. The basic management principle is to stop the bleeding and to replace the volume loss. Volume replacement is performed according to the 3 : 1 rule, which means that one unit of lost blood must be replaced by three units of fluid due to loss into the third compartment [6]. Thus, for illustration, the management of a simple femoral shaft fracture associated with up to 1,500 ml blood loss requires about 4,500 ml



fluid replacement for adequate resuscitation. The potential requirement of surgical hemorrhage control must be determined during the early resuscitative phase. Significant external hemorrhages are temporarily stopped by external compression and sterile dressing in the emergency room followed by surgical wound management in the operating room. Major internal bleeding sources which require immediate surgical control are: • massive hemothorax: initial management by open chest drain placement. Requirement of urgent thoracotomy in cases of penetrating trauma and/or after blunt trauma with massive bleeding via chest tube (> 1,500 ml immediately or continuFigures 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 laceration, intracranial hematoma and multiple long bone fractures (A). The Injury Severity Score later phase) [6, 53–55]. (ISS) was 50 points. Damage control surgery was performed by “crash”-laparotomy, Pringle ma• intraabdominal hemorrhage: indineuver and intraabdominal packing (B) and external fracture fixation. The abdominal wall was cations for urgent laparotomy innot closed – in terms of a provisional laparostoma (C) – for avoidance of abdominal compartclude hemodynamically unstable ment syndrome and further staged procedures including changes of packings within 24–48 h. The postoperative CT scan (D) shows the “packed” liver with the central laceration (arrow). patients with blunt abdominal trauma and positive ultrasonography explorative laparotomy with pelvic “packing” is warand patients with penetrating abdominal injuries [6]. ranted in order to achieve surgical hemorrhage control Patients “in extremis” with severe multiple injuries [20, 33, 47, 48, 68]. It is crucial to know that > 80% of have a significantly increased chance of survival if the hypotensive patients due to pelvic hemorrhage are surgical procedure is abbreviated and definitive repair “nonresponders” [69]. The hallmark of these patients’ of intraabdominal injuries is delayed in terms of a staged survival is a rapid recognition and surgical control of procedure (crash-laparotomy, “packing”, laparostoma/ hemorrhage, since mortality in pelvic fracture-associattemporary Ethizip® closure), as compared to patients with early total care [28–30, 66, 67] (Figure 3). Definied hemorrhage is still as high as 50–60% [70]. Interventive surgery is followed within 24–48 h after stabilizational measures like angiography and embolization are obsolete for the management of these patients, since tion of vital parameters in the ICU. arterial bleeding sources are present in < 10% of all • pelvic ring disruption with massive retroperitoneal hemorrhage: unstable pelvic injuries with posterior pelvic cases and successful embolization can be performed in < 2% [69, 71]. In addition, angiography has several disring disruption are associated with massive uncontrolled retroperitoneal bleeding of up to 5,000 ml due to advantages due to the necessity of transporting a hemodynamically unstable patient and the average time of lacerations of the presacral and paravesical venous plexus and cancellous bone bleeding [47]. These paabout 2.5 h until angiography is performed in a level I trauma center, which extends way beyond the “golden tients require immediate closed reduction of the pelvic 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 fixforming 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 refor early hemorrhage control in the initial phase [6]. suscitation – cannot achieve hemodynamic stability, The propagated “damage control” procedure for he-


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modynamically unstable patients Table 2. Timing and priorities of operative interventions in polytrauma patients depending on the physiological status [24]. with pelvic ring disruptions includes closed reduction and external fixaPhysiological status Operative procedures Timing tion with explorative laparotomy, Compromised vital functions 씮 Life-saving surgery pelvic “packing” and provisional Stable vital functions 씮 Delayed primary surgery Day 1 closure of the abdomen with surgi® Highly unstable/in extremis 씮 Damage control surgery cal zippers (Ethizip ) [20, 33, 47, 48, Hyperinflammation “Second looks” only! Day 2–4 68]. This therapeutic modality has ”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 was shown to unequivocally exclude an aortic rupture within 24–48 h and definitive surgery is to follow during [80–84]. An aortography or transesophageal echocarthe “time window of opportunity” from the 5th to 10th day after trauma (Table 2). diography are nowadays only indicated in rare cases with equivocal findings in the CT scan [80, 82]. Conven• intracranial bleeding sources: aside from acute epidutional X-rays of extremities and spine series are perral hematoma from arterial bleeding sources (see formed during the secondary survey according to the above), dural sinus bleeding may represent a major individual injury pattern [6]. source of intracranial hemorrhage requiring immediate surgical intervention by trepanation and craniotoDelayed Primary Surgery (“Day-1 Surgery”) my [65]. Surgical interventions which are not immediately re• penetrating and blunt vascular injuries, “mangled exquired for resolving life-threatening conditions are pertremity”: arterial injuries with clinical signs of limb formed after further evaluation of the stabilized patients ischemia due to blunt or penetrating trauma require in the secondary survey. Hereby, the term “delayed” reimmediate surgical management without further difers to primary surgical interventions within the first agnostics [72–74]. The “Mangled Extremity Severity 24 h (“day-1 surgery”). These operations are aimed at Score” (MESS) has been established as a guideline reducing the “antigenic load”, saving injured limbs and for early determination whether limb salvage is joints at risk, decompressing the spinal cord, and optiachievable as opposed to early amputation, with an mizing the therapeutic modalities on the ICU [21, 22, established “cutoff” level of the MESS at 7 points 24, 85]. [75–79]. Such interventions in the context of “day-1 surgery” include: Secondary Survey The phase of the secondary survey can only begin after • decompression of compartments under pressure in non-immediately life-threatening conditions: unstable the resuscitative measures of the primary survey are vertebral fractures with spinal stenosis, subdural hecompleted according to the A-B-C-D-E algorithm and matoma, compartment syndromes of the extremities; the patient has been hemodynamically stabilized and • laparotomy for hollow viscus injuries; demonstrates normal vital functions [6]. The secondary survey comprises an extended anamnestic evaluation of • revascularization of vascular injuries; • debridement of contaminated soft tissue and open concomitant diseases and events associated with the mechanism of injury and a complete and thorough fractures/joint injuries; • external fracture fixation of long bones; “head-to-toe” examination including a full neurologic status. Diagnostic adjuncts to the secondary survey in• dorsal fixation of unstable vertebral fractures by internal fixator. clude a multislice polytrauma CT scan which nowadays These operative measures should take as little time as represents a fast and highly sensitive “gold standard” possible to avoid an iatrogenic “second hit” [86] which is for further evaluation of hemodynamically stable polyassociated with adverse outcome in polytrauma patrauma patients [80, 81]. The multislice CT has been shown to be a highly sensitive tool also for detecting tients, particularly in the presence of concomitant head injury [31, 64, 65, 87, 88]. aortic rupture, whereby a normal CT scan of the aorta

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Intensive Care and Scheduled Definitive Surgery Following the operative interventions, subsequent transfer to the ICU is aimed at the earliest time point possible for further stabilization of the polytrauma patient and for restoration of the following “endpoints of resuscitation” [21, 22, 24]: • stable hemodynamics without need for vasoactive or inotropic stimulation; • no hypoxemia, no hypercapnia; • serum lactate ≤ 2 mmol/l; • normal coagulation; • normothermia; • urinary output > 1 ml/kg/h. The pathophysiological phase of hyperinflammation between days 2–4 after trauma (Table 2) is a time period of enhanced susceptibility to a “second-hit” injury and thus does not allow any surgical intervention [24, 86]. Exceptions are short operations such as sterile change of dressing, exchange of tamponades and “second-look” operations for further debridement of necrotic tissue and avoidance of bacterial contamination [24, 89]. These measures are necessary to reduce the overall stress to the organism through necrotic tissue and inflammatory mediators (“antigenic load”) and to avoid infectious complications and the development of sepsis and organ failure [90, 91]. The next management phase takes into account the presence of a physiological “window of opportunity” between days 5–10 after trauma, which corresponds to the interval between the early hyperinflammatory phase and the period of immunosuppression which follows the 2nd week after trauma (Table 2) [24]. Thus, during the “time window of opportunity”, the fully resuscitated patient is a candidate for changes in operative strategies and definitive scheduled surgical procedures. These include the change from external to internal fixation of long bone and pelvic ring fractures, the definitive osteosynthesis of joint injuries, completing ventral spondylodesis for unstable vertebral fractures, and definitive soft-tissue coverage by skin grafting and/or secondary wound closure [24, 31, 64, 87–89, 92]. During the phase of immunosuppression (Table 2) no surgery should be performed due to the high susceptibility to a “second-hit” injury with an increased risk of complications such as developing sepsis and multiple organ failure [24, 86]. Only after the 3rd week should further reconstructive operations be performed, if required. These include secondary cancellous bone


grafting and definitive orthopedic reconstructive interventions aimed at restoring a good functional long-term result. Conclusion The complex management of polytraumatized patients can be optimized by standardized and validated approaches using well-established algorithms, such as the ATLS® program. In addition, new concepts in recent years have demonstrated that highly critical polytrauma patients in extremis have a significantly improved overall outcome, if surgical procedures are abbreviated for the benefit of an early transfer to intensive care. This notion – which is in sharp contrast to the classic concept of “early total care” – has been defined as ”damage control” surgery. The kinetics of the physiological response to severe injury must be taken into account for the timing and priorities of surgical interventions in the further course after trauma. As such, the “time window of opportunity” for scheduled definitive surgical interventions lies between the 5th to 10th day after injury, whereas the time of hyperinflammation (day 2–4) and immunosuppression (2nd–3rd week) are associated with a high susceptibility to iatrogenic “second hits” induced by prolonged surgical interventions, leading to adverse outcome due to development of sepsis and multiorgan failure. This golden balance between mandatory primary and secondary measures and the knowledge of the pathophysiological reactions in adherence with established diagnostic and therapeutic algorithms will help improve the overall outcome of polytrauma patients. Acknowledgment Dr. Stahel is supported by grants from the German Research Founda Ztion (DFG) No. STA 635/1-1, 635/1-2, and 635/2-1.

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Address for Correspondence PD Philip F. Stahel, MD Klinik für Unfall- und Wiederherstellungschirurgie Charité – Universitätsmedizin Berlin Campus Benjamin Franklin Hindenburgdamm 30 12200 Berlin Germany Phone (+49/30) 8445-645270, Fax -4464 e-mail: [email protected]

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