Managing the Polytrauma Patient

Every day, individuals are brought to emergency rooms or trauma centers with multiple injuries as a result of traumatic events such as car or motorcycle crashes or other high-energy impacts to the body, including falls from heights, crush injuries, or gunshots. A person involved in a traumatic event who has sustained multiple injuries is a polytrauma patient (Fig.). The term polytrauma comes from the ancient Greek words poly-, meaning many or multiple, and trauma, meaning a wound or an injury to living tissue caused by an external agent. The Centers for Disease Control (CDC) reports that 192,000 people under the age of 46 died from traumatic injuries in 2014. The CDC also states that, after heart disease and cancer, trauma is the leading cause of death for adults over the age of 45. However, current advances in treatment are helping to improve outcomes for polytrauma patients.

 

A multidisciplinary approach
Treatment of the polytrauma patient requires both a multidisciplinary approach and the proper timing of musculoskeletal care. Thus a coordinated effort by several highly specialized medical teams is usually required to manage and stabilize the polytrauma patient. The first responders take care of the initial resuscitation and transport of the patient by ambulance or helicopter to either the hospital or trauma center. There the patient is triaged and initially listed as being in 1 of 4 possible conditions: 1) physiologically stable; 2) unstable; 3) borderline; or 4) in extremis (extremely unstable). As traumatically sustained injuries often cause either internal bleeding or bleeding from an injured extremity, the amount of blood lost usually determines the patient’s condition. This blood loss is initially treated by administering fluids directly into the patient’s blood stream or through blood transfusions. The emergency medicine team then works to further stabilize the patient through lifesaving protocols and to evaluate the patient’s injuries by obtaining the proper imaging. Based on these images, the radiologist then aids in diagnosing these injuries, and an interventional radiologist can often treat ongoing bleeding through minimally invasive techniques.

Next, the orthopaedic trauma surgeon is responsible for stabilizing the patient’s musculoskeletal injuries based on his or her condition. As fractures can cause ongoing bleeding—for example, patients with pelvic or femur fractures can lose several liters of blood—temporarily splinting, and so stabilizing, a fracture can be lifesaving.
Afterward, depending on the patient’s clinical condition, treatment consists of 1 of 2 basic approaches for musculoskeletal stabilization: damage control orthopaedics (DCO) or early total care (ETC). Once the patient has been stabilized through 1 of these treatment protocols, intensive care unit (ICU) physicians and nurses assume the major responsibility for the patient’s care. The patient will remain in the ICU until his or her clinical condition improves enough to allow transfer to a regular hospital floor bed.

 

What is damage control orthopaedics (DCO)?
DCO is the performance of lifesaving interventions through rapid fracture stabilization to stop the cycle of ongoing musculoskeletal injury and bleeding. In patients with unstable pelvic fractures, the pelvis can be a source of ongoing bleeding. Thus pelvic binders or sheets are often applied around the patient’s pelvis to compress the area and stop the bleeding. Additionally, external fixators—pins placed into the bone that are connected to bars and clamps applied outside the body—are frequently positioned to stabilize fractures and soft tissue injuries of not only the pelvic area, but also the extremities. These interventions are able to stabilize the patient quickly without the added insult to the body that more invasive surgery would entail.

 

What is early total care (ETC)?
ETC is the performance of definitive fracture stabilization at the time of the initial surgery. One advantage of this approach is that it can enable the patient to get back on his or her feet sooner. It can also help prevent other health issues, such as pneumonia, ulcers from lying in bed, blood vessel abnormalities (such as blood clots), gastrointestinal problems, and even mood disorders, from occurring due to the more rapid mobilization of the patient after surgery. However, as surgery involving definitive fracture stabilization often takes more time and is more invasive, performing this type of treatment on an otherwise unstable patient can add insult to injury. ETC should therefore be performed only on those patients who are already in stable condition.

 

Better management, better outcomes
Two major factors affecting early survival of the polytrauma patient are the initial status of the patient (determined largely by the amount of blood loss sustained) and the time to transfer the patient to a trauma center. Brain injury, which is often the result of blunt trauma, can cause early death in the polytrauma patient, while sepsis (an inflammatory response caused by infection and involving the entire body) typically causes death later on. Fortunately, advances in diagnosis and treatment of traumatic musculoskeletal injuries—including prehospital, interventional, surgical, and intensive care—have led to increased survival rates for polytrauma patients.

 

Author: Aaron D. Schrayer, MD | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 28, Number 3, Summer 2016.