Chapter 9: Management of the Multiply Injured Patient

Hans Christoph Pape, Peter V. Giannoudis

Chapter Outline

Epidemiology of Polytrauma

Incidence and Mortality

Trauma is a major cause of death and disability worldwide that mainly affects young adults.427 According to the World Health Organization (WHO) 2nd Global Status Report on Road Safety, which involved 178 countries, over 1.2 million people die each year worldwide because of road traffic injuries.440,441 However, only 10% of these fatalities occur in high-income countries. The WHO predicts that the rate of fatal injuries will increase in the next few decades. In addition, between 20 and 50 million patients are injured on the world’s roads every year. Severe injuries have an especially large impact on society and health systems. Trauma registries in western countries have been established to document the epidemiology, pattern, and causes of death, thereby enhancing the quality of trauma care systems. 
The definition of multiple trauma varies among surgeons from different specialties and between different centers and countries. This variation has led to the development of standardized scoring systems to allow comparable stratification of injuries between centers and to aid prediction of morbidity and mortality. 
Polytrauma is a term describing injured patients who have sustained injuries to more than one body region or organ system of which at least one is life threatening. The cumulative severity of this trauma load on the injured patients’ anatomy and physiology is usually expressed using the injury severity score (ISS) with polytrauma being defined as an ISS of ≥16 or ≥18.5,383 Trentz emphasized the pathophysiologic systemic impact of multiple trauma defining polytrauma as “a syndrome of multiple injuries exceeding a defined severity (ISS ≥ 17) with sequential systemic reactions (systemic inflammatory response syndrome (SIRS) for at least 1 day) that may lead to dysfunction or failure of remote organs and vital systems, which have not themselves been directly injured.”199,415 
About 30 years ago, the concept of a trimodal distribution of deaths was introduced by Trunkey.417 Deaths occurred at the scene of the accident, within 60 minutes, in the emergency department or operating room, within 1 to 4 hours, or later after 1 week. Severe brain injury and exsanguination were documented as the leading causes of death within the first 1 to 6 hours. However recent epidemiologic studies from the Trauma Registry of the German Society of Trauma Surgery (TR-DGU) and the Trauma Audit and Research Network (TARN, UK) show a bimodal distribution of mortality with a first and a second peak occurring within 0 to 6 hours and 1 to 6 days, respectively. Massive hemorrhage and severe brain injury remain the commonest causes of death in the first 6 hours. Later deaths are associated with advanced age and complications such as sepsis and organ failure. 
The TR-DGU was established in 1993 and documents data from 367 participating clinics from 7 European countries.220 The recently published annual report from 2011 included epidemiologic evaluation of 67,782 trauma patients. The potential need for intensive care treatment and admission from the trauma bay were the main inclusion criteria. A typical multiply injured trauma patient is male (71.5%) with a mean age of 43.4 years.221 Blunt trauma accounts for 95.2% of all cases and motor-vehicle-traffic–related injuries account for 57.3% of all cases. These were followed by falls (>3 meters = 16.3%; <3 meters = 15.1%) and suicides (5.1%). The analysis of the injury distribution according to the body region using the abbreviated injury scale (AIS) ≥2 demonstrates that craniocerebral injuries and thoracic trauma are present in 60.7% and 61.9%, respectively. Injuries of the upper extremity (34.7%), lower extremity (31.8%), pelvis (22%), and spine (34.2%) were less common. 
Recent data show that the time period from the initial injury to emergency department admission was approximately 70 minutes (a mean of 20 minutes to arrival + 30 minutes on site + 20 minutes for patient transport to the hospital).451 The initial focused abdominal sonography in trauma (FAST) was performed within an average of 6 minutes after admission. The mean time interval to the first chest and pelvis x-rays was 13 minutes and 17 minutes, respectively. Computed tomography (CT) of the head and a whole-body CT scan were performed after 24 minutes and 28 minutes from the time of arrival. Emergency surgical intervention was initiated approximately 79 minutes after arrival at the trauma room. 
According to the TR-DGU trauma registry there has been a continuous decrease in the mortality rate of multiply injured patients in the past decades.352 The mortality within the first 24 hours after admission was 7% and approximately 13.2% died during the hospital stay. Demographic changes in society can also be observed in this database. The elderly population is becoming increasingly active. The mean age increased from 38 years in 1990 to 43 years in 2011 and 25% of the trauma patients were older than 65 years of age.221 This increasing prevalence is important since the elderly often have diminished physiologic reserve and associated significant comorbidities, which require special consideration. The distribution of injuries and type of injury mechanism is likely to be different in a population with a high incidence of osteoporosis. Elderly patients can become multiply injured following low-energy trauma and these injuries may have worse outcomes. For example, while falls have been reported to account for only 9% to 11% of injury-related deaths in the general population, they comprise more than 50% of trauma deaths in persons over 65 years of age.10 Patients with limited mental or physical capacity are also more likely to be involved in accidents as they are slower to identify and respond to dangerous situations.195,213 One must also consider the likelihood of a medical emergency such as a myocardial infarction (MI) or stroke precipitating an accident, making it necessary to treat this pathology as well as the patient’s injuries. 

Effects of Legislation

In 1997, in the United States, motor-vehicle accidents resulted in 41,967 deaths (16/100,000/yr) and 3.4 million nonfatal injuries (1270/100,000/yr).94 Motor-vehicle–related injuries were the leading cause of death among persons aged 1 to 24 years.94 
Between 1982 and 2001, in a review of 858,741 traffic deaths in the United States, five risk factors were noted to contribute to mortality: (a) alcohol use by drivers and pedestrians (43%), (b) not wearing a seat belt (30%), (c) lack of an air bag (4%), (d) not wearing a motorcycle helmet (1%), and (e) not wearing a bicycle helmet (1%).82 Over the 20-year period, mortality rates attributed to each risk factor declined due to legislation. There were: (1) 153,168 lives saved by decreased drinking and driving, (2) 129,297 by increased use of seat belts, (3) 4,305 by increased air bag prevalence, (4) 6,475 by increased use of motorcycle helmets, and (5) 239 by increased use of bicycle helmets. 
Research has shown the effectiveness of lower blood alcohol laws for young and inexperienced drivers and of intervention training programs for servers of alcoholic beverages.444 All the 50 states and the District of Columbia have laws defining it as a crime to drive with a blood alcohol concentration (BAC) at or above 0.08%. 
Seat belts stop the occupant with the car and therefore prevent the body from being ejected when the car stops. Deceleration energy is spread over more energy absorbing parts of the body such as the pelvis, chest, and shoulders. Safety belts are the single most effective means of reducing fatal and nonfatal injuries in motor-vehicle crashes and primary enforcement seat belt laws, where the police are allowed to stop a driver and issue a ticket for the sole reason of not wearing a seat belt, are likely to be more effective than secondary laws, which allow nonbelted occupants or drivers to be ticketed only after being stopped for another moving violation.287,340,379,380 According to the National Highway Traffic Safety Administration (NHTSA)286 seat belt use nationwide was 82% in 2007, ranging from 63.8% in New Hampshire to 97.6% in Hawaii. Twenty-eight states had primary enforcement seat belt laws. However, almost 70% of the 16- to 34-year-old passenger vehicle occupant fatalities killed during night time hours were unrestrained.286 All states have child passenger protection laws. These vary widely in age and size requirements as do the penalties for noncompliance. Child-restraint use in 1996 was 85% for children aged less than 1 year and 60% for children aged 1 to 4 years. Since 1975, deaths among children aged less than 5 years have decreased by 30% to 3/100,000/yr, but the rate of deaths in the 5 to 15 years group has declined by only 11% to 13%.285 In a study reviewing accidents involving 4,243 children aged 4 to 7 years between 1998 and 2002, injuries occurred among 1.81% of all 4- to 7-year olds, including 1.95% of those in seat belts and 0.77% of those in belt-positioning booster seats. The odds of injury were 59% lower for children in belt-positioning boosters than in seat belts. Children in booster seats sustained no injuries to the abdomen, spine, or lower extremities, while children in seat belts alone had injuries to all body regions.99,100 

Motor-vehicle Design/Passive Car Safety and Prevention

Driver air bags have been shown to reduce mortality by 8%, whether the driver was belted or not. However, seat belts provide much greater protection, with seat belt use reducing the risk of death by 65% (or by 68% in combination with an air bag).81 No differences in the risk of frontal crash deaths were observed between adult occupants with sled-certified and first-generation air bags. Together with reports of decreases in air bag–related deaths, significant reductions in frontal deaths among children seated in the right-front position in sled-certified vehicles have also been reported.40 Air bags have been reported to be associated with reduced in-hospital mortality and decreased injury severity.442 In a systematic review, helmets have been shown to reduce the risk of death by 42% and the risk of head injury by roughly 69% in motorcycle riders.231 
Current evidence supports the view that reduced speed limits, speed-camera networks, and speed calming substantially reduce the number of road deaths, a trend that is apparent in the United Kingdom, Australia, France, and other countries.336 There is also evidence that speed enforcement detection devices are a promising method for reducing the number of road traffic injuries and deaths.444 It is of note however that in the United States, there are no speed-camera networks.336 
With regard to pedestrians, cars and light trucks (vans, pickups, and sport utility vehicles) are responsible for most of the pedestrian deaths (85.2%) in the United States. Heavy trucks, buses, and motorcycles are responsible for the remainder.318 Buses kill eight times as many pedestrians as cars per mile of vehicle travel. Vehicle characteristics such as mass, front end design, visibility,66 and degree of interaction with pedestrians probably determine their risk per mile.318 Therefore, one option to reduce pedestrian fatalities might be the modification of motor vehicles. However, every type of motor vehicle has to be evaluated on an individual basis. Lowering the front end of light trucks, and consequently the point of impact with a pedestrian’s body, might reduce the likelihood of serious head and chest injuries.64 
In order to investigate the relationship between changes in the mechanism and pattern of injury for vehicular trauma victims with modern vehicle design, restrained car occupants, bicyclists, and pedestrians injured between 1973 and 1978, and between 1994 and 1999 in a specific region in Germany were compared.337 Lower average ISSs (5.0 vs. 12.1), lower rates of polytrauma (4.5% vs. 15 %), and lower mortality rates (3.4% vs. 14%) were measured for all groups during the later period. Analysis showed that the crash severity was unchanged between the two periods and the reductions were related to improvements in vehicle design and not just seat belt use.337 

Economic Impact on Society

Trauma Care Systems

Organized civilian trauma care in the United States has its origins in the late 1960s when it was stated that the quality of civilian trauma care in the United States was below the standard in combat zones in Vietnam: “If seriously wounded, the chances of survival would be better in the zone of combat than on the average city street.” A trauma system provides the full range of coordinated care to all injured patients in a defined geographic area. It includes injury prevention, pre- and in-hospital care as well as rehabilitation. The concepts of organized trauma care320 have proven to be one of the most important advances in the care of the injured patient over the last 30 years.170,226 The number of states with a trauma system increased from 7 in 1981 to 36 in 2002.377 Nevertheless, in 2000 approximately 40% of the US population still lived in states without a trauma system.281 
Using an established trauma system network also might facilitate the care of victims of natural disasters307 or terrorist attacks.180 The performance of hospitals and health providers in a trauma system is subjected to review from both within and without the system.247,276,321 Research and constant re-evaluation are necessary for continuous assessment of the system and improvement of its outcomes and efficiency.227,377 According to a systematic review of published evidence245 of the effectiveness of trauma systems in the United States, until 1999 the implementation of trauma systems decreased hospital mortality of patients who were severely injured to approximately 15%.48,193,239,245,275 The relative risk of death due to motor-vehicle accidents was 10% lower in states with organized systems of trauma care than in states without such systems.281 However it took about 10 years to establish an organized system of trauma care that was effective in reducing mortality. Nathens et al. concluded that this is consistent with the maturation and development of trauma triage protocols, inter-hospital transfer agreements, organization of trauma centers, and ongoing quality assurance.280 Counties with 24-hour availability of surgical specialties, CT scanners, and operating rooms have a lower motor-vehicle–collision–related mortality, compared with counties without these resources. Counties with designated trauma centers have lower motor-vehicle–related mortality rates.257 Recently published, prospectively collected, data comparing mortality in trauma centers to nontrauma centers showed a 25% mortality reduction in patients under 55 years of age when treated in a trauma center.236 Outcome results obviously depend on every single part of the chain in the trauma system, as well as on the interplay of these elements and there is a lack of evidence in the understanding of the contribution of individual components on the efficacy of the system. However, pre-hospital notification protocols and performance improvement programs appear to be most associated with decreased risk-adjusted odds of death.226 With regard to pre-hospital trauma care, there are ongoing national and international debates and studies as to which system is best39,95 and how pre-hospital trauma care could be improved.47,68,108,138,328 Analysis shows that worldwide there are three different types of organized pre-hospital trauma care systems. These are: 
  1.  
    Basic life support (BLS) systems
    •  
      noninvasive supportive care to trauma patients by emergency medical technicians (splinting)
    •  
      transport trauma patients rapidly to a medical care facility
  2.  
    Paramedic advanced life support (PARAALS) systems
    •  
      undertake invasive procedures such as intubation and intravenous (IV) fluid therapy, administer drugs
  3.  
    Physician advanced life support (PHYSALS) systems
The pre-hospital trauma system in the United States results from the experience in the Vietnam war, where trained paramedical personnel were responsible for initial treatment in the combat zone, whereas physicians were thought to best contribute in a hospital setting.279 Extensive medical care at the scene was almost impossible due to combat, so that “load and go” or “scoop and run” was favored. In contrast, Franco-German95 emergency medical systems are physician directed and in most cases prefer longer periods at the scene of the accident (“stay and play”) to stabilize the patient before transport to an appropriate hospital. 
An international study comparing these systems279 by using shock rate at the Emergency Department (ED shock rate) and early trauma fatality rate as outcome parameters to assess pre-hospital outcomes found out that the ED shock rate did not vary significantly between PHYSALS and PARAALS systems. The early trauma fatality rate was significantly lower in PHYSALS systems compared to PARAALS systems. Therefore a physician at the scene may be associated with lower early trauma fatality rates. However, often there is a lack of data to allow proper comparisons of outcomes between the emergency medical systems of different countries.95 
Several other studies and reviews focusing on pre-hospital trauma care systems however have concluded that there is no evidence supporting advanced pre-hospital trauma care (ALS). Almost all of these studies used hospital trauma fatality as the main outcome parameter and only compared ALS with BLS systems.51,224,225,349 One further study also compared PARAALS in Montreal to PHYSALS in Toronto and BLS in Quebec using in-hospital mortality as the outcome parameter.225 The PHYSALS system was not associated with a reduction in risk of in-hospital death, so that the conclusion was that in urban centers with highly specialized level I trauma centers, there is no benefit in having on-site ALS for the pre-hospital management of trauma patients.225 
Moreover, it has been questioned whether the trauma system dictates the surgical priorities in trauma care. In a recently published study, the timing and management of major fractures in multiply injured patients were compared between level I trauma centers in the United States and Germany. This matched pair analysis demonstrated that the timing of fracture fixation is comparable between a cohort treated at a level I trauma center in the United States and the German Trauma Registry (Table 9-1).314,368 
Table 9-1
A Comparison of the Mean Time to Definitive Treatment of Major Fractures in Patients with Multiple Injuries in the United States and Germany
Duration Until Definitive Treatment USA n = 77 GERMANY n = 93 p-value
All fractures 5.5 ± 4.2 d 6.6 ± 8.7 d n.s
Humerus fractures 5 ± 3.7 d 6.6 ± 6.1 d n.s
Radius fractures 6 ± 4.7 d 6.1 ± 8.7 d n.s
Femur fractures 7.9 ± 8.3 d 5.5 ± 7.9 d n.s
Tibia fractures 6.2 ± 5.6 d 6.2 ± 9.1 d n.s
Pelvis fractures 5 ± 2.8 d 7.1 ± 9.6 d n.s
 

d = days

 

Schreiber V, Tarkin IS, Hildebrand F, et al. The timing of definitive fixation for major fractures in polytrauma—a matched pair comparison between a US and European level I centers: analysis of current fracture management practice in polytrauma. Injury. 2011;42(7):650–654.

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Reimbursement and Development of Costs

Trauma is a global problem and continues to have a major impact on health systems. Trauma-associated expenses have been calculated by numerous study groups.19,78,146,255,290,327 However, due to the heterogeneity of the health and trauma systems and methodologic differences the comparison of these calculations is difficult. Studies have emphasized the importance of cost calculation in trauma care by indicating that it allows not only the estimation of the national burden of injury, but it also enables the identification of inefficient treatment strategies and assessment of the development of costs.19,78,146,255,290,327 Standardized analyses have been suggested in order to compare different trauma systems. This data can be crucial for political decision making. The expenses of trauma care in developed countries have been shown to be similar to the costs of cancer and stroke.254 Due to an aging society an immense increase of trauma-associated expenses is expected. Injury burden in the United States exceeds $400 billion in medical care costs, but 80% of these costs were related to loss of productivity.78 It has been suggested that productivity and the ability to work be used as long-term outcome parameters in patients with multiple injuries. Occupation and financial independence have been shown to be associated with superior long-term quality of life.78 Therefore, the health economics issue is currently an important topic of debate in every National Health System around the world. In patients with multiple injuries, the issue of reimbursement is still unresolved and has been the focus of considerable discussion lately. 
Most of the health systems continue to be in deficit as a result of their disproportionate funding and inadequacy of reimbursement policies.146,203,327,348,363,383,388 Before, however, one decides to evaluate the real cost of treatment of a specific procedure to the National Health System, one must be familiar with the elements that a thorough economic analysis should include. A thorough economic analysis of any medical condition measures direct, indirect, and intangible costs.196,403 It incorporates both fixed and variable costs; the direct monetary expenses and the indirect expenses associated with the duration of therapy, the final functional outcome, disability payments, and the monetized quality of life aspects.85,200,330 
Fixed costs are related to the hospital’s overhead and are those where the clinician has the least control. The variable costs are mostly related to clinical practice and thus they have been more extensively studied. Direct medical and nonmedical costs are easier to record, compared to the indirect costs, and most of the existing literature focuses on these. The indirect and intangible costs are considered to be more difficult to estimate and they require longer follow-up of the patients. However they can be significantly larger than the direct costs. Thus, a large deficit of the existing health economics studies evidence is their lack of an “all-inclusive cost analysis.” 
The health economics of orthopedic trauma rely heavily on resources and expertise that span the entire trauma system, including pre-hospital, in-hospital, and post-hospital care. The financial implications are very diffuse and not easily assessed. In polytrauma patients a complete economic evaluation is even more difficult. It involves expenses related to the pre-hospital and emergency services, the intensity of the medical and nursing staff workload that varies with individual patient and the element of “trauma readiness.”103 “Trauma readiness” is related to the ongoing evolution of the personnel’s expertise, the infrastructure’s effectiveness, and the efficacy of the trauma team coordination. The expense of maintaining a dedicated trauma team on a 24-hour-a-day schedule has been proven to be the most difficult economic parameter to assess and reimburse.402 Over the years several authors have attempted to address the trauma and polytrauma cost issues.80,164,191,206,261,291,382,430 In all these studies it was evident that conventional cost accounting tools were inadequate despite the recent advances in “operations management” and health economics. The necessary components of an all-inclusive economic analysis of a trauma system were first outlined in the Model Trauma Care Systems Plan published by the U.S. Bureau of Health Resources Development in 1992.101 Table 9-2 presents a description of the different aspects of trauma-related health economics. 
Table 9-2
The Different Aspects of Health Economics that Need to be Evaluated in an All-inclusive Financial Profile of the Management of Trauma
Direct Costs Indirect Costs Intangible Costs
Medical Nonmedical
Personnel costs
Supplies costs
Length of hospitalization
Diagnostic interventions
Medications
Transportation
Lodging of patients and relatives
Lost productivity
Lost earnings
Impairment payments
Residential and nursing care
Quality of life (pain, suffering, grief)
QALY evaluation (quality-adjusted life years lost)
Psychosocial parameters
Surgical interventions
Outpatient attendances
Rehabilitation
Pre-hospital costs
Trauma readiness
Trauma training
Insurance costs
Legal costs
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Allowing for the difficulties in undertaking cost estimations, medical spending on injuries in the United States in 1987 was $64.7 billion. In 2000 it accounted for 10.3% of the total medical expenditure and had reached $117.2 billion. The considerable increase in the expense of trauma can also be seen in studies from the United Kingdom, Germany, Switzerland, and the rest of Europe.18,114,135,278,294,295,299,353,398 
Taking the above issues into consideration one can easily appreciate the reasons why providing a service for these cases is not sustainable. The issue of reimbursement is still unresolved and has been the focus of recent discussion. Most health care organizations and trauma systems apply a predetermined charge for their trauma services, which does not relate to each injured patient’s direct or indirect medical and nonmedical costs. It is no surprise therefore, that especially for complex cases and polytrauma patients, cost estimation has been proven to be inadequate and inaccurate. The overall comparison of the actual direct costs of polytrauma and the relative reimbursement resulted in a negative balance of 80% to 900% across the different health systems.383 Moreover, the absence of a single formal trauma network and the existence of many small informal networks centered upon teaching or large general hospitals, almost certainly hinders the efforts to achieve a thorough financial assessment of the trauma services that are provided. Without an accurate assessment of the overall provided services, reimbursement and justification of adequate resources are hampered. 
The workload of the trauma hospitals in these networks varies significantly; and is often unrecognized, and under-funded by the authorities. These units often function under significant pressure. The continuous and intense utilization of the infrastructure’s resources (operating room time, intensive care unit [ICU] beds, etc.) for trauma and polytrauma patients, prolongs the waiting lists, and limits the level of services provided to local patients for the more rewarding and better reimbursed routine elective treatments.83,90,185,316 Thus these centers often present a less “healthy” profile, according to strict financial and managerial criteria, in comparison to smaller hospitals with a reduced trauma workload. In the United Kingdom, the National Health Service (NHS) revenues from elective orthopedic cases have been shown to be more than those of acute trauma cases, again highlighting the problem of inadequate, trauma tariffs.24 Unfortunately, as the number of trauma cases grows the administrative focus is directed more to the government imposed targets on elective waiting lists and is therefore reducing the resources of specialist trauma services such as pelvic or spine units24 despite the fact that pelvic fractures are the third most common cause of death after motor-vehicle accidents.198 
The health economics of patients with pelvic trauma was evaluated in 2004.24 The authors identified that one of the main reasons for the financial difficulties inherent in treating pelvic trauma and polytrauma, in tertiary centers in the United Kingdom, was the establishment of an out of area transfer system (OATS) in 1999. According to the analysis, the acquired reimbursement covered only 60% of the treated cases due to the fact that it was calculated in a retrospective manner and referred to trauma workloads of previous years. The increasing numbers of trauma cases in such centers requires a more accurate and up-to-date estimation of the actual volume of the trauma care services and their costs. 
It is of note that currently a comprehensive and complete evaluation of the financial implications of polytrauma does not exist. The assessment of the cost effectiveness of any trauma system must be correlated with the return of trauma victims to a productive life. The complexity and multiplicity of the different aspects of treatment and rehabilitation in these patients is the main reason for the deficiency of the contemporary health economics literature. However, the necessity for good health economics literature cannot be overstressed in order to develop and monitor the provided services, and assess the deficiency of the associated financial frameworks. Trauma centers must identify and understand their cost structure not only to improve their efficiency, but also to survive. In this context, medical and financial researchers must focus on all the different aspects of the polytrauma expenses. More specifically, the following recommendations can be made: 
  1.  
    The direct medical costs should include all the diagnostic and therapeutic procedures and interventions in these patients and avoid the limitations of the “polytrauma tariff.” The target should be to achieve an accurate assessment of all the expenses of the trauma hospital services in order to claim a satisfactory reimbursement.
  2.  
    The concept of “trauma readiness” is of particular importance to the in-hospital personnel and services. The variability and intensity of the trauma workload cannot be compared with that of any other medical service. The 24-hour-a-day availability of a trauma team and the financial implications of this have to be included at any trauma economic analysis and then reimbursed.
  3.  
    The costs of pre-hospital services related to trauma and polytrauma should also be assessed on a prospective and all-inclusive basis taking into account the aspects of “readiness” and also the secondary transportation of individual polytrauma patients to tertiary specialized centers with established pelvic and spine units.
  4.  
    The health authorities should assess the tertiary referral trauma centers using different criteria and financial algorithms than the referring hospital centers. The “waiting list targets” and “length of hospital stay” of these hospitals should be compared with those of similar trauma centers with a proportionate trauma workload and multidisciplinary readiness, and not with those of hospitals which provide services of a more elective nature.
  5.  
    The difficulties of evaluating the more difficult factors such as the monetized quality of life and the psychosocial costs of trauma and polytrauma should not discourage the researchers. A prospective study following up these patients so that their final outcome is known should be initiated as soon as possible. It would provide all the necessary information to the Health Service administration of the real and unrecognized socioeconomic burden of contemporary trauma. This could then be used to justify requests for increased resources to the policy-making authorities.
  6.  
    The multi-fragmentation of health services and trauma networks should be also avoided. The conclusions and the decisions made after an all-inclusive assessment of the financial implications should include all the health care providers that are involved with polytrauma care.

Pathophysiology and Immune Response to Trauma

Local and Systemic Inflammatory Response

A fracture is associated with damage to bone, periosteum, and adjacent soft tissues such as muscle and connective tissue. Adjacent blood vessels bleed into the affected area and cause a hematoma. Bone marrow content in the form of stem and precursor cells then gains access to the hematoma. Limited oxygenation and restricted nutrient supply induce necrosis of the surrounding tissue. The analysis of fracture hematoma has been studied numerous times but its content is not completely understood. It is clear that fracture hematoma plays a crucial role in bone and tissue regeneration.208 The removal of fracture hematoma is associated with prolonged fracture healing.147,264,317 In contrast, the implantation of it into tissue remote to the fracture leads to new bone formation.147,264,317 It is known that local tissue damage stimulates the liberation of damage-associated molecular patterns (DAMPs), chemokines, and alarmins which lead to systemic spill over and activation of the systemic immune response.199,249 The additional activation of the complement cascade initiates the chemotaxis of leukocytes and neutrophil cells.282 Surprisingly, studies have shown that human skin and muscle tissue demonstrate limited activation (cytokine expression [IL-1β, IL-6, and TNF-α] and neutrophil cell migration) as a result of adjacent blunt femoral fracture.421 In contrast, pronounced pro- and anti-inflammatory immune response was identified in adipose tissue.421 The authors postulated that cytokines are mainly produced by adipose tissue surrounding the fracture after blunt trauma. Thus, it is feasible to trigger the local and systemic inflammatory response after trauma. If muscle tissue is injured, cellular composition of muscle hematoma appears to have discrepancies compared with fracture hematoma.364 The initial rate of neutrophil cell migration was reduced in fracture hematoma when compared to levels measured in muscle hematoma.364 Moreover, fracture hematoma was associated with higher percentages of CD4+ T helper cells and reduced rates of CD8+ cytotoxic cells.364 Whether these differences affect the local and systemic immune response could not be deduced from these studies. 
During the past century the physiologic response to injury was described as showing 3 phases: (a) a hypodynamic ebb phase (shock) where our body initially attempts to limit the blood loss and to maintain perfusion to the vital organs; (b) a hyperdynamic flow phase lasting for up to 2 weeks, characterized by increased blood flow, in order to remove waste products and to allow nutrients to reach the site of injury for repair; and (c) a recuperation phase, lasting for months, to allow the human body to attempt to return to its pre-injury level.118 However, with the knowledge accumulated during the past 20 years, it soon became clear that the physiologic response to injury was not as simplistic as it was initially thought but rather it represents a complex phenomenon involving the immune system and even today is still not fully understood. With the advances made in every field of medicine and particularly in the disciplines of molecular biology and molecular medicine, it is now possible to characterize and quantify the cellular elements and molecular mediators involved in this dynamic physiologic process. 
The first physiologic reaction after injury involves the neuroendocrine system leading to an adrenocortical response characterized by the increased release of adrenocorticosteroids and catecholamines.55 Subsequently, the work of Hans Selye further illustrated the importance of this neuroendocrine response to trauma by pointing out that this was involved in what he named “the general adaptation syndrome.”374 This is considered nowadays as a forerunner to the SIRS.30 This activation of the neuroendocrine system is responsible for the increase in heart rate, respiratory rate (RR), fever, and leukocytosis observed in trauma patients after major injury. Besides trauma, SIRS can be induced by other insults such as burns, infection or major surgery and is defined as being present when two or more of the criteria apply (body temperature: >38 or <36°C; heart rate: >90/min; RR: >20/min or PaCO2 < 32 mm Hg; white blood cell count: >12,000 or <4,000/mm3 or >10% band forms).30 
The activation of the immune system following a traumatic insult is necessary for hemostasis, protection against invading microorganisms, and for the initiation of tissue repair and tissue healing. Restoration of homeostasis is dependent on the magnitude of the injury sustained and the vulnerability of the host who may possess an abnormal or defective local and systemic immune response and fail to control the destructive process. Multiple alterations in inflammatory and immunologic functions have been demonstrated in clinical and experimental situations following trauma and hemorrhage, suggesting that a cascade of abnormalities that ultimately leads to adult respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS) is initiated in the immediate postinjury period.126,130,132,133,159 Blood loss and tissue damage caused by fractures and soft tissue crush injuries induce generalized hypoxemia in the entire vascular bed of the body. Hypoxemia is the leading cause of damage as it causes all endothelial membranes to alter their shape. Subsequently, the circulating immune system, namely the neutrophil and macrophage defense systems, identify these altered membranes. The damaged endothelial cell walls, by trying to seal the damaged tissue, induce activation of the coagulatory system (Fig. 9-1). This explains why these patients develop a lowered platelet count. Further cascade mechanisms, such as activation of the complement system, the prostaglandin system, the specific immune system, and others, are set in motion. 
Figure 9-1
Four cycles demonstrate the pathophysiologic cascades associated with the development of post-traumatic immune dysfunction and endothelial damage.
 
The exhaustion of the compensatory mechanisms results in development of complications such as ARDS/MODS.
The exhaustion of the compensatory mechanisms results in development of complications such as ARDS/MODS.
View Original | Slide (.ppt)
Figure 9-1
Four cycles demonstrate the pathophysiologic cascades associated with the development of post-traumatic immune dysfunction and endothelial damage.
The exhaustion of the compensatory mechanisms results in development of complications such as ARDS/MODS.
The exhaustion of the compensatory mechanisms results in development of complications such as ARDS/MODS.
View Original | Slide (.ppt)
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The release of mediators of both pro-inflammatory and anti-inflammatory nature is dependent primarily on the severity of the “first hit phenomenon” (accidental trauma) and secondarily on the activation of the various molecular cascades during therapeutic or diagnostic interventions, surgical procedures, and post-traumatic/postoperative complications (“second” or “third” hits).119,127 The mediators that are involved in the sequelae of post-traumatic events are released from the cellular populations locally at the site of injury and subsequently systemically. The sequestration and the activation mainly of the polymorphonuclear granulocytes (PMN), the monocytes, and the lymphocytes trigger a multifocal molecular and pathophysiologic process. The pathomechanism of complement activation, leukostasis, and macrophage activation has been associated with the concept of the “low flow syndrome”332 and more recently with endothelial and PMN leukocyte activation.168,223 The cells interact and adhere to the endothelium via adhesion molecules like L-selectin, ICAM-1, and integrin β2 (representatives of the selectin, immunoglobulin, and integrin superfamilies, respectively). After firm adhesion, PMN leukocytes can extravasate and by losing their autoregulatory mechanisms can release toxic enzymes causing remote organ injury in the form of ARDS, MODS.127,159 
If the systemic immune response is not able to restore the integrity of the host, dysregulation of the immune system will occur leading initially to an exaggerated systemic inflammation and at a later stage to immune paralysis.31 However, recent studies analyzing the genome expression of leukocytes in the postinjury period support the idea of simultaneous induction of the innate and suppression of the adaptive immune systems452 (Fig. 9-2). The analysis of the genomic response to trauma has shown a “genomic storm” with activation of more than 5,136 genes.452 Trauma has stimulated the expression of genes involved in innate immunity, microbial recognition, or inflammation. In contrast, the expression was decreased in genes for T-cell function and antigen presentation. Moreover, a comparable genetic response was registered after severe blunt trauma, severe burns, and low-dose endotoxemia. These results indicate that the initiation of the immune response following both trauma and sepsis starts through common pathways (e.g., TLR-4). In addition, this study revealed that the gene expression between patients with complicated versus uncomplicated clinical recovery is not qualitative, but rather quantitative. Patients with uncomplicated recovery were associated with a down regulation of genes within 7 to 14 days after trauma.452 
Figure 9-2
 
A: Current paradigm shows initial pro-inflammatory response associated with the development of systemic inflammatory response syndrome and delayed immunosuppression also known as compensatory anti-inflammatory response syndrome (CARS). B: New data shows a simultaneous induction of pro- and anti-inflammatory genes and suppression of adaptive immune system following trauma (Xiao W, Mindrinos MN, Seok J, et al. A genomic storm in critically injured humans. J Exp Med. 2011;208(13):2581–2590.).
A: Current paradigm shows initial pro-inflammatory response associated with the development of systemic inflammatory response syndrome and delayed immunosuppression also known as compensatory anti-inflammatory response syndrome (CARS). B: New data shows a simultaneous induction of pro- and anti-inflammatory genes and suppression of adaptive immune system following trauma (Xiao W, Mindrinos MN, Seok J, et al. A genomic storm in critically injured humans. J Exp Med. 2011;208(13):2581–2590.).
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Figure 9-2
A: Current paradigm shows initial pro-inflammatory response associated with the development of systemic inflammatory response syndrome and delayed immunosuppression also known as compensatory anti-inflammatory response syndrome (CARS). B: New data shows a simultaneous induction of pro- and anti-inflammatory genes and suppression of adaptive immune system following trauma (Xiao W, Mindrinos MN, Seok J, et al. A genomic storm in critically injured humans. J Exp Med. 2011;208(13):2581–2590.).
A: Current paradigm shows initial pro-inflammatory response associated with the development of systemic inflammatory response syndrome and delayed immunosuppression also known as compensatory anti-inflammatory response syndrome (CARS). B: New data shows a simultaneous induction of pro- and anti-inflammatory genes and suppression of adaptive immune system following trauma (Xiao W, Mindrinos MN, Seok J, et al. A genomic storm in critically injured humans. J Exp Med. 2011;208(13):2581–2590.).
View Original | Slide (.ppt)
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The availability of techniques to measure molecular mediators has allowed different research groups to search for inflammatory markers which could detect patients in a borderline condition and who are at risk of developing post-traumatic complications. Appropriate treatment may then prevent the onset of adverse sequelae. Serum markers of immune reactivity can be selectively grouped into markers of acute phase reactants, mediator activity, and cellular activity (Table 9-3).122,256,284,312,397 
 
Table 9-3
View Large
Table 9-3
Serum Pro- and Anti-inflammatory Markers314
Pro-inflammatory Cytokines Cellular Sources Function in Inflammation
TNF Monocytes/macrophages, mast cells, T lymphocytes epithelial cells Stimulates upregulation of endothelial adhesion molecules. Induction of other cytokines, chemokines, and NO secretion. The inducer of acute phase response. Induce fever. Short half life, not useful marker of the inflammatory response after trauma.
IL-1 Monocytes/macrophages, T lymphocytes endothelial cells, some epithelial cells Similar to TNF.
IL-6 Monocytes/macrophages, T lymphocytes, endothelial cells Inducer of acute-phase response. Stimulate proliferation of T and B lymphocytes. Long half life, the best prognostic marker of complications after trauma(SIRS, sepsis, MOF).
Chemokines (IL-8) Macrophages, endothelial cells, T lymphocytes, mast cells The function of chemoattractant, leukocytes activation. Useful for diagnostic markers of ARDS.
Anti-inflammatory Cytokines Cellular Sources Function in Inflammation
IL-10 Monocytes/macrophages, T lymphocytes Inhibit pro-inflammatory cytokines secretion, oxygen radical production, adhesion molecule expression, and Th-1 lymphocyte proliferation. Enhance B lymphocyte survival, proliferation, and antibody production. IL-10 levels are correlated with severity of injury and the risk of development of sepsis, ARDS, and MOF.
IL-6 See the Table of anti-inflammatory cytokines. Reduction of TNF and IL-1 synthesis. Regulate the release of IL-1Ra and sTNF-Rs.
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Interleukin-6 (IL-6) has perhaps been the most useful and widely employed of these mediators, partly due to its more consistent pattern of expression and plasma half life.315 A measurement of >500 pg/dL in combination with early surgery has been associated with adverse outcome.315 Clinical parameters are also useful in such an assessment with the SIRS score having been developed for such a purpose.243 Though both systems have previously been correlated with injury severity, with early elevation being associated with adverse outcome,343 little work examining in detail the relationship between these two assessments exists. In a recent study it was found that in the early phase both IL-6 and SIRS are closely correlated with the new injury severity score (NISS) and each other. A cut-off value of 200 pg/dL was shown to be significantly diagnostic of an “SIRS state.” Significant correlations between adverse events and both the IL-6 level and SIRS state were demonstrated.121 
Lately, the quest to discover new biomarkers of immune reactivity has led to the discovery of signaling substances termed alarmins, so named because they are danger signals.22 The alarmins are endogenous molecules capable of activating innate immune responses as a signal of tissue damage and cell injury. In this group of endogenous triggers belong molecules such as the high mobility group box 1 (HMGB1), heat shock proteins (HSPs), defensins, cathelicidin, eosinophil-derived neurotoxin (EDN), as well as others. These structurally diverse proteins function as endogenous mediators of innate immunity, chemoattractants, and activators of antigen presenting cells (APCs).300 HMGB1 is a nuclear protein which influences nuclear transactions and plays a role in signaling after tissue damage. In contrast to alarmins, the so-called pathogen-associated molecular patterns (PAMPs) represent inflammatory molecules of a microbial nature being recognized by the immune system as foreign due to their peculiar molecular patterns. Both PAMPS and alarmins are currently considered to belong to the larger family of DAMPs.22 PAMPs and DAMPs are being recognized by our immune system by the expression of multiligand receptors such as the Toll-like receptors (TLRs).453 Overall, the above molecules represent a newly documented superfamily of danger signals being capable of activating innate immune responses after trauma. The number of molecules being categorized in this superfamily is expanding but their pathophysiologic contribution in trauma-related induced systemic activation is still under investigation. 
The evolution of molecular biology has allowed scientists to monitor different variables related to the endothelial cell activation and interaction process. We can now achieve characterization and quantification of the endothelial response to the initial trauma and to the subsequent stress events, thus monitoring the clinical course of the patient.110,228 It is now becoming clear that the problem of managing patients with multiple injuries has shifted from early and effective resuscitation to the treatment of the host response to injury. The quantification of the resulting activity of the variety of the circulating mediators may predict a potential disaster but does not necessarily contribute to the salvage of the patient at risk. Too much or too little immune response? Which one of the two opposites is worse or better? Can we intervene and if so at what stage, in which direction, and in which of the affected individuals? The real question may well be whether all these markers and molecules are just epiphenomena or related to the outcome. Currently, research is attempting to better understand all the processes and the cascade of events that regulate these responses. Research has aimed to describe responses to surgery at the molecular level and to develop and evaluate techniques to modify surgical stress responses. The release mechanisms of the surgical stress response as well as the factors that could amplify the response should be considered by the surgeons. The severity of the injury, type of anesthesia, administration of adequate pain relief, the type of surgical procedure, the timing and length of surgery, the pre-existing comorbid conditions, any genetic influences that will cause an adverse outcome, the expertise of the theatre staff, and the expertise of the surgeon are some of the important factors to be taken into account. 

Genetics and Trauma

It has been our observation that there are still patients who do not “obey” the roles set by the predictive parameters following trauma. Some patients fare worse and some others fare better than predicted. In the early 1990s it was recognized that these differences in the clinical course of the patients and outcome are subject to biologic variation in the context of trauma or surgery.148 This biologic variation is highly dependent on the genetic constitution and the importance of genes as cause of diseases or as predisposing factors has become indisputable. The observed polymorphisms are of different types. Some of them are mutations located within endonuclease restriction sites whereas others are SNPs, or consist of insertions or deletions of larger fragments, as detected by the polymerase chain reaction technique.131 The polymorphism can be located within the gene or in the promoter region. Polymorphisms are different alleles, none of which is predominant in the population. A specific polymorphism variation can be associated with a genetic disease. The polymorphism can also interact with the environment and then exert detrimental actions. 
With the availability of molecular diagnostic techniques, there has been an increased interest in conducting “disease-gene association” studies determining the role of genetic variations in the inflammatory response to injury and infection. The existence of susceptible genotypes for postoperative sepsis is no longer a myth. A growing body of evidence suggests now that genetic susceptibility influences the development of surgical sepsis and its sequelae of ARDS and MODS. The identification of functional polymorphisms in several cytokine genes and other important molecules provides a potential mechanism whereby these variations may exist. Several studies have reported the relationship between different polymorphic variants and the risk of developing post-traumatic complications.137,139,194,232,334,369,435 
However, when investigating genetic polymorphisms, it is not enough just to determine the presence of a polymorphism. One has to take several criteria into account. Patients do show evidence of different genetic constitutions. Investigating polymorphisms linked to disease can be blurred by the existing genetic variation. Therefore, it is necessary to determine the overall genetic constellation of the population under investigation. Furthermore, the power of the study has to be sufficient to be able to have specific results. One has to consider whether other genes may be involved. These genes might be the actual cause for the differences that are being investigated. The investigated gene is then just an epiphenomenon. It is therefore important to study family genetics at the same time. The family constitution can tell more about underlying genes involved in the disease process. If differences in disease outcome are linked to one or more genetic polymorphisms, one has to perform a subsequent study in another cohort. This cohort has to show similar linkage of genes to outcome. Currently, the abovementioned studies, and others,232,341,369 have indicated the influence of specific polymorphic variants of important genes in the development of post-traumatic sepsis. However, most of the published studies have been undertaken in small populations, with geographic, but not necessarily ethnic, differences. This makes the interpretation of the results more difficult. Because of the limited groups examined and the fact that not all studies have adhered to specific genetic association criteria, application of genetic information to random patients will need multicenter and multinational studies. 
Future research should focus on a broad array of genes. Single nucleotide polymorphism (SNP) genotyping assays can do that and categorize the patients. Early identification of patients at risk would allow direct interventions with biologic response modifiers in an attempt to improve morbidity and mortality rates. Early results appear to have been achieved in septic patients. In these patients, goal-directed therapy, low-dose steroid supplementation, blood glucose control, and activated protein C therapy appear to be associated with an improved outcome after sepsis.84,341,342 Hopefully, similar achievements can be made in patients with acute trauma in the future. 

Scoring Systems

Trauma patients are a very heterogeneous population. The need for comparative analysis of the injury-, management-, and outcome-related parameters among the different patient groups, hospitals, trauma management strategies, and health systems has stimulated the development of many trauma scoring systems and scales over the last 40 years.11,38,42,59,205,439 
These scoring systems represent a means of quantifying the injuries that have been sustained together with multiple other independent parameters such as comorbidities, age, and mechanism of injury. They serve as a common language between clinicians and researchers. Initially, they were designed for the purpose of field triage and in that regard they needed to be simple and user friendly. Subsequently, they have evolved to more complex and research-focused systems. Their concept is based on converting many independent factors into a one-dimensional numeric value that ideally represents the patient’s degree of critical illness. They are often based on complex mathematical models derived from large data sets and registries such as the major trauma outcome study (MTOS) or the TARN.61,413 
Ideally, a complete trauma scoring system should reflect the severity of the anatomic trauma, the level of the physiologic response, the inherent patient reserves in terms of comorbidities and age, and as proven recently, should incorporate immunologic aspects and genetic predisposition parameters.15,117,128,129,131,132,386 The variety of the potential applications of such scoring systems ranges from the basic pre- and inter-hospital triage and mortality prediction to other prognostic parameters such as the length of hospital stay and risk of disability. These systems can be used as a tool for comparison of diagnostic or therapeutic methods as well as for the auditing of trauma management. 
The existing injury scoring systems can be classified into scales based on anatomic parameters. Examples of these are the AIS,9 the injury severity score (ISS),11 the maximum abbreviated injury severity scale (MAIS),9 the NISS,301 the anatomic profile (AP),77 the modified anatomic profile (mAP),355 the organ injury scale (OIS),4 and the ICD-9 injury severity score (ICISS) (ICISS).354 Other scoring systems are based on physiologic parameters. Examples of these are the trauma score (TS),62 the revised trauma score (RTS),63 the acute physiology and chronic health evaluation (APACHE).456 Some scoring systems are based on combinations of these parameters. Examples are the trauma and injury severity score (TRISS),42 a severity characterization of trauma (ASCOT),205 and the physiologic trauma score (PTS).214 Numerous studies have assessed the accuracy, reliability, and specificity of the different trauma scores (TSs).60,202 

Anatomical-based Scales and Scoring Systems

The AIS was initially introduced in 1971.73 It has been revised a number of times and is continuously monitored and evolved by a committee of the Association of Advancements of Automotive Medicine (AAAM).131 Its latest version was published in 2005,116 but the most used versions in the current literature are the AIS90 and AIS98. In general, the AIS is an anatomically based consensus-derived, global severity scoring system that classifies each injury by body region according to its relative significance. All the different anatomic injuries are matched with a different seven digit number code. They are classified by (1) the affected body region (first digit, with body region 1 = head, 2 = face, 3 = neck, 4 = thorax, 5 = abdomen, 6 = spine, 7 = upper extremities, 8 = pelvis and lower extremities, and 9 = external and thermal injuries); (2) the type of anatomic structure (second digit, ranges from 1 to 6); (3) the specific anatomic structure (third and fourth digits, range from 02 to 90); and (4) the level of the injury (fifth and sixth digits, range from 00 to 99). The last digit of each 7-digit AIS-code follows a dot and represents the injury severity of the specific injury on a scale of 1 to 6 (1 = minor, 2 = moderate, 3 = serious, 4 = severe, 5 = critical, and 6 = maximal currently untreatable injury). This last severity digit has been developed by a consensus of many experts and is continuously monitored by the committee. 
The ISS was introduced by Baker et al. in 1974.11 Each injury in the patient is allocated an AIS code and then the codes are grouped in six ISS-body regions: head and neck, face, chest, abdomen, extremities and pelvis, and external. Only the highest AIS severity score (post dot digit—seventh digit of the AIS code) in each ISS body region is used. The ISS is the sum of the squared AIS scores from the three most severely injured ISS-body regions. It can take values from 1 to 75. A value of 75 can be assigned either by the sum of three AIS severities of 5 in three different ISS-body regions, or by the presence of at least one AIS severity of 6. Any patient with an AIS severity of 6 in any body region is automatically given an ISS of 75 independent of any other injuries. The ISS score is virtually the only anatomical scoring system in widespread use. It has been validated on numerous occasions and it has been shown to have a linear correlation with mortality, morbidity, hospital stay, and other measures of injury severity. Currently, it represents the gold standard of anatomic trauma scoring systems.36,238,258 However, it has certain weaknesses as any error in AIS coding or scoring increases the ISS error. In addition, it is not weighted over the different body regions and injury patterns and it often underestimates the overall anatomic injury particularly in penetrating trauma, or in multiple injuries of one body region. The ISS is not a useful triage tool as a full description of the patient’s injuries is not initially available. 
The MAIS is another anatomic injury score often used in daily clinical practice and research, which also originates from the AIS. It is the highest AIS code in a multitrauma patient, and is used by researchers to describe the overall injury to a particular body region and to compare frequencies of specific injuries and their relative severity.184,262 
In order to address some of the disadvantages of the ISS Osler et al.301 described the new ISS (NISS) in 1997. This is calculated as the sum of the squares of the highest three AIS severity scores regardless of the ISS-body regions. It has been found to be better than the ISS especially for orthopedic trauma and penetrating injuries.13,14,158,181 However, it has still not extensively evaluated and has the disadvantage of requiring an accurate injury diagnosis before a precise calculation can be made. 
The AP76,117 was also introduced to address the weaknesses of the ISS. It was described as one of the components of the ASCOT and includes all the serious injuries (AIS severity ≥3) of all the body regions. It is also weighted more toward the head and the torso. All serious injuries are grouped into four categories (A = head and spine, B = thorax and anterior neck, C = all remaining serious injuries, and D = all nonserious injuries). The square root of the sum of squares of the AIS-scores of all the injuries in each of the four categories is computed and by logistic regression analysis a probability of survival is calculated. The AP has been proven to be superior to the ISS in discriminating survivors from nonsurvivors. However, its complex computational model has restricted its applications and limited its use. 
A mAP355 has subsequently been introduced. This is a four number characterization of the injury. These four numbers are the MAIS severity across all body regions, and the modified A, B, C component scores of the original AP (mA = head and spine, mB = thorax and neck, and mC = all other serious injuries).76 The mAP component score values (A, B, C) are equal to the square root of the sum of the squares of the AIS values for all serious injuries (AIS 3 to 6) in the specified body region groups. This leads to an AP score, a single number defined as the weighted sum of the four mAP components. The coefficients are derived from logistic regression analysis of 14,392 consecutive admissions to four level I trauma centers of the MTOS.61 
The OIS is a scale of anatomic injury within an organ system or body structure. It was originally designed in 1987. The OIS offers a common language between trauma surgeons, but it is not designed to correlate with patient outcomes. The organ injury scaling committee of the American Association for the Surgery of Trauma (AAST) is responsible for revising and auditing the OIS tables that can be found on the AAST web site.4 The severity of each organ injury may be graded from 1 to 6 using the severity subcategories of the AIS. The injuries can also be divided by mechanism such as blunt or penetrating or by anatomic description such as hematoma, laceration, contusion, or vascular. 
Recently, another anatomical injury scoring system was introduced based on the well-accepted and popular coding system of international classification of diseases (ICD)-9 instead of that of the AIS. The ICD-9 is a standard taxonomy used by most hospitals and health care providers. The ICISS354 utilizes survival risk ratios (SRRs) calculated for each ICD-9 discharge diagnosis. The SRRs are calculated by relating the number of survivors of each different ICD-9 code to the total number of patients with such an injury. The product of all the different SRRs of a patient’s injuries produces the ICISS. Neural networking has been employed to further improve ICISS accuracy. ICISS has been shown to be better than ISS and to outperform TRISS in identifying outcomes and resource utilization. However, in several studies the mAP scores, AP and NISS appear to outperform ICISS in predicting hospital mortality.156,269,270,396 

Physiology-based Scores

Initially, the trauma scoring systems based on physiology parameters were introduced as field triage tools. The basic characteristic of these physiology-based scores is that they are comparatively simple but also time dependent. In 1981, Champion et al.62 hypothesized that early trauma deaths are associated with one of the three basic systems: the central nervous, cardiovascular, and respiratory systems. They designed a scoring system, the trauma score (TS), based on a large cohort of trauma patients, which focused on five parameters these being the Glasgow coma scale (GCS), the unassisted RR, respiratory expansion, the systolic blood pressure (SBP), and capillary refill. All contributed equally in the calculation of this score. It was proven to be useful in predicting survival outcomes, with good inter-rater reliability, but was shown to underestimate head injuries and it also incorporated parameters, such as respiratory expansion and capillary refill, which were difficult to assess in the field.63 
Consequently a revised trauma score (RTS) was developed 8 years later63 by the same authors. This was internationally adopted and is still in clinical use as both a field triage and a clinical research tool. It includes three variables (GCS, RR, SBP), and a coded value from 0 to 4 can be assigned to each (Table 9-4). An RTS score may range from 0 to 12 with lower scores representing a more critical status. In its initial validation this physiologic scoring system identified 97% of the fatally injured as those having an RTS ≤11. It also indicated certain weaknesses which suggested that it should be used in combination with an anatomic-based score.271,347 Currently, the threshold of 11 is used as a decision-making tool for transferring an injured patient to a dedicated trauma center. 
 
Table 9-4
Unweighted Revised Trauma Score as Used in Field Triage
GCS RR (per Minute) SBP (mm Hg) Coded Value
13–15 10–29 >89 4
9–12 >29 76–89 3
6–8 6–9 50–75 2
4–5 1–5 1–49 1
3 0 0 0
 

GCS, Glasgow coma scale; RR, respiratory rates; SBP, systolic blood pressure.

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The RTS is used in its weighted form in clinical research, auditing, and accurate outcome prediction and is called coded RTS (RTSc). It is calculated with the following mathematical formula that allows weighting of the three contributing parameters (GCS, RR, SBP) and their significance. 
RTSc = 0.9368 GCS + 0.2908 RR + 0.7326 SBP 
The RTSc emphasizes the significance of head trauma and ranges from 0 to 7.8408 with lower values representing worse physiologic derangement. The threshold for transfer to dedicated trauma centers for the RTSc is 4. Besides the obvious calculation difficulties that this formula may impose, the use of the RTS or the RTSc is compromised by the fact that the GCS cannot be estimated in intubated and mechanically ventilated patients or in intoxicated patients. Also the calculated value may vary with the physiologic parameters, which often change rapidly. It may also underestimate the severity of trauma in a well-resuscitated patient. 
The APACHE was introduced in 1981207 and its latest revision in 2006 (APACHE IV) represents the most modern scoring system utilized in the demanding environment of ICU and therefore also in intensive trauma units (ITU). The evaluated parameters include the age of the injured patient, any chronic health comorbidities, several physiologic elements required for the calculation of the acute physiology score (APS),456 previous length of ITU stay, emergency surgery, admission source, and diagnosis on admission to ITU. These parameters are responsible for both the complexity of the APACHE score as well as for its superior prognostic accuracy. 

Combined Scores

The individual deficiencies of the anatomic scales and the physiology-based TSs led researchers to develop combined approaches to more accurately translate the overall injury load of a trauma victim to a single score or value. The TRISS38 uses both the ISS and the RTS as well as the patient’s age to predict survival. The probability for survival (Ps) is expressed using the formula Ps = 1/(1 + e−b), where e is a constant (approximately 2.718282) and b = b0 + b1(RTS) + b2(ISS) + b3(age factor). The b coefficients are derived by regression analysis from the MTOS database.61 The probability of survival according to this model ranges from 0 to 1.000 for a patient with a 100% expectation of survival. TRISS has been used in numerous studies.34,35,50,93,241,298,389,433 Its value as a predictor of survival or death has been shown to be from 75% to 90% depending on the patient data set used. However, the deficiencies that govern the ISS and the RTS were also found in their derivative, the TRISS. In particular, the inability to account for multiple injuries in the same anatomic region, the variability of the RTS value, the inability to calculate a value in intubated patients, because of the inaccuracy of the GCS, and RR, the difficulty of assessing comorbidities, and the physiologic reserve of the injured patient encouraged the researchers to continue their quest for a better TS. 
In 1990, another more inclusive trauma scoring system was introduced. ASCOT59 attempts to incorporate anatomic (AP) and physiology (RTS) parameters as well as the patient’s age in a more efficient way than TRISS. The ASCOT score is derived from the same formula (Ps = 1/(1 + e−b) as the TRISS but has different coefficients for blunt and penetrating injuries. The principal claimed advantage of ASCOT was the use of the AP instead of the ISS, which better reflected the cumulative anatomic injury load of the patient. However, while the predictive performance of the ASCOT was marginally better than that of the TRISS its complexity is considerably greater.155,246,302 
In 2002, the physiologic trauma score (PTS) was described. This incorporated the SIRS score on admission (range 0 to4, one point for the presence of each of the following: T > 38° or < 36°C; HR > 90/min; RR > 20/min; neutrophil count >12,000 or <4000/mm3, or the presence of 10% bands), the age, and the GCS into a simple calculation to predict mortality. This new statistical model appeared to be accurate and comparable with the TRISS, or the ICISS in subsequent studies.214 
Despite the considerable effort that has gone into designing these different assessment methodologies and mathematical models, it is very difficult to translate the multifactorial problems inherent in an injured patient into a single number or score and all scoring systems will have advantages and disadvantages. In the future additional factors are likely to be evaluated and incorporated into future trauma scoring systems. Obvious examples are the immunologic responses to trauma and possibly genetic predisposition. Until the development of an “ideal” scoring model, we should be cautious in our conclusions regarding the existing systems and the prediction of outcome of the injured patient. 

Initial Evaluation and Management of the Multiply Injured Patient

Principles of ATLS

The management of a polytrauma patient can be divided into the pre-hospital phase and the in-hospital phase. The chance of survival and the extent of recovery are highly dependent on the medical care that follows the injury. The speed with which lethal processes are identified and halted makes the difference between life and death and between recovery and disability. Time is an independent and cynical challenger of any physician managing multiply injured patients. Thus the adopted approach to this peculiar clinical setting should be based on getting most things right and very few things wrong. Due to the inherent imperfections of the human nature of medical personnel, this approach should be based on simple, well-organized and standardized principles. 
Starting from the pre-hospital phases of extrication and transfer to the hospital the initial evaluation and management, despite its inherent limitations due to lack of time and means, has been proven to be decisive for the severely injured patient.304 The effect on survival of early extrication,443 the initial management from trained emergency personnel whether they are physicians or paramedics,189,375,407 and equally importantly, fast transfer to designated trauma centers338,405 has been evaluated and highlighted in numerous studies. The concept of advanced trauma life support (ATLS) was initially introduced by an orthopedic surgeon in cooperation with the University of Nebraska in 1978.7,57 After having an airplane crash with his family he recognized that there were serious deficiencies in medical education and inconsistencies in the delivery of trauma care in the United States at that time. This initiative encouraged surgeons and doctors in Nebraska to develop a regional training course including lectures and lifesaving demonstrations. One year later the American College of Surgeons Committee of Trauma adopted this course and developed it further to create a practically orientated educational program. The main purpose of this course was to train doctors in order to standardize the process of care of injured patients. In particular, an effective approach to initial assessment and the clinical skills required for good initial management should be taught to surgeons early in their training. 
The concept of ATLS was kept very simple. The ABCDE rule allows a standardized and ordered evaluation of patients.6 The greatest threats to life should be identified first and addressed in an efficient and adequate manner. The definitive diagnosis is not immediately important and should never impede the application of required treatment. Necessary critical interventions should be performed early. Therefore, required clinical skills are taught in “skill stations” where several emergency scenarios are simulated. During the primary survey the following sequential steps should be addressed. 

A: Airway Maintenance with Cervical Spine Protection

The assessment of the airway should be performed first. Airway obstruction due to facial fractures, foreign bodies, or bleeding should be identified as soon as possible. In patients with severe head injuries (GCS < 8), or who are unconsciousness, definitive management is usually required. During the initial assessment the immobilization of the cervical spine should be accomplished and maintained to avoid further spinal cord injuries. 

B: Breathing and Ventilation

Injuries of the lung, chest wall, and diaphragm may compromise gas exchange. Therefore, clinical and radiologic examination, with a chest radiograph, should be performed as soon as possible in order to identify injuries that can impair ventilation, these commonly being tension pneumothorax, flail chest with pulmonary contusion, massive hemothorax, and open pneumothorax. Adequate and effective treatment of the respiratory disorder has to be initiated immediately. 

C: Circulation with Hemorrhage Control

Hemorrhagic shock is a common cause of death in severely injured patients. Hidden bleeding is most likely in the chest, abdomen, pelvis, or long bones. In patients with clinical signs or radiologic signs of thoracic or abdominal bleeding IV volume resuscitation, using crystalloids or blood products, has to be initiated and the patient investigated in case they need surgery to control the bleeding. In the case of unstable pelvic injuries pelvic stabilization can be achieved with pelvic binders in the trauma bay. 

D: Disability (Neurologic Evaluation)

Hemodynamic and respiratory stable patients should be evaluated for the presence of neurologic deficits. In trauma victims suspected of having brain injury repeated evaluation of pupillary size and level of consciousness is required. Decreased level of consciousness might be a clinical sign of reduced cerebral perfusion or direct cerebral trauma. Therefore, unconscious patients should be re-evaluated for airway maintenance and adequate oxygenation, ventilation and circulation status. 

E: Exposure/Environmental Control

Patients should be completely undressed in order to identify clinical signs of hidden injuries. Rewarming of patients with warm blankets avoids the development of hypothermia and associated complications such coagulopathy, circulatory dysfunction, inadequate oxygenation, and the appearance of cardiac arrhythmias. 
If the patient demonstrates vital functions and the primary survey is completed a secondary survey can be started within 12 to 24 hours after injury. During the secondary survey a complete examination from head-to-toe should be performed including the evaluation of the complete history, where this is possible, medication, allergies, and past illnesses. In particular, the presence of hidden injuries should be actively sought. 
Following these principles and the structured initial diagnostic evaluation of the traumatized patient, the priorities of the airway, breathing, circulation, and disability (neurologic deficit) have proven to be the gold standard. Together with direct triage to the appropriate health center, protection of the spine, early aggressive pre-hospital resuscitation, modern telemedicine and informatics, advances in transportation, and the rationalization of the location of the trauma centers have resulted in minimizing pre-hospital mortality and reaching mortality rates that are lower than those of the predicting mathematical models (TRISS, ASCOT).47,303,358 With reference to the pre-hospital period in the course of trauma management some of the important subjects of current debate are 
  1.  
    the management of the airway
    1.  
      pre-hospital endotracheal intubation (ETI) or not45,87,96
    2.  
      the use of neuromuscular blocking agents86,88
    3.  
      effect of hyperventilation, which is common in the pre-hospital setting, on the outcome of patients in shock244 or with head trauma71)
  2.  
    the control of the hemorrhage and circulatory resuscitation
    1.  
      control of external hemorrhage with modern dressings283
    2.  
      appropriate pre-hospital fluid resuscitation endpoints—limited fluid resuscitation versus standard aggressive strategy,23,65 the optimal type of resuscitation fluids.46,75,140,142,344,428 Standard crystalloid fluids (N/S 0.9%, R/L) versus hypertonic fluids (N/S 7.5% ± 6%) Dextran 70 versus polymerized hemoglobin blood substitutes)
  3.  
    the management of potential spinal injuries
     
    The universally accepted guidelines are that the spine should be protected if any suspicion of spinal injury is raised by the mechanism of injury or the clinical findings. However, recently some concerns regarding the liberal use of these guidelines have been reported.20,43,160 However, the lack of strong evidence promoting the liberal pre-hospital protection of the spine currently supports the more conservative and traditional approach.
  4.  
    Improved triage
     
    With current financial restrictions and a demand for optimal management of resources and facilities,123 the role of transfer of each trauma victim to the most appropriate hospital according to the injury load and the patient-related reserves, is crucial. The basic tool to accomplish this task is the different triage scales and scores.236 The use of models combining physiology-based data together with patient-related and mechanism-of–injury–related parameters is of considerable interest.74,174,175

Respiratory Function Assessment

Airway obstruction has been shown to be usually due to the following injuries or problems. 
  1.  
    Mid-facial fractures with obstruction of the nasopharynx
  2.  
    Mandibular fractures with the obstruction of the pharynx by the base of the tongue
  3.  
    Direct laryngeal or tracheal injury
  4.  
    Blood or vomit aspiration
  5.  
    Foreign bodies (e.g., dentures)
Treatment should prioritize removal of any airway obstruction. If the obstruction is sub-glottic, emergency cricothyroidotomy or tracheostomy can be lifesaving. Obstruction of the trachea in the region of the mediastinum can cause severe respiratory impairment. This can lead to severe mediastinal emphysema and perforation of the endotracheal tube. 
The next priority is to maintain respiration, which can be compromised by thoracic or central nervous dysfunction. Disorders of the respiratory system can be diagnosed clinically from symptoms and signs including dyspnea, cyanosis, stridor, depressed conscious level, abnormal chest expansion, and the presence of major thoracic injuries. Thoracic injury can cause acute respiratory derangement, including lung contusion, tension pneumothorax, and hemothorax. Tension pneumothorax is a life-threatening condition and represents an acute life-threatening condition. The management of pneumothorax and hemothorax should include the insertion of a chest drain to decompress the chest. 
Pulmonary edema can be caused by cardiac dysfunction and can occur as a consequence of direct cardiac trauma419 or secondary MI. Alternatively, isolated blunt thoracic trauma may cause high-pressure edema, which has also been observed following thoracic compression. Management of these two conditions differs—one requiring fluid replacement therapy and the other the use of diuretics. However, the initial management of both types of edema involves continues suction and the use of positive end expiratory pressures (PEEPs). 
Severe head injury can cause central respiratory impairment and severe shock may result in severe cerebral hypoxia and subsequent respiratory impairment. It is important that the emergency physician does not underestimate the effect of hemorrhagic shock. Continuous observation of the spontaneously breathing patient with minor injuries can be justified in these cases. In the severely or multiply injured patient, immediate intubation and ventilation for adequate oxygenation is indicated. The tidal volume of 8 to 10 mL/kg of body weight, PEEP of 5 mL, and 50% O2 saturation of the air are prerequisite for adequate ventilation. 

Assessment of Volume Status

Using a parallel approach it is usual to start the immediate management of post-traumatic shock while full evaluation of respiratory, neurologic, and cardiovascular status is ongoing. Prolonged shock can lead to further post-traumatic complications and therefore impact negatively on the patient’s prognosis. Two large bore IV cannulae should be inserted during the preclinical phase and rapid fluid replacement therapy should commence as soon as possible. The cannulae are usually placed in the antecubital fossa and fastened securely to prevent them being dislodged. 
On arrival to the emergency room, further IV lines can be inserted as appropriate. Single internal jugular or subclavian vein lines have the disadvantage of being too long and narrow to allow rapid transfusion of large amounts of fluid. If the lines in the peripheral veins are not feasible a venous cut down can be undertaken using the long saphenous vein at the ankle. 
The choice of fluid for trauma resuscitation remains a controversial issue.268 Historically, crystalloid solutions were considered unsuitable, as they were rapidly lost from circulation, with plasma or serum being preferred. In the 1960s, it was discovered that resuscitation with crystalloid solutions was associated with lower rates of renal impairment and mortality. It was considered that losses into the interstitial space occurred due to edema formation that required additional fluid replacement. Therefore infusion of a combination of crystalloid and blood in a 3:1 ratio was recommended. The application of these principles, particularly in military conflicts, coincided with the emergence of “adult respiratory distress syndrome” or shock lung as a clinical entity in survivors of major trauma. Whether this was a consequence of large volume crystalloid infusion was unclear. Interest in the use of colloid products was therefore renewed. However, early results were conflicting, partly due to shortcomings in trial design. Meta-analyses of these smaller studies revealed no overall difference in the rate of pulmonary insufficiency following resuscitation with either fluid type. Moreover, when final mortality was considered, particularly in the subgroup of trauma patients, a significant improvement in the overall survival rate was observed in the group administered crystalloid.67,362 Crystalloid fluid is therefore considered to be the first treatment choice in most centers and is particularly favored in US trauma centers. Ringer’s lactate has various theoretical advantages over isotonic saline though clinical trials have not shown differences in outcome. Research into fluid selection for resuscitation is ongoing, particularly as much early evidence is based on the use of albumin as a colloid. More recently, newer products with higher molecular weights have become available that should be more efficient in maintaining fluid in the intravascular space. There is further evidence however that in cases of severe hemorrhagic shock, increased capillary permeability allows these molecules to leak into the interstitium, worsening tissue edema and oxygen delivery.268 
Animal studies demonstrating that small bolus administration of hypertonic saline was as effective as large volume crystalloid infusions have provoked considerable interest with regard to potential clinical applications.267 This effect was enhanced by combination with dextran.384 Though improvements in microvascular circulation were observed, this also appeared to increase bleeding. A meta-analysis of early clinical trials revealed that hypertonic saline offered no advantage over standard crystalloid resuscitation although hypertonic saline dextran might.428 This effect was particularly striking in patients with closed head injury and further animal studies have revealed that hypertonic saline can increase cerebral perfusion while decreasing cerebral edema.376 
Damage control using hypotensive resuscitation is a new concept in controlling hemorrhage in injured patients. This concept has evolved from military experience and is based on the argument that aggressive resuscitation leads to dislodgement of clot, dilutional coagulopathy, and consequently more bleeding. The modern approach to damage control resuscitation refers to prevention of iatrogenic resuscitation injury (hypotensive resuscitation) followed by correction of hypercoagulopathy and the surgical control of the bleeding (i.e., minimizing the blood loss prior to surgical intervention). This is accomplished by maintaining a blood pressure lower than normal and utilizing transfusion of red blood cells, plasma, and platelets in a 1:1: 1 ratio together with coagulation factors such as the recombinant factor VIIIa, fibrinogen concentrates, and cryoprecipitate. 

Frequent Sources of Hemorrhage

External blood loss is usually obvious though the volume lost prior to admission is usually unclear. Furthermore, the identification of external sites of hemorrhage should not distract from a rigorous search for internal bleeding, the identification of which can be more problematic. Internal blood loss should be suspected in all patients, particularly where shock is recalcitrant. This usually occurs in the thorax, abdomen, or pelvis. Differentiation of the site of internal bleeding can usually be made by using a combination of clinical judgment, thoracic and pelvic AP radiographs, and abdominal ultrasonography. Abdominal ultrasound should be conducted in the first few minutes of the patient’s arrival to the emergency room, where this is available. Increasingly, emergency department and trauma personnel are being trained in ultrasound examination and appropriate equipment is being made available. 

Endpoints of Volume Therapy

An adequate clinical response includes improvement of the pulse, blood pressure, capillary refill, and urine output. In the severely injured or complex patient, invasive techniques including invasive arterial monitoring and central venous or pulmonary artery pressure recording should be considered at an early stage. Though controversy still exists in specific situations, current goals include normalization of vital signs and maintenance of the central venous pressure between 8 and 15 mm Hg. Serial recording of acid–base parameters, the base excess and serum lactate in particular, have been shown to be particularly useful in assessing response to therapy and detecting the presence of occult hypoperfusion in apparently stable patients.26,69,259 Ongoing requirement for blood transfusion should be monitored by regular measurement of the hemoglobin concentration. This value can be rapidly estimated where necessary using the majority of bedside arterial blood gas analyzers. Ongoing excessive fluid or blood requirement should always prompt a further search for sources of hemorrhage. Shock treatment is a dynamic process and in cases where there is ongoing bleeding, surgical intervention is often indicated. 
More recently several methods for improved monitoring of cardiovascular status have been introduced including gastric tonometry, near infrared spectroscopy, transthoracic impedance, cardiography, central venous oximetry, and skeletal muscle acid–base estimation. Many of these techniques remain experimental and they are currently not available on a widespread basis. They may be available in certain centers and expert advice is essential. 

Replacement of Blood and Coagulation Products

Secondary to maintaining intravascular volume, preservation of the patient’s oxygen carrying capacity is essential. In cases of massive hemorrhage this will inevitably require the replacement of red blood cells. Furthermore, lost, depleted, and diluted components of the coagulation cascade will also require replacement. However, it should be noted that it is becoming increasingly apparent that, particularly in young healthy trauma victims, much lower hemoglobin concentrations than previously thought optimal are tolerated and indeed may be beneficial.150 Not only is blood a precious resource, but transfusion also carries the risk of various complications including the transmission of infectious agents. Traditionally, target hemoglobin concentrations of 10 g/L have been advocated, but it has recently been shown that concentrations as low as 5 g/L are acceptable in normovolemic healthy volunteers.437 Randomized trials in selected normovolemic intensive care patients showed that maintenance of hemoglobin concentrations between 7 and 9 g/L resulted in equivalent and perhaps superior outcomes to maintenance of hemoglobin concentrations above 10 g/L166,242 and transfusion requirement has been shown to constitute an independent risk factor for mortality in trauma.165 This may be related to the potential of blood products to cause an inflammatory response in the recipient.3,165 
In cases with severe blood loss, there is no clear point where continued administration becomes futile.423 Ideally, fully cross-matched blood should be used but in an emergency universal donor O-negative blood can be utilized immediately. A sample should be drawn for cross-match prior to administration as the transfusion of O-negative blood can interfere with subsequent analysis. The blood bank should be able to deliver type-specific blood within 15 to 20 minutes of the patient’s arrival in the emergency room. This blood is not fully cross-matched and therefore still carries a relative risk of transfusion reaction. Cross-matched blood should be available within 30 to 40 minutes in most cases. Administration of platelets, fresh frozen plasma, and other blood products should be guided by laboratory results and clinical judgment. Expert hematologic advice is often required.92,157 Pro-coagulant therapy for severe coagulopathy remains experimental, though early results are promising. 
The costs and potential adverse effects of autologous blood transfusion are becoming increasingly relevant, but so far no convincing evidence has been found that tetrameric polymerized human hemoglobin can be used on a routine basis.268 Instead, the use of Factor VII appears to be a promising alternative in patients who present with uncontrollable coagulopathy if there is no surgical source of bleeding.248,367 

Differential Diagnosis of Hemorrhagic Shock

Hemorrhagic shock should be distinguished from other causes like cardiogenic and neurogenic shock. The presence of flat jugular veins might indicate the presence of hemorrhagic shock. An elevated jugular venous pressure (JVP) can be diagnostic of cardiogenic shock, caused by coronary heart disease, MI, cardiac contusion, tension pneumothorax, or cardiac tamponade. To establish this diagnosis the insertion of a pulmonary artery catheter may be necessary. 
  1.  
    Neurogenic Shock: Relative hypovolemia is the cause of neurogenic shock. This is usually due to spinal injury. Loss of autonomic supply leads to a decrease in vascular tone with blood pooling in the periphery. This pooling can occur without significant blood loss. The resultant increase in skin perfusion leads to warm peripheries and a decrease in central blood flow. This type of shock may be difficult to distinguish from hypovolemia.
  2.  
    Cardiogenic Shock: Cardiogenic shock requires immediate attention and often immediate surgical intervention. The heart can be impaired by cardiac tamponade, tension pneumothorax, and hemothorax or in rare cases by intra-abdominal bleeding. These pathologies may necessitate immediate surgical intervention including placement of a chest drain, pericardiocentesis, or emergency thoracotomy. If there is indirect impairment of cardiac function, medical treatment should be introduced and normovolemia should be restored. An elevated jugular venous pressure in cardiogenic shock may be the result of right-sided heart failure. This should be confirmed through measurement of the central venous pressure. Impaired right heart function may result in blood pooling in the pulmonary vasculature. This can be difficult to distinguish from peripheral blood loss. The two can co-exist and may impair cardiac function. These conditions include cardiac tamponade, tension pneumothorax, MI, and cardiac contusion.
The presence of penetrating cardiac trauma associated with an elevated central pressure and a decreased peripheral systemic pressure should alert the treating doctor to the possibility of cardiac tamponade. A normal chest x-ray may not rule out this possibility, but ultrasound can provide an immediate diagnosis. The treatment of this condition should include emergency pericardiocentesis. Following aspiration of 10 mL of fluid from the pericardial sac, an immediate improvement of the heart stroke volume is seen with an increase in the peripheral systemic perfusion. Emergency thoracotomy is rarely indicated. If required it can be performed through an incision between the fourth and fifth ribs on the left side, followed by opening the pericardium in a craniocaudal direction to avoid injury to the phrenic nerve. One or two transmural stitches allow temporary cardiac closure and cardiac massage can then be conducted. 
Tension pneumothorax causes rapidly increasing cyanosis and a rapid deterioration of respiratory function. It can also cause acute right ventricular failure. As the condition progresses, raised intrathoracic pressure causes reduced right-sided venous return to the heart. As mediastinal shift occurs, kinking or obstruction of the vena cava can lead to complete obstruction resulting in cardiac arrest. Rapid diagnosis followed by immediate decompression is a lifesaving measure. 
Cardiac failure may cause MI independent of the trauma. This diagnosis should be considered in elderly people following road traffic accidents. In these patients MI may have been caused by hypovolemia, hypoxia, or the acute release of catecholamines at the time of the accident. Alternatively, MI may have occurred incidentally causing the accident. A diagnosis of MI can be confirmed from acute changes on the ECG and an increase of blood markers. The treatment of MI should include medical therapy to control arrhythmias. Patients with MI should be treated in the ICU with continued monitoring from the medical team. 
Cardiac contusion can be difficult to differentiate from MI. Contusion is usually seen following a blunt anterior thoracic wall trauma associated with fracturing of the sternum. Differentiating this condition from MI in the acute setting is of secondary importance to the initial management as both diagnoses require similar management, including control of cardiac arrhythmias and heart failure, with continuous invasive monitoring. 

Assessment of Neurologic Status

If a patient has to be intubated and sedated it is important for the emergency doctor to evaluate their neurologic status fully. The size and reaction of the pupils are important indicators of the presence of any central impairment. The light reflex reflects the function of the second and third cranial nerves, the oculocephalic reflex depends on the integrity of the third and fourth cranial nerves and the corneal reflex represents intact fifth and seventh cranial nerves. The GCS also provides important information regarding the neurologic status of patients, particularly where serial measurements are possible. It can provide a useful aid in clinical decision making: It has been argued that CT should be performed if the GCS is less than 10, and if GCS is less than 8, continuous intracranial pressure monitoring may be necessary. These indications are only estimates and the severity of impact and the clinical condition of the patient should also be used for evaluation. 

Staging of the Patient’s Physiologic Status

Once the initial assessment and intervention is complete patients should be placed into one of the four categories in order to guide the subsequent approach to their care. This categorization is done on the basis of overall injury severity, the presence of specific injuries, and the current hemodynamic status as detailed above (Table 9-5).133 Three out of the four parameters must be met to allow a patient to be classified in a particular category. Patients who respond to resuscitation can be managed with early definitive fracture care as long as prolonged surgery is avoided. 
 
Table 9-5
Classification Systems for Clinical Patient Assessment
View Large
Table 9-5
Classification Systems for Clinical Patient Assessment
Parameter Stable (Grade I) Borderline (Grade II) Unstable (Grade III) In Extremis (Grade IV)
Shock Blood pressure (mm Hg) 100 or more 80–100 60–90 <50–60
Blood units (2 h) 0–2 2–8 5–15 >15
Lactate levels Normal range Around 2.5 >2.5 Severe acidosis
Base deficit (mmol/L) Normal range No data No data >6–8
ATLS classification I II–III III–IV IV
Coagulation Platelet count (μg/mL) >110 90–110 <70–90 <70
Factor II and V (%) 90–100 70–80 50–70 <50
Fibrinogen (g/dL) 1 Around 1 <1 DIC
D-dimer Normal range Abnormal Abnormal DIC
Temperature <33°C 33–35°C 30–32°C 30°C or less
Soft Tissue Injuries Lung function; PaO2/FiO2 350–400 300–350 200–300 <200
Chest trauma scores; AIS AIS 1 or 2 AIS 2 or more AIS 2 or more AIS 3 or more
Chest trauma score; TTS 0 I–II II–III IV
Abdominal trauma (Moore) < or = II < or = III III III or > III
Pelvic trauma (AO class.) A type (AO) B or C C C (crush, rollover abd.)
Extremities AIS I–II AIS II–III AIS III–IV Crush, rollover extrem.
X
Any deterioration in the patient’s clinical state or physiologic parameters should prompt rapid reassessment with adjustment of the management approach as appropriate. Achieving the endpoints of resuscitation is of paramount importance for the stratification of the patient into the appropriate category. Endpoints of resuscitation include stable hemodynamics, stable oxygen saturation, lactate level <2 mmol/L, no coagulation disturbances, normal temperature, urinary output >1mL/kg/hr and no requirement for inotropic support. 

Stable

Stable patients have no immediately life-threatening injuries, they respond to initial therapy and they are hemodynamically stable without inotropic support. There is no evidence of physiologic disturbances such as coagulopathy or respiratory distress nor ongoing occult hypoperfusion which will present as abnormalities of acid–base status. They are not hypothermic. These patients have the physiologic reserve to withstand prolonged operative intervention where this is appropriate and they can be managed using an early total care (ETC) approach, with reconstruction of complex injuries. 

Borderline (Patients at Risk)

Borderline patients have stabilized in response to the initial resuscitative attempts but they have clinical features or combinations of injury, which are often associated with poor outcome and put them at risk of rapid deterioration. These have been defined as follows. 
  •  
    ISS >40
  •  
    Hypothermia below 35ºC
  •  
    Initial mean pulmonary arterial pressure >24 mm Hg or a >6 mm Hg rise in pulmonary artery pressure during intramedullary nailing or other operative intervention
  •  
    Multiple injuries (ISS >20) in association with thoracic trauma (AIS >2)
  •  
    Multiple injuries in association with severe abdominal or pelvic injury and hemorrhagic shock at presentation (systolic BP <90 mm Hg)
  •  
    Radiographic evidence of pulmonary contusion
  •  
    Patients with bilateral femoral fracture
  •  
    Patients with moderate or severe head injuries (AIS 3 or greater)
This group of patients can be initially managed using an ETC approach but this should be undertaken with caution and careful thought given to the operative strategy should the patient require a rapid change of treatment. In addition, invasive monitoring should be instituted and provision made for ICU admission. A low threshold should be used for conversion to a damage control approach to management at the first sign of deterioration. 

Unstable

Patients who remain hemodynamically unstable, despite initial intervention, are at a greatly increased risk of rapid deterioration, subsequent multiple organ failure, and death. Treatment in these cases has evolved to utilize a “damage control” approach. This entails rapid, essential lifesaving surgery and timely transfer to the ICU for further stabilization and monitoring. Temporary stabilization of fractures using external fixation, hemorrhage control, and exteriorization of gastrointestinal injuries where possible is advocated. Complex reconstructive procedures should be delayed until stability is achieved and the acute immunoinflammatory response to injury has subsided. This rationale is intended to reduce the magnitude of the “second hit” of operative intervention or at least delay it until the patient is physiologically equipped to cope. 

In Extremis

These patients are very close to death having suffered severe injuries and they often have ongoing uncontrolled blood loss. They remain severely unstable despite ongoing resuscitative efforts and are usually suffering the effects of a “deadly triad” of hypothermia, acidosis, and coagulopathy. A damage control approach is certainly advocated. Only absolutely lifesaving procedures are attempted in order to avoid exhaustion of their biologic reserve. The patients should then be transferred directly to intensive care for invasive monitoring and advanced hematologic, pulmonary, and cardiovascular support. Orthopedic injuries can be stabilized rapidly in the emergency department or ICU using external fixation and this should not delay other therapy. Any reconstructive surgery is again delayed and can be performed if the patient survives. 

Staging of the Patient’s Management Periods

The in-hospital period in which the evaluation and management of the trauma patient is undertaken is divided into four different periods. These are: 
  1.  
    Acute “reanimation” period (1 to 3 hours)
  2.  
    Primary “stabilization” period (1 to 48 hours)
  3.  
    Secondary “regeneration” period (2 to 10 days)
  4.  
    Tertiary “reconstruction and rehabilitation” period (weeks)
This division allows surgeons to anticipate potential problems and undertake sensible decision making regarding the timing of surgical interventions using a systematic approach. 

Acute “Reanimation” Period

This phase covers the time from admission to the control of the acute life-threatening conditions. Rapid systematic assessment is performed to immediately identify potentially life-threatening conditions. Diagnosis should be followed by prioritized management of the airway and any breathing disorders followed by circulatory support as set down in ATLS. This is followed by the “secondary survey,” a complete acute diagnostic “check-up,” but this should only be undertaken if there is no acute life-threatening situation, which would make immediate surgery necessary. In these cases this secondary assessment is intended to identify all the injuries in which definitive treatment should be delayed until the patient is properly stabilized. 

Primary “Stabilization” Period

This phase begins when any acute life-threatening situation has been remedied and there is complete stability of the patient’s respiratory, hemodynamic, and neurologic systems. This is the usual phase where major extremity injuries are managed, including acute management of fractures associated with arterial injuries or the treatment of acute compartment syndrome. Fractures can be temporarily stabilized with external fixation and the compartments released where appropriate. The primary period lasts about 48 hours. 

Secondary “Regeneration” Period

In this phase the general condition of the patient is stabilized and monitored. It is vital to regularly re-evaluate the constantly evolving clinical picture to avoid any harmful impact from intensive care treatment or any problems associated with complex operative procedures. Unnecessary surgical interventions should not be performed during the acute response phase following trauma. Physiologic and intensive care scoring systems may be employed to monitor clinical progress. In the presence of systemic inflammation and MODS, appropriate supportive measures should be undertaken in an ICU. 

Tertiary “Reconstruction and Rehabilitation” Period

This final rehabilitation period is when any necessary surgical procedures, including final reconstructive measures, should be undertaken. Only when adequate recovery is demonstrated should complex surgical procedures be contemplated. Such interventions include the definitive management of complex mid-face fractures, spinal or pelvic fractures, or joint reconstruction. 
The acute period of “reanimation” originally included the initial 1 to 3 hours from admission, but due to the improvement of the pre-hospital trauma care it is now considered to extend from the arrival of the emergency services at the scene until the acute problems are controlled. This first period of trauma management is governed, in a large number of countries, by the ATLS principles.422 The concept of a dedicated trauma team coordinated by someone who is experienced in trauma and emergency management has been adopted in most trauma centers.141,297,331 Rapid primary assessment and simultaneous interventions to control the airway and the cervical spine, to facilitate respiration, and to maintain the circulation are started immediately. After establishing a nonacute life-threatening situation the secondary survey is undertaken and a thorough examination aims to identify all injuries and clinically relevant conditions. 
During this treatment clinicians should use appropriate diagnostic tests to assist the decision-making process.162,216,230,333,426,449 The use of standardized diagnostic and therapeutic protocols has been shown to improve timing, quality, and the overall clinical outcome of the therapeutic process.457 It has been shown that the use of predefined and validated algorithms helps inexperienced personnel and reduces mortality, particularly in moderately severe polytrauma patients (ISS 20–50).25 The primary goal of the initial management is to rapidly diagnose and immediately treat all life-threatening conditions, including airway obstruction or any injury, such as laryngeal trauma, that causes asphyxia, tension pneumo/hemothorax, cardiac tamponade, open thoracic trauma or flail chest, and massive internal or external hemorrhage. The acute management of these conditions may necessitate an urgent transfer to the operating room thereby delaying the use of diagnostic algorithms and the secondary survey. An example would be the neglect of an intra-abdominal or pelvic hemorrhage, while attempting to deal with a severe extremity injury. Of particular importance is the fact that the condition of a polytrauma patient is dynamic and may become unstable at any moment. The continuous awareness of this by the treating team and the flexibility to change the management process is essential.44,70,136,346,391 
The initial evaluation of multiply injured patients has continued to evolve as has the debate about the ATLS protocols. Continuous monitoring of the blood pressure, electrocardiography, the use of pulse oximetry to monitor oxygen saturation, assessment of the ventilatory rate, the insertion of urine and/or gastric catheters, the assessment of the initial full blood count and arterial blood gases, and cross-matching of the patient have been generally accepted as important objectives of the acute phase. There is more debate regarding the usefulness of radiographs and imaging in the first stages of the patient’s evaluation and management. The current ATLS manual recommends AP chest, AP pelvis, and lateral cervical spine x-rays, and the use of deep peritoneal lavage (DPL) or abdominal ultrasonography. 
The introduction of modern imaging modalities such as multislice computed tomography (MSCT)27 and total-body digital x-rays28 has caused a change in the initial radiographic assessment protocols in many trauma centers and a degree of confusion between the trauma and emergency personnel. The necessity for the AP pelvis x-ray201,293 and the lateral cervical spine x-ray197,424 has been disputed by the advocates of these new imaging techniques. However, studies105,109,329,381 demonstrate promising results from these new imaging modalities, and it appears that despite their additional costs, their expected benefits in improving the effectiveness of trauma management will be significant. The advantages and disadvantages of these new modalities still have to be fully evaluated and compared with current practice. 

Imaging

The use of MSCT has revolutionized early diagnostic radiology in most level I trauma centers. Nowadays, the availability of such imaging is the standard of care in these institutions. Nevertheless, many other diagnostic tools are available to give a complete picture of all injuries. While clinical examination and judgment still provide the fundamental basis of contemporary trauma management, the role of emergency radiology continues to expand. 
In the current trauma and emergency setting the 24-hour-a-day availability and immediate proximity of emergency radiology units (ERU) to the accident and emergency (A&E) departments is considered essential. The architectural design and the infrastructure planning demand the close coordination of the four components of acute trauma services these being the resuscitation room, the ERU, the trauma operating room, and the ITU.106,446 

Conventional Radiography—Plain X-rays

Conventional radiography is currently used in most of the institutions that have adopted the ATLS concept. It consists of the standard three x-rays (AP chest, AP pelvis, and a lateral cervical spine) that are usually taken with portable bedside machines during the primary survey. This is followed by abdominal ultrasound and, in many cases, by a CT scan and additional plain x-rays of the extremities. This standard protocol is accepted in all trauma centers and in general hospitals that treat trauma. 
The initial bedside lateral cervical spine x-ray is considered necessary in case an urgent intubation is required and the patient’s GCS does not allow a clinical screening. It is considered accurate enough to diagnose severe or unstable fractures or fracture dislocations but it is less effective in identifying more subtle fractures, or clearing the thoracocervical area.212,306 
The supine chest x-ray remains the most important of the three initial bedside x-rays. Its sensitivity is very high (>95%) for identifying a large hemothorax, flail chest, pneumothorax, hemomediastinum, pulmonary contusions, and lacerations. However, its specificity is quite low and a number of injuries, such as diaphragm ruptures and small hemothoraces are likely to be missed.52,371,390 
The routine use of the AP pelvis x-ray, in the first phase of trauma evaluation and management, has received some criticism. Pelvic trauma can be used as a paradigm of polytrauma120 because it reflects the severity of injury in a multiply injured population with potential hemodynamic compromise. After the use of the CT scan in the secondary survey of moderately or severely injured trauma patients become common it was considered that the routine bedside pelvic x-ray for hemodynamically stable patients might be abandoned. However in hemodynamically unstable patients it is still considered to be a useful screening tool to allow for early notification of the orthopedic team and the interventional radiologist. It also facilitates the use of techniques such as pelvic binders, plain sheet rapping and keeping the lower extremities adducted in internal rotation, to reduce the disrupted pelvis.311,335 
The introduction of digital x-ray imaging appears to offer certain advantages even in the resuscitation room.52 Recently, the use of total-body x-rays in the acute evaluation of multiply injured patients was introduced. Despite the increasing role of modern CTs this new technology appears to offer additional quick and vital information in the resuscitation room. It is based on an enhanced linear slot-scanning device that produces high-quality radiographic biplane whole-body images of any size in seconds. It has been evaluated in a number of centers17,274 and its usefulness is expected to be confirmed in the near future. 

Ultrasonography

The ultrasound scan has a significant role in the acute trauma setting, and it is now considered a vital tool in the hands of the trained emergency physician or trauma surgeon.351 Although it is operator dependent, its advantages are its flexibility, speed, noninvasiveness, and ease of repetition. 
The focused assessment with sonography for trauma (FAST) scan, introduced in 1990, offers a quick, comprehensive, and sensitive method of detecting free intra-abdominal fluid or a pericardial effusion. It includes: 
  1.  
    A transverse subxiphoid view (pericardial effusion, left liver lobe)
  2.  
    A longitudinal right upper quadrant view (right liver lobe, right kidney, free fluid at Morrison’s pouch)
  3.  
    A longitudinal left upper quadrant view (spleen, left kidney, free fluid)
  4.  
    Transverse and longitudinal suprapubic views (bladder, free fluid at Douglas pouch)
  5.  
    Bilateral longitudinal thoracic views (pleural effusions)
The reported sensitivity for intra-abdominal free fluid is high (70% to 98%), but it is highly dependent on the volume of the free fluid, and on the completion of scanning in all areas.41,204,209 
The sensitivity of FAST is poor for the diagnosis of solid organ injuries (45% to 85%).289 However, its specificity for either free fluid or visceral injuries is high (86% to 100%).41,204 It has been shown to be more sensitive in the diagnosis of pneumothorax than plain x-rays387 and its efficacy is recorded as excellent (97% to 100%) in the detection of cardiac injuries and pericardial collections.350 Its limitations are mostly in the identification of solid organ injuries. However, it should be noted that it is highly operator dependent58 and there is a need for free access to the previously described anatomic areas. In addition, movement of the patient may affect its accuracy.277,360 

Computed Tomography (CT Scan)

Since the generalized use of CT scanning in trauma management became common in the 1980s its contribution has been immense. CT is the basic adjunct of the ATLS secondary survey and is the gold standard for head, spinal, chest, and abdominal imaging. Its disadvantages are the time that is required to transfer the patient, undertake the scan, and assess the images, its inaccuracy in noncompliant patients, and its radiation dose.445 Currently, in certain trauma centers its use is moving to even earlier phases of acute trauma management. The use of IV contrast enhancement, the advances of modern software and the image reconstruction ability of modern scanners have significantly enhanced the quality and considerably shortened the duration of a whole-body scan undertaken for trauma. Contemporary MSCT is capable of producing high-quality whole-body images in only a few minutes.438 
Compared with MSCT, the traditional techniques of acute diagnostic evaluation for blunt trauma have certain disadvantages. The fundamental clinical examination has a diagnostic accuracy for abdominal trauma of about 60% to 65%.240,373 DPL, despite its high sensitivity, had a low specificity and was replaced by FAST because it provided an overview of the intra-abdominal trauma and not an accurate diagnosis. Whole-body scanning gives diagnostic information regarding head, spinal, pelvic, and chest trauma. MSCT minimizes the time to accurate diagnosis, particularly for hemodynamically stable patients.167 The advantages of this new CT-scanning modality can also be employed after a more traditional approach and it can be done after an initial bedside chest x-ray, a FAST scan, the initial resuscitation of the unstable patient, or even after urgent surgery of the patients in extremis.310,345 The existing evidence related to the new MSCT-based protocols is encouraging especially for intubated, sedated, and hemodynamically stable patients. Nevertheless further proof from well-designed randomized prospective trials is needed before radically changing the established ATLS protocols. 

Angiography

CT angiography has assumed a central role in the diagnosis and management of injured patients. It is the best method for detecting traumatic aortic and vascular injuries. In addition to the detection of these life-threatening injuries, in the presence of trained vascular radiologist, it offers the possibility of intervening to stop hemorrhage.112,154 Its inherent disadvantages are the necessary infrastructure, allergic reactions to the contrast, the difficulty of finding an experienced vascular radiologist, given the inconsistent time schedule of trauma, and most importantly its duration because of the time it takes to transfer the injured patient to the angiographic suite, perform the investigation, and undertake any intervention that is required. 
Initially, the indication for angiography and subsequent intervention was in stable hemodynamic patients.152,370 Subsequently, the indications expanded to include the “transient responders” to fluid resuscitation,153 and lately also to include those cases where hemodynamic instability persists even after laparotomy, thoracotomy, or packing have been undertaken as a salvage procedure.356,409 Its successful use is often associated with pelvic trauma,414,425 arterial vessel injury,149,322,414 and abdominal solid organ injuries.21,229,266,366,385 
The available radiologic interventional practices that are employed in acute trauma management are either embolization of moderate to small vessels and injured solid organs, using gelfoam slurry or coils, or percutaneous endovascular balloon-expandable stenting of larger vessels. They are considered to be minimal risk procedures especially in the setting of trauma management where they represent potentially lifesaving interventions. Currently, the angiographic protocols, with or without radiologic intervention, differ significantly between the different centers and trauma care systems. The main controversial issues relate to the difficulty and expense of providing a 24-hour vascular radiology service and in providing evidence that it is a worthwhile service. 

Priorities for Lifesaving Surgeries

In patients with polytrauma the decision as to which injury to address first can be lifesaving. Among the emergent operative treatments that do not permit prolonged diagnostic procedures are the treatment of cardiac tamponade, arterial injuries to major vessels, and head trauma with imminent herniation. Furthermore, injuries to cavities associated with severe hemorrhage and shock must be addressed promptly. In a multidisciplinary approach close communication is therefore crucial. 

Chest Trauma

Hemothorax

Hemothorax is usually easily diagnosed from the chest x-ray, although in the presence of extensive lung contusion or atelectasis the diagnosis can be difficult. Ultrasound examination can identify free thoracic fluid though CT remains the gold standard and often reveals the source of bleeding.1 
Significant bleeding into the pleural cavity with a resultant hemothorax is treated during the primary survey by the insertion of a chest tube. Usually, the decision is made following a review of the chest x-ray and only occasionally are clinical findings the sole indication for chest tube insertion, as a chest x-ray can usually be performed very rapidly. Standard surgical practice is to insert the chest tube in the mid-axillary line at the fifth intercostal space. Lower insertion risks injury to the diaphragm or intra-abdominal organs. The use of blunt dissection should prevent structural injury and it is important to use blunt dissection even where the operator is confident of positioning as intra-abdominal injuries may lead to increased intra-abdominal pressure and diaphragmatic elevation or even rupture. A traditional chest tube of least 28 gauge should be used to drain a hemothorax. The modern percutaneous drains used in thoracic medicine should not be used. The larger diameter reduces the danger of coagulation, allows rapid blood evacuation and the surgeon can be relatively confident that the drained contents are representative of thoracic blood loss. It is usual to direct the tube caudally to drain blood and cranially in the presence of a pneumothorax. 
The presence of a hemothorax is not diagnostic of major thoracic hemorrhage. In most cases, bleeding is the result of injury to one intercostal vessel and this will usually stop spontaneously. Indications for emergency department thoracotomy remain controversial although recognized indications include traumatic arrest and recalcitrant profound hypotension in penetrating trauma, rapid exsanguination (>1500 mL initially or 250 mL/hr) and unresponsive hypotension in blunt thoracic trauma. As a last resort it can be used to control catastrophic sub-diaphragmatic hemorrhage by cross-clamping the aorta. These interventions are useless in patients with blunt thoracic trauma, in cardiac arrest where there has been no witnessed cardiac output and in patients with severe head injuries. There is recent evidence that increased caution should be employed before undertaking emergency thoracotomy in blunt trauma patients for all indications, particularly in the emergency department, due to the relatively high rate of nontherapeutic procedures and poor outcome.12,178 

Mediastinal Hemorrhage and Thoracic Aortic Injury

Mediastinal hemorrhage due to injury to the thoracic aorta is commonly misdiagnosed due to the poor quality chest radiographs that are often obtained in emergency situations. Mediastinal enlargement observed on chest x-ray is nonspecific. In this context, one should pay careful attention to the presence of dilated jugular veins which help differentiate cardiac from aortic injuries. Nonetheless, further imaging should be rapidly obtained in the hemodynamically stable patient with contrast enhanced thoracic CT. Though traditional CT scanning sometimes lead to false positive results, and angiography is often regarded as providing the best diagnosis, many centers feel that contrast enhanced high resolution spiral CT is preferable.56,97,365 
Rupture of the thoracic aorta is exceedingly rare in patients surviving long enough to reach the emergency room alive. In most cases, the adventitia is preserved and further intra-thoracic blood loss is prevented by the parietal pleura. Furthermore there is increasing evidence that repair can be delayed in the presence of other life-threatening injuries and occasionally conservative management can be successful.176,218,401 These patients should, however, always be treated in a center with an acute thoracic surgical service. Nonoperative treatment of incomplete aortic ruptures in hemodynamically stable patients consists of permissive hypotension or active reduction of blood pressure while controlling for a difference in blood pressure between the upper and lower body parts. Indications for immediate intervention include the development of hemodynamic instability without an alternative explanation, hemorrhage via the chest tubes (>500 mL/hr) or a blood pressure gradient between upper and lower extremities leading to an impaired perfusion of the lower limbs (difference of mean blood pressure >30 mm Hg). Given the high mortality of emergency repair in cases of traumatic aortic injury there is increasing interest in the use of endovascular stenting in such situations.182,217,357 
If the clinical situation arouses the suspicion of cardiac injury in the presence of radiologic mediastinal abnormality the diagnosis is generally cardiac tamponade. Pericardiocentesis should be performed. If there is acute decompensation, an emergent thoracocentesis is indicated. Further diagnostic tests are too time consuming in this immediately life-threatening situation. If the patient is still hemodynamically stable, a very sensitive and readily available test is the transthoracic echocardiogram. 
The thoracic trauma severity score (TSS) is a standardized method for evaluation of thoracic injuries.169 This CT-independent scoring system evaluates anatomical and physiologic parameters at the time of admission (Table 9-6). The TTS score ranges from 0 to 25 and includes the following parameters: PaO2:FiO2 ratio (0 to 5 points), presence of rib fractures (0 to 5 points), pulmonary contusion (0 to 5 points), lung lesions (hemothorax/pneumothorax) (0 to 5 points), and patient age (0 to 5 points). 
 
Table 9-6
Thoracic Trauma Severity Score
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Table 9-6
Thoracic Trauma Severity Score
Grade PO2/FiO2 Rib Fractures Pulmonary Contusion Pleural Lesion Age (years) Points
0 >400 0 None None <30 0
I 300–400 1–3 unilateral 1 lobe unilateral
1 lobe bilateral
Pneumothorax 30–40 1
II 200–300 4–6 unilateral 2 lobes unilateral Hemothorax/hemopneumothorax unilateral 41–54 2
III 150–200 >3 bilateral <2 lobes bilateral
≥2 lobes bilateral
Hemothorax/hemopneumothorax bilateral 55–70 3
IV <150 Flail chest Tension pneumothorax >70 5
 

Described by Hildebrand F, van Griensven M, Garapati R, et al. Diagnostics and scoring in blunt chest trauma. Eur J Trauma Emerg Surg. 2002;28(3):157–167.

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Abdominal Trauma

Exsanguinating Abdominal Hemorrhage Versus Expanding Intracranial Hematoma

There is controversy over how this difficult combination of injuries should be treated. There is increasing evidence for conservative management of abdominal injuries, except in the most unstable patients, and it should be remembered that apparent intra-abdominal hemorrhage is often pelvic in origin. Evacuating an intracranial hematoma if the patient exsanguinates is obviously futile. However, there is equally little, and some would say less, benefit in saving a patients life if the result is profoundly disabling brain injury or death from tentorial herniation. Once compensatory autoregulatory mechanisms are overwhelmed, intracranial pressure rapidly increases. There is evidence that in people with head injury, mortality from extracranial causes alone is unusual. In a study of almost 50,000 trauma patients 70% of deaths were attributed to the head injury alone and only 7% to extracranial trauma, with the rest caused by a combination of both.115 However, craniotomy should not be undertaken, without imaging to confirm an operable lesion, except in the rarest of circumstances. CT scanning is time consuming and can cause a significant delay in treatment. This time might be better spent attempting rapid hemodynamic stabilization. There is also evidence that in hypotensive patients undergoing head CT emergency laparotomy is required far more frequently than craniotomy (21% vs. 2.5%).447 Furthermore, poorer outcomes have been demonstrated in head injured patients with shock, suggesting that early correction of hypotension may minimize secondary brain injury.429 
It is clear that in these patients rapid complex management decisions must be made and clinical experience is essential. Thankfully, it would appear that such dilemmas seldom occur. In a review of 800 patients with significant head and abdominal injuries, 52 required craniotomy, 40 laparotomy, and only 3 required both.406 

Pelvic Trauma

Pelvic fractures are often seen in conjunction with multi-system trauma and they can lead to rapid occult hemorrhage. Treatment should be seen as part of the resuscitative effort and early intervention can be lifesaving (Fig. 9-3).125 Bleeding is commonly from multiple small sites rather than injured major vessels and in severe cases, due to the large volume of the retroperitoneum, spontaneous arrest is unusual.145 Furthermore, it is common for the retroperitoneum to be breached during the injury further decreasing the barrier to ongoing hematoma expansion. Treatment with a pneumatic antishock garment or pelvic belt straps can give some temporary stabilization432 but results are inconclusive and severe complications have been reported in relation to their use. 
Figure 9-3
Treatment algorithm for patients with pelvic fractures and hemodynamic instability.
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Although there has been increasing interest in the use of selective angiography in these cases to embolize bleeding vessels this intervention is often time consuming to organize and perform. Patients must be relatively stable and careful selection is crucial. Embolization can be used as an adjunct to other interventions where continued arterial hemorrhage is suspected. In severe injuries with profound hemodynamic instability, external fixation, pelvic C-clamps, and open tamponade with packing is recommended.395,404 With the patient supine preparation from the sub-costal margin to the pubic symphysis is performed with the abdomen and pelvis completely exposed. If a C-clamp has already been applied for posterior pelvic instability it should be rendered mobile. In vertical pelvic instability (C type injury), the appropriate lower extremity should be accessible to allow reduction where necessary. 
If there is prior evidence of free intraperitoneal fluid following application of an external fixation device a midline laparotomy should be performed and the intra-abdominal organs examined for bleeding following standard management protocols for blunt abdominal trauma. If, however, initial diagnostic imaging has shown no evidence of intra-abdominal fluid and a major source of pelvic hemorrhage is suspected a lower midline laparotomy can be employed. Initial attention should be directed to the retroperitoneum. Following the skin incision ruptured pelvic soft tissues are usually readily visible. Any hematoma is evacuated and the paravesical space explored for bleeding sources. Large bleeding vessels should be ligated where possible. In diffuse bleeding well-directed packing with external stabilization is recommended (Fig. 9-4). 
Figure 9-4
Retroperitoneal packing of the pelvis.
 
A: Midline vertical incision (white arrow) is demonstrated (yellow arrow represents lower abdominal transverse incision). B: Incision of linea alba (white arrow). C: Retraction of the bladder to one side (black arrow) and placement of unfolded lap sponges in to the true pelvis (white arrow). Note that the first lap sponge is placed adjacent to the sacroiliac joint and the next should be placed anteriorly to the middle of the pelvic brim and the retropubic space. D: CT pelvic image revealing a lateral compression fracture pattern. E: Schematic representation of the position of the packs around the pelvic floor.
A: Midline vertical incision (white arrow) is demonstrated (yellow arrow represents lower abdominal transverse incision). B: Incision of linea alba (white arrow). C: Retraction of the bladder to one side (black arrow) and placement of unfolded lap sponges in to the true pelvis (white arrow). Note that the first lap sponge is placed adjacent to the sacroiliac joint and the next should be placed anteriorly to the middle of the pelvic brim and the retropubic space. D: CT pelvic image revealing a lateral compression fracture pattern. E: Schematic representation of the position of the packs around the pelvic floor.
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Figure 9-4
Retroperitoneal packing of the pelvis.
A: Midline vertical incision (white arrow) is demonstrated (yellow arrow represents lower abdominal transverse incision). B: Incision of linea alba (white arrow). C: Retraction of the bladder to one side (black arrow) and placement of unfolded lap sponges in to the true pelvis (white arrow). Note that the first lap sponge is placed adjacent to the sacroiliac joint and the next should be placed anteriorly to the middle of the pelvic brim and the retropubic space. D: CT pelvic image revealing a lateral compression fracture pattern. E: Schematic representation of the position of the packs around the pelvic floor.
A: Midline vertical incision (white arrow) is demonstrated (yellow arrow represents lower abdominal transverse incision). B: Incision of linea alba (white arrow). C: Retraction of the bladder to one side (black arrow) and placement of unfolded lap sponges in to the true pelvis (white arrow). Note that the first lap sponge is placed adjacent to the sacroiliac joint and the next should be placed anteriorly to the middle of the pelvic brim and the retropubic space. D: CT pelvic image revealing a lateral compression fracture pattern. E: Schematic representation of the position of the packs around the pelvic floor.
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If hemorrhage is obviously originating from a deep dorsal source, particularly in cases of posterior pelvic instability, attempts at further extraperitoneal exploration should be made in the presacral region. Large bleeding sources can be identified and treated appropriately. In cases of catastrophic arterial hemorrhage, temporary control can be achieved by cross-clamping the aorta. Often in venous hemorrhage, no single bleeding source is identifiable. Usually, bleeding originates from disruption of the presacral venous plexus or the fracture site itself. Again, well-directed packing can often adequately control hemorrhage. Recent studies have reported mortalities rates between 25% and 30% following pelvic packing in unstable patients.79,411 
Following this intervention, temporary abdominal closure is performed and correction of physiologic derangements should be undertaken without delay, with particular regard being given to coagulopathy and hypothermia. Packing is left in situ and changed routinely at 24 to 48 hours, though in cases of suspected ongoing hemorrhage and recalcitrant shock earlier re-intervention should be considered. During planned revision the cavity should be debrided as required. Any residual hematoma should be removed and it should be thoroughly examined for sites of ongoing hemorrhage. Further bleeding points can be dealt with, but if diffuse hemorrhage persists further packing should be used and later surgical revision undertaken. 

Timing of Definitive Stabilization of Major Fractures: Indications for Early Definitive Fixation

Before fracture fixation in polytrauma patients was routinely performed patients did poorly and the mortality rate secondary to fat embolism syndrome and organ failure was high. The major fear of surgeons treating these patients was the development of fat embolism syndrome. Pulmonary dysfunction is the hallmark of this problem, and develops several days after trauma. Once the fat embolism syndrome becomes full blown treatment is often unsuccessful and mortality rates of about 50% have been reported.16 
The syndrome was found to be caused by fat and intramedullary contents liberated from an unstabilized fracture. It was therefore concluded that fixation of major fractures could prevent this complication in addition to minimizing soft tissue damage and ongoing blood loss. Multiple authors reported dramatic improvements in the clinical condition when fracture fixation was performed routinely.188,339,418 
A decrease in the incidence of pneumonia and ARDS, a shorter stay in the ICU, and better survival rates were reported. The first prospective, randomized trial by Bone et al.29 demonstrated the advantages of early fracture stabilization, now referred to as ETC. Patients with delayed fracture stabilization had a prolonged duration of ventilatory therapy and stayed longer in both critical care and hospital.29,339 It was therefore accepted that a major aim in the treatment of the multiple trauma patient with fractures was rapid stabilization of the pelvic and extremity injuries. An essential prerequisite for ETC was optimization of retrieval conditions and a reduction of the retrieval time. Furthermore, the improvements in intensive care medicine with improved cardiovascular monitoring and facilities for prolonged ventilatory support facilitated the development of a more aggressive surgical approach. 
The strict application of ETC even in patients with a high ISS, brain injury, or severe chest trauma limited discussion about the best management for these polytraumatized patients. As it became evident that these specific subgroups of polytraumatized patients do not benefit from ETC, the borderline patient was identified. These patients were demonstrated to be at particular risk of a poor late outcome. The clinical and laboratory characteristics of the borderline patient have been previously described.133 
The concept of damage control orthopedics (DCO) provided a solution to the management of these borderline patients together with patients in an unstable or extremis condition. The term damage control was initially described by the US Navy as the capacity of the ship to absorb damage and maintain mission integrity. In the polytraumatized patient, this concept of surgical treatment intends to control but not to definitively repair the trauma-induced injuries early after trauma. After restoration of normal physiology (core temperature, coagulation, hemodynamics, respiratory status), definitive management of injuries is performed.378 The damage control concept consists of three separate components: 
  1.  
    Resuscitative surgery for rapid hemorrhage control
  2.  
    Restoration of normal physiologic parameters
  3.  
    Definitive surgical management
Within the DCO framework, the first stage involves early temporary stabilization of unstable fractures and the control of hemorrhage. The second stage consists of resuscitation of the patients in the ICU and optimization of their condition. Finally, the third stage involves delayed definitive fracture management when the patient’s condition allows. The favorite tool of the trauma surgeon to achieve temporary stabilization of the fractured pelvis or a long bone is the external fixator. External fixation is a quick and minimally invasive method of providing stabilization and it can be used very efficiently to accomplish early fracture stabilization and it postpones the additional biologic stresses posed by prolonged surgical procedures. The delayed definitive procedure to stabilize long bone fractures, in particular the femur, is usually intramedullary nailing which is carried out when the condition of the patient allows. Recent studies have reported that the DCO approach was a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.288,313,361 The application of DCO in the multiply injured patients is illustrated in Figure 9-5
Figure 9-5
Treatment of severely injured patients with damage control orthopedics (DCO) algorithm.
 
Early total care (ETC) with definitive stabilization of fractures can be used in stable patients. Unstable patients require a damage control orthopedic strategy with temporary external fixation of fractures. “Patients at risk” are patients with a high injury severity score (ISS), hypovolemia, lactate over 2.5 mmol/L, and associated chest and abdominal injuries. These patients need aggressive resuscitation and repeated evaluation as to whether DCO or ETC is indicated.
Early total care (ETC) with definitive stabilization of fractures can be used in stable patients. Unstable patients require a damage control orthopedic strategy with temporary external fixation of fractures. “Patients at risk” are patients with a high injury severity score (ISS), hypovolemia, lactate over 2.5 mmol/L, and associated chest and abdominal injuries. These patients need aggressive resuscitation and repeated evaluation as to whether DCO or ETC is indicated.
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Figure 9-5
Treatment of severely injured patients with damage control orthopedics (DCO) algorithm.
Early total care (ETC) with definitive stabilization of fractures can be used in stable patients. Unstable patients require a damage control orthopedic strategy with temporary external fixation of fractures. “Patients at risk” are patients with a high injury severity score (ISS), hypovolemia, lactate over 2.5 mmol/L, and associated chest and abdominal injuries. These patients need aggressive resuscitation and repeated evaluation as to whether DCO or ETC is indicated.
Early total care (ETC) with definitive stabilization of fractures can be used in stable patients. Unstable patients require a damage control orthopedic strategy with temporary external fixation of fractures. “Patients at risk” are patients with a high injury severity score (ISS), hypovolemia, lactate over 2.5 mmol/L, and associated chest and abdominal injuries. These patients need aggressive resuscitation and repeated evaluation as to whether DCO or ETC is indicated.
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In patients with additional severe injuries to the head, chest, and pelvis with life-threatening hemorrhage an acute change in the clinical condition may rapidly occur. The EAST evidence-based workgroup conducted a systematic review of the literature regarding the timing of fracture fixation in different subsets of patients with multiple trauma.98 Specifically, this group concluded that there is no compelling evidence that early long bone stabilization neither enhances nor worsens the outcome in patients with severe head injury or in patients with associated pulmonary trauma. While the available data suggests that early fracture fixation may reduce associated morbidity in certain patients with polytrauma the workgroup stopped short of recommending early fixation for all patients. An algorithm for the treatment of these patients is shown in Figure 9-6
Figure 9-6
Management of orthopedic injuries in patients with associated injuries (e.g., traumatic brain injury).
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The practice of delaying definitive surgery in DCO attempts to reduce the biologic load of surgical trauma on the already traumatized patient. This hypothesis was assessed in a prospective randomized study by means of measuring pro-inflammatory cytokines. Clinically stable patients with an ISS >16 and a femoral shaft fracture were randomized to ETC (primary intramedullary nailing of the femur within 24 hours) and DCO (initial temporary stabilization of the femur with external fixator and subsequent intramedullary nailing). A sustained inflammatory response (higher levels of IL-6) was measured after primary (<24 hours) intramedullary femoral instrumentation, but not after initial external fixation or after secondary conversion to an intramedullary implant. The authors concluded that DCO surgery appears to minimize the additional surgical impact induced by the acute stabilization of the femur.312 
Other issues that have been discussed with regard to the DCO concept include the ideal timing at which to perform the secondary definitive surgery and whether it is safe to convert an external fixator to an intramedullary nail or is this associated with an unacceptably high infection rate? It has been shown that days 2 to 4 do not offer optimal conditions for definitive surgery. In general during this period, marked immune reactions are ongoing and enhanced generalized edema is observed.436 Nevertheless, these patients represent a highly diverse group and individual clinical judgment is more reliable, especially when combined with information from the newer laboratory tests. In a retrospective analysis of 4,314 patients treated in our clinic, it was found that a secondary procedure lasting more than 3 hours was associated with the development of MODS. Also the patients who developed complications had their surgery performed between days 2 and 4, whereas patients who did not go on to develop MODS were operated on between days 6 and 8 (p < 0.001).309 
With regard to the issue of whether external fixation can be converted safely to intramedullary nailing, the infection rates reported in the literature are low ranging from 1.7% to 3%.288,361 According to these reports conversion of the external fixator to a nail should be done within the first 2 weeks as this minimizes the risk of developing deep sepsis. 
In general terms, the measurement of inflammatory mediators has been shown to be sensitive in predicting the clinical course, morbidity, and mortality in trauma patients.72,183,219 Based on the latest available studies, the following recommendations can be made in terms of patient selection for ETC and DCO (Tables 9-7 and 9-8). 
 
Table 9-7
Indications for Early Total Care
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Table 9-7
Indications for Early Total Care
Stable hemodynamics
No need for vasoactive/inotropic stimulation
No hypoxemia, no hypercapnia
Lactate <2 mmol/L
Normal coagulation
Normothermia
Urinary output >1 mL/kg/h
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Table 9-8
Indications for “Damage Control” Surgery
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Table 9-8
Indications for “Damage Control” Surgery
  1.  
    Physiologic criteria
    •  
      Blunt trauma: hypothermia, coagulopathy, shock/blood loss, soft tissue injury = Four vicious cycles
    •  
      Penetrating trauma: hypothermia, coagulopathy, acidosis = “Lethal Triad”
  2.  
    Complex pattern of severe injuries—expecting major blood loss and a prolonged reconstructive procedure in a physiologically unstable patient
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Standard of Care for the Treatment of Skeletal Injuries

The sequence of fracture treatment in multiply injured patients with multifocal injuries to an extremity is a crucial part of the management concept. Some parts of the body are prone to progressive soft tissue damage because of their anatomy. Therefore, the recommended sequence of treatment is tibia, femur, pelvis, spine, and upper extremity. 
In this context the simultaneous treatment of different extremity injuries should be considered. Initially, trauma surgeons must undertake the shortest possible interventions in these patients to minimize the “second hit phenomenon,”117,118 The simultaneous employment of different surgical approaches and different surgical specialties, whenever this is feasible, minimizes the risks and facilitates the transfer of the unstable patient to the controlled environment of the ITU as early as possible. Even in the later reconstructive phase of treatment it may be possible to undertake simultaneous operations at different anatomic sites. This is straightforward if there are contralateral fractures of the upper and lower extremities, or a combination of facial, thoracic, and lower extremity trauma. These combinations of injuries allow two different teams such as orthopedic and plastic surgeons or maxillofacial and thoracic surgeons to work together thereby minimizing the duration of anesthesia, the surgical stress on the injured patient, and at the same time optimizing the operating room time, and the costs of treatment.118,123,311 
As the main goal in any trauma system is to offer definitive, specialized care for the injured patient in the shortest possible time the preservation of high standards of acute trauma care requires complex clinical capabilities, particular infrastructure logistics, and, even more importantly, algorithms facilitating simultaneous activities in diagnosis and therapy. 
Unfortunately, the existing evidence about the role of simultaneous surgery for polytraumatized patients is not of adequate quality and quantity to justify generalized conclusions. However, it is anticipated that in the future there will be further research which will better define its role. It is also important to realize that the type of osteosynthesis used in multiply injured patients not only depends on the state of the bone and soft tissues but much more so on the general, pulmonary, and hemodynamic status of the patient. 

Management of Unilateral Fracture Patterns

In multifocal injuries of the upper extremity, the surgeon should be aware of the overall fracture distribution rather than consider each fracture as an isolated problem. Even though an early definitive osteosynthesis would be preferred in all fractures, often the general state of the multiply injured patient or the local fracture conditions do not permit this. In these cases it is recommended that careful immobilization of diaphyseal fractures is the first phase of fracture management. If there are periarticular fractures of the large joints and urgent open reduction and fixation is impossible transarticular external fixation (TEF) should be performed. In any case with a concomitant vascular injury or any evidence of a developing compartment syndrome, fasciotomies should be undertaken. 
In multifocal injuries of the lower extremity such as ipsilateral distal femoral and proximal tibial fractures, known as a floating knee, similar flexible but nonetheless structured and priority-oriented management protocols should be applied. The overall status of the patients is crucial to the concept. If the floating knee occurs in a stable patient, a retrograde femoral nail can be inserted through a small incision at the knee joint which is flexed at 30 degrees. An antegrade tibial nail can then be inserted through the same incision. The same fracture pattern in an unstable patient is best treated using a transarticular external fixator to span both fractures. A secondary definitive osteosynthesis can then be done when the patient has recovered from the initial, potentially life-threatening injuries. It is very important that there is good communication between the anesthesiologist and the surgeon since the procedure may have to be adapted to any change in the patient’s vital parameters. 
In metaphyseal and periarticular fractures, the priorities of treatment are often dictated by the state of the soft tissues. A high priority is given to femoral head and talar fractures. Other periarticular fractures have a lower priority unless complicated by factors such as vascular dysfunction, compartment syndrome, or an open wound. Apparently minor fractures to the hand, fingers, tarsus, and toes should not be overlooked. They should be considered in the overall management concept and treated appropriately. 

Management of Bilateral Fracture Patterns

In bilateral fractures, simultaneous treatment is ideal. This is particularly true in bilateral tibial fractures where both legs are surgically cleaned and draped at the same time. However, the operative procedure is performed sequentially because of the problems inherent in the use of fluoroscopy. If the vital signs of the patient deteriorate during the operation the second leg may be temporarily stabilized using an external fixator. The definitive osteosynthesis then may be delayed until the general status of the patient is stabilized again. The priorities in the treatment of bilateral fracture patterns follow the evaluation of the injury severity with more severe injuries being treated first. 

Upper Extremity Injuries

The management of upper extremity fractures in multiply injured patients is usually undertaken secondary to the treatment of injuries of the head, trunk, or lower extremity. If there is a closed fracture of the upper extremity without any associated injury, such as vascular or nerve damage or compartment syndrome, proximal fractures of the shoulder girdle, proximal humerus, and humeral shaft can be stabilized by a shoulder body bandage. If definitive osteosynthesis is required it may be performed during the secondary management phase, possibly after further imaging. External fixation is an alternative for the temporary stabilization of humeral diaphyseal fractures and TEF may be used to stabilize fractures about the elbow if definitive stabilization has to be delayed. Primary management of fractures of the forearm, wrist, and hand is often with a cast but temporary external fixation may be used. 

Lower Extremity Injuries

Our experience suggests that long bone fractures associated with a severe head injury or chest trauma require a specially modified strategy. We strongly recommend the expanded monitoring of respiratory function, ventilation (capnography), and pulmonary hemodynamics. In addition, intracranial pressure monitoring is mandatory in patients with severe head injury.48 

Unstable Pelvic Injuries

The management of the rare unstable pelvic injury is much easier if a standardized protocol is followed. A thorough clinical and radiologic examination is essential for the assessment of pelvic injuries. This assessment is usually done during the initial examination phase. Following this examination it may only be possible to arrive at an approximate classification of the pelvic injury. However, sophisticated classifications of pelvic injuries in this context are not of much use. Instead, the simple AO classification, the A B C system (Fig. 9-7), can assist in the decision-making process.273 In this classification, type A injuries include stable fractures such as fractures of the pelvic rim, avulsion fractures and undisplaced anterior pelvic ring fractures. The posterior rim is not injured at all. Type B injuries comprise fractures with only partially intact posterior structures and rotational dislocations may be possible. Sometimes, this injury may initially be an internal rotation dislocation resulting in marked bone compression and stabilization of the pelvis. However these injuries are associated with a high risk of intra-abdominal damage. If the injury results in an open book type of fracture with both alae being externally rotated urogenital lesions and hemorrhagic complications are much more common. 
Figure 9-7
Classification of pelvic ring fractures in A, B, and C type fractures similar to the AO classification.
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Since the differentiation of AO type B and C injuries may be difficult, a CT scan of the pelvis is strongly recommended. If there is no CT available diagonal inlet and outlet x-rays may serve as an alternative. In C type injuries, the pelvis shows translational instability of the dorsal pelvic ring, because the stabilizing structures are all divided (Fig. 9-8). One or both hemipelves are separated from the trunk. This injury is associated with an extremely high rate of hemorrhagic complications and other pelvic injuries. The simple AO classification has significant therapeutic implications. In type A injuries operative treatment is generally not required whereas in type B injuries adequate stabilization is obtained by osteosynthesis of the anterior pelvic ring only. Type C injuries require anterior and posterior osteosynthesis to gain adequate stability. 
Figure 9-8
Type C pelvic fracture.
 
Three-dimensional computed tomography scan.
Three-dimensional computed tomography scan.
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Figure 9-8
Type C pelvic fracture.
Three-dimensional computed tomography scan.
Three-dimensional computed tomography scan.
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The differentiation of several sectors of injury has also proved useful. Transsymphyseal, transpubic, transacetabular, and transiliacal fractures are differentiated from transiliosacral and transsacral fractures. This process is easy to memorize and requires a careful analysis of the x-rays. For each of the injured regions we have standardized the recommendations for osteosynthesis. Thus an adequate management plan is available for the small numbers of unstable pelvic fractures that will be seen. Since more than 80% of unstable pelvic injuries are associated with multiple injuries, stabilization techniques that can be undertaken with the patient in the supine position are much preferred during the primary period. In addition, the supine position facilitates reconstruction of symphyseal and iliosacral ruptures. Generally speaking, we recommend that fractures of the pelvic ring be stabilized as soon as possible to avoid ongoing blood loss and to simplify ICU care and promote early ambulation.125 

Complex Pelvic Injuries

Pelvic injuries associated with any other injury to local pelvic organs are called complex pelvic injuries.32 These injuries comprise about 10% of pelvic injuries and they are associated with a significantly higher mortality of between 30% and 60% in comparison with simple pelvic injuries. During the early phase hemorrhage is the most common cause of death. Later ARDS and MODS occur because of the blood loss. 
During the acute treatment phase, only immediate priority-guided management protocols save the lives of these severely injured patients and improve their prognosis. A variety of methods for hemorrhage control in pelvic injuries are discussed in the literature. Along with these techniques several complex therapeutic protocols have been developed. Our own experience has resulted in a rather simple algorithm requiring three decisions to be made within the first 30 minutes after admission. The therapeutic goal is based on a combined strategy of intensive shock treatment, early stabilization of the pelvic ring, and potential operative hemorrhage control and packing rather than a single treatment option. Once hemorrhage control has been achieved the associated urogenital and intestinal injuries should be treated expeditiously to avoid septic complications. 
In urogenital injuries reliable drainage of the urine is the primary goal. During the first laparotomy intraperitoneal ruptures of the bladder are repaired. In injuries of the urethra, it is recommended that the urethra be splinted with a transurethral catheter in the acute phase and that a definitive reconstructive procedure be undertaken during the secondary period to reduce the incidence of late strictures. If early realignment is not possible, then a suprapubic catheter should be inserted. 
In open pelvic fractures with injuries to the rectum or anus a temporary colostomy of the transverse colon generally guarantees proper excretion and safeguards the healing process in the pelvis. At the end of the procedure, an extensive antegrade wash-out of the distal colon is assumed to reduce the microbial load. Any potential muscular or skin necrosis is radically debrided to reduce the risk of infection. 

Unstable Injuries of the Spine

In general, operative treatment of unstable spine injuries in multiply injured patients is mandatory, if only for intensive care nursing purposes. Nonoperative treatment using a plaster jacket or a halo-body fixator is unsuitable for multiply injured patients because the immobilization is associated with a high risk of complications. Not only are the intensive care nursing procedures much easier after internal stabilization, but also the period of immobilization and the period of intensive care stay are significantly reduced. Spinal fractures associated with neurologic dysfunction are usually stabilized at the same time as the spinal cord is decompressed. However in recent years there has been a move toward stabilizing more unstable injuries of the spine in patients who present without neurologic symptoms for the same reasons. It is our experience that after diagnosing an unstable injury of the spine in a patient who does not have neurologic symptoms a closed reduction should be undertaken if there is a fracture of the cervical spine or an AO type C rotational injury of the lower thoracic or lumbar spines. In any other injury, the reduction is performed in the operating room just before the actual procedure. It is important to understand that even if there is a slight suspicion that a fracture fragment or a protruding intervertebral disc may narrow the spinal canal after closed reduction, further diagnostic imaging with a CT or MRI scan should be carried out preoperatively. 
In multiply injured patients in particular closed reduction may be difficult because of co-existing extremity injuries. In these cases correct axial and rotational alignment should be obtained intraoperatively. If there is interposition of a bone fragment or an intervertebral disc, open reduction is indicated to avoid spinal cord compression. 
We routinely use the anterior approach for operative management of the upper (C1 to C3) and lower (C4 to C7) cervical spine. The patient’s head is fixed to a special reduction apparatus using the rim of the halo fixator. In thoracic or lumbar spine injuries associated injuries to the chest and abdomen have to be considered. Nonetheless, in our experience, injuries requiring posterior and anterior stabilization may usually be fixed with a posterior internal fixator in the acute management period. Depending on the general status of the patient, the anterior stabilization may be performed secondarily. Even intrathoracic or intra-abdominal injuries are not necessarily a contraindication to the use of the prone position which is required for posterior instrumentation. The prone position can even be used successfully in patients with severe lung injury. 

Assessment of Fracture Severity

Closed Fractures.

Fractures in polytrauma patients managed either with the ETC or the DCO approach must be stabilized before being admitted to the ITU. Stabilized fractures not only reduce pain but also minimize the release of intramedullary material into the circulation and secondary damage to the soft tissues. Furthermore, nursing is easier and early functional treatment can be initiated. 
Assessment of the degree of soft tissue damage in closed fractures is often difficult. A skin contusion over an otherwise closed fracture may present more therapeutic and prognostic problems than an inside-out puncture wound in an open fracture. Although the skin wound may not be particularly impressive, this type of blunt injury can lead to significant skin damage. As necrosis is the main complication of a skin contusion secondary infection can occur, particularly in the ICU. This issue has been addressed by the development of a classification system which allows the clinician to decide the appropriate therapeutic approach that would be beneficial to the patient’s overall condition. The Tscherne classification of closed fractures is detailed in Table 9-9.296 
 
Table 9-9
Classification of Soft Tissue Injury in Closed Fractures
  •  
    Closed fracture C0: No injury or very minor soft tissue injury. The C0 classification covers simple fractures caused by indirect mechanisms of injury.
  •  
    Closed fractures C1: Superficial abrasions or contusions from internal fragment pressure. Simple to moderate fracture types are included.
  •  
    Closed fractures C2: Deep, contaminated abrasions or local dermal and muscular contusions. An incipient compartment syndrome is also classified as a C2 fracture. These injuries are usually caused by direct forces, resulting in moderate to severe fracture types. The closed segmental tibia diaphyseal fracture is a good illustration of a C2 fracture.
  •  
    Closed fractures C3: Extensive skin contusions or muscular damage, subcutaneous degloving and clinical compartment syndrome in any closed fracture are graded as C3 fractures. Severe and comminuted fractures occur in this subgroup.
  •  
    Closed fractures C4: The same injuries as listed in the C3 fracture classification but the C4 group are associated with significant vascular requiring operative treatment.
 

Oestern HJ, Tscherne H. Pathophysiology and Classification of Soft Tissue Injuries Associated with Fractures. Berlin: Spinger-Verlag; 1984.

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Open Fractures.

In polytrauma patients prompt evaluation and treatment of open fractures is of paramount importance. It involves careful assessment of the damage to the soft tissues, radical debridement, extensive irrigation, and stable fracture fixation. Careful assessment of the injury severity is the first step in the development of a treatment strategy. The time and mechanism of injury, the energy of the causative force and the severity of the fracture should be considered. The extent of any co-existing vascular and nerve damage and the general condition of the patient are also of great importance. In high-energy trauma the soft tissues may be severely damaged and may require careful evaluation and extensive debridement during the initial assessment. 
Open fractures resulting from low-energy trauma are usually associated with less soft tissue damage and may almost be treated like closed injuries. After the initial debridement, the fracture may be appropriately stabilized. Open fractures resulting from high-energy trauma often have extensive soft tissue damage combined with significant bone destruction. This injury requires a sequential program of management. The treatment plan consists of an adequate debridement, initial temporary stabilization followed by definitive secondary stabilization and wound closure. Our experience with this type of injury indicates that each fracture has almost unique characteristics which require individual management. In multiply injured patients the overall injury severity has to be considered as has the degree of shock and the initial blood loss. Once these factors have been taken into account a clear therapeutic plan should be established for each patient. Open fractures are discussed further in Chapters 10, 11 and 12

Classification of Soft Tissue Damage.

Several classifications have been proposed over the years for the grading of open fractures but the standard system of classifying the soft tissue component of a fracture remains that of Gustilo and Anderson.151 Despite the doubts which have been raised over its reliability, it seems likely to remain in common usage as it is straightforward to remember and to apply. 
In multiply injured patients a thorough assessment of soft tissue damage is even more crucial. In this group, the prognosis for the soft tissue damage depends on a multitude of parameters including tissue hypoxia, acidosis, and hypoperfusion of the extremities due to hemorrhagic shock. All these factors should be taken into account in clinical decision making and planning. 

Reconstruction Versus Amputation?

With advances in free tissue transfer and microsurgical techniques and a better appreciation of the usefulness of the Ilizarov technique of limb preservation, especially in Gustilo grade IIIb and IIIc fractures of the lower extremity reconstruction is more commonly attempted nowadays. Reconstructive bone and soft tissue surgery usually requires repeated operations, long-term hospital stays and prolonged periods of treatment. The surgeon must appreciate that this is very difficult for the patient and his or her family and there are often significant social and economic consequences. Several authors have therefore looked into criteria to help guide surgeons in their decision between reconstruction and amputation of a severely injured extremity. From the surgical point of view an attempt to preserve the limb often seems to be the best decision for the patient. However from a socioeconomic point, multiple prolonged hospital stays may have a deleterious effect on the patient. The financial loss for the patient from prolonged hospital stays and time off work may prove to be higher than that associated with a primary amputation and not infrequently multiple attempts at reconstruction leave patients incapable of earning their living for more than 2 years.372 In addition, it should be remembered that many patients with reconstructed limbs often find it difficult to return to their occupations at all. 
If a severely injured patient survives after a primary amputation the question that arises is whether the amputation was unavoidable or whether reconstruction was possible. If the patient dies the question is whether the severity of the injuries was underestimated initially and would an early amputation have saved the patient’s life? Lastly, if the patient survives after primary reconstruction but suffers from complications requiring prolonged treatment, the question is whether the bad outcome justified the resources that were expended. 
Several classification systems have been developed in order to help surgeons in this decision-making process.143,163,179 Recently, McNamara et al. evaluated the mangled extremity severity Score (MESS) by retrospectively studying 24 patients with Gustilo IIIc fractures. The results confirmed high predictability. To improve the predictive value nerve damage and a detailed assessment of the bone and soft tissue damage were included. The new score that resulted from this is called the nerve injury, ischemia, soft tissue injury, skeletal injury, shock and age (NISSSA) score. It has been shown to have a sensitivity of 81.8% and a specificity of 92.3%.252 Amputations are discussed further in Chapter 14

Debridement.

After deciding to salvage the limb, a careful extensive debridement is the first step in the operative treatment plan. All soft tissues have to be considered. If the debridement is overcautious this may lead to a deterioration of the patient’s condition and even organ failure. Adequate surgical exposure of the injury is essential to both assess and treat the soft tissue damage. In multiply injured patients there is a high risk of late soft tissue necrosis secondary to impaired soft tissue perfusion which may occur with post-traumatic edema, increased capillary permeability, massive volume resuscitation, and an unstable circulation. Therefore, in many patients regular operative explorations need to be undertaken. These second look surgeries allow for continuous assessment of the soft tissues. This strategy enables the surgeon to undertake re-debridement procedures every 48 hours if required. Once debridement is complete fracture stabilization and soft tissue repair should be planned and undertaken. 

Operative Strategy Depending on the Overall Injury Severity.

Clearly, the ability of the multiply injured patient to tolerate reconstructive surgery depends mainly on the overall condition of the patient and the extent of any co-existing injuries. Any lengthy reconstruction or reimplantation procedure may potentially harm the patient and induce a life-threatening situation. Attention also has to be paid to the long-term prognosis of an open injury in the multiply injured patient. All these variables need to be considered when constructing a therapeutic plan. 

Patients with an ISS of 1 to 15 or 16 to 25 and Gustilo Grade IIIa, b, or c Soft Tissue Injuries.

In this subgroup of multiply injured patients reconstruction is indicated. The surgical process is now largely standardized. After a radical debridement, the second step consists of vascular repair, if this is required. This may necessitate the use of an interposition vein graft. Following this the fractures should be stabilized, ideally using intramedullary osteosynthesis. Intramedullary implants are much less damaging to the soft tissues than direct osteosynthesis. There is less soft tissue stripping and only minimal impairment of the circulation of the bone.211 
The closure of any associated soft tissue defect depends on the extent of the injury. In most cases, the wound will be temporarily covered with synthetic skin grafts or vacuum systems, before final closure using plastic reconstructive surgery techniques. This is discussed further in Chapter 15. In general, the expected result of a reconstructive limb saving strategy should be better than that of amputation. 

Patients with an ISS of 1 to 15 or 16 to 25 with Complete or Incomplete Amputations.

The surgical management of these injuries is very similar. The option of reimplantation has to be considered and this may require referral to a specialized center. If reimplantation is anticipated appropriate preparations must be made. Hemorrhage should be stopped by elevation and application of a pressure bandage. The treatment of the amputated limb follows clear emergency medicine guidelines.399 

Patients with an ISS of 26 to 50 Points or >50 Points.

In recent years level I trauma centers have improved their critical care and fracture management techniques and they now succeed in saving most severely traumatized extremities. However, unfortunately these limbs still sometimes require secondary amputation.187 In very severely injured patients with extremity injuries the preservation of the extremity should not be attempted at all. The principle “life before limb” should hold true and the indications for amputation are generous. If the decision to amputate a limb is made the actual procedure should ideally be performed quickly through healthy tissue using a guillotine method. Under these circumstances primary closure is associated with an extremely high rate of complications because the overall extent of the soft tissue damage and post-traumatic edema cannot be adequately estimated. 

Open Intra-articular Fractures.

A two-step strategy has been advocated for the management of open intra-articular fractures. Initially, the injury is debrided and the joint surface is reconstructed using a minimal invasive osteosynthesis technique. The joint is then immobilized by bridging, or transarticular, external fixation. The definitive osteosynthesis is carried out secondarily following soft tissue healing. In this procedure, the previously reconstructed articular segment is attached to the metaphysis. Sometimes bone shortening has to be accepted, at least temporarily, to close potential bony or soft tissue defects. The Ilizarov frame is often used under these circumstances. This is discussed further in Chapter 15

The Timing of Soft Tissue Defect Reconstruction

In many multiply injured patients primary wound closure represents bad practice. The relative hypoxia of the tissues may lead to impaired and delayed wound healing associated with a higher risk of wound infection. In small soft tissue injuries, we recommend secondary closure of the wound after covering the wound with artificial skin until the swelling decreases. An absolute prerequisite for wound closure is to completely cover implants with well-perfused soft tissues. In these defects, artificial skin cover is used primarily and the wound is secondarily closed later over a period of several days. In some selected cases, continuous wound closure may also be an option. This is discussed further in Chapter 10
In medium-sized soft tissue defects secondary closure is often achieved by local soft tissue transposition following appropriate mobilization of the soft tissues. In extensive soft tissue defects, associated with exposure of bone, with significant periosteal damage the soft tissues used to cover the defect require to be very well perfused. Soft tissue reconstruction should be undertaken within 72 hours of the trauma or there is danger of further damage. 
Large post-traumatic soft tissue defects are very challenging for the surgeon and require a well-defined therapeutic strategy. The overall concept of soft tissue coverage depends on the extent of uncovered bone, tendons, and nerves. For bone associated with significant periosteal stripping, damaged neurovascular structures and injuries involving open joints soft tissue cover with well-perfused tissues is essential. To achieve satisfactory results timely communication and continuous cooperation between trauma and plastic surgeons is essential. 

Soft Tissue Reconstruction

There are numerous local and distant flaps described in the literature to cover soft tissue defects. See Chapter 15

Local Flaps.

Rotational flaps are used to cover small- and medium-sized soft tissue defects. These flaps consist of different combinations of muscle, fascia, and skin. They are very adaptable but are associated with a number of disadvantages. In multiply injured patients it may be difficult to use local flaps because of co-existing injuries to the adjacent soft tissues. Meticulous preoperative planning is mandatory. Local flaps are discussed in more detail in Chapter 15

Distant Flaps.

For the reasons stated earlier distant flaps are commonly used in multiply injured patients. However the choice of flap is often difficult. On the one hand the patient may need urgent soft tissue closure but on the other hand a prolonged procedure may be contraindicated. Careful planning is essential (see Chapter 15). 

Special Situations

Geriatric Trauma

The incidence of severely injured elderly patients is expected to increase in the near future. This is related to increasing life expectancy and to a more healthy and active lifestyle in people of advanced age. In addition, physiologic changes associated with the aging process including muscle atrophy, cardiovascular and neurovascular diseases, osteoporosis, and alterations in senses, vision and hearing, make the elderly patients prone to more severe injuries even after low-energy trauma. There is an increasing incidence of hypertension, obesity, diabetes mellitus, and heart disease among patients aged 55 years and older.107,272 However, it must be kept in mind that the aging process is a subject of considerable individual variation. Thus, the chronologic age might not be reflected in the biologic age. The distribution of injuries and the injury mechanisms are different from those in young trauma victims.215 Elderly patients more frequently fall and are involved in motor-vehicle injuries either as drivers or pedestrians.215 The prevalence of severe (AIS ≥ 3) chest, abdominal, and extremity injuries has been shown to decrease with the age, in contrast to an increase of head injuries in older patients.215 
The primary evaluation of multiply injured elderly patients can be very challenging. It has been suggested that early invasive monitoring and prompt adequate treatment be done in designated trauma centers to avoid complications.215 The principles of initial assessment are similar to those in younger patients. Several characteristics of aged patients should be considered and are summarized below. 

Airway Maintenance with Cervical Spine Protection

The airway should be examined in order to avoid airway obstruction. The presence of age-related neurologic disorders or dementia may be associated with the loss of protective airway reflexes. Liquids or vomit may be aspirated into the lung and lead to pneumonia and respiratory complications. It should be remembered that dentures may act as foreign bodies in the oral cavity. The immobilization and protection of the cervical spine is crucial. Chronic degenerative disease may facilitate fractures in the cervical spine. 

Breathing and Ventilation

The aging process in the lung is characterized by loss of elasticity, decreased pulmonary compliance and alveolar loss.251 Pre-existing pulmonary diseases, such as chronic obstructive pulmonary disease or emphysema, limit the gas exchange within the lung. Blunt chest trauma frequently results in multiple fractures related to osteoporosis and chest rigidity in the aged population and this may significantly compromise mechanical ventilation and oxygenation of the patient. 

Circulation with Hemorrhage Control

Younger patients compensate for blood loss by increasing the heart rate and myocardial contractility. Stiffness of the myocardium and reduction of the pump function in elderly patients reduces the cardiac reserve and the response to hypovolemia. Circulatory decompensation can therefore rapidly occur. Furthermore, clinical signs of hypovolemia may be masked by β-blockers or other heart medications. 

Disability (Neurologic Evaluation)

Brain injuries are often present in elderly trauma patients and are the leading cause of death. Patients develop intracranial bleeding because of the increasing vulnerability of brain vessels with advanced age. This injury can be compounded by anticoagulation therapy. Repeated re-evaluation of the neurologic status and invasive monitoring is crucial. In the case of neurologic deficits it is important to distinguish whether these might be related to pre-existing conditions, such as stroke or dementia, or to the trauma itself. 

Orthopedic Injuries

In patients with fractures, muscle atrophy and osteoporosis should be considered when considering the treatment strategy. Implants from earlier fractures, joint prostheses, and the presence of arthritis can make fracture treatment very challenging. In addition, alterations of the immune system, decreased circulation of the skin and pre-existing metabolic diseases may affect wound healing. 
In stable patients a complete head-to-toe assessment should be undertaken. This secondary survey allows the surgeon to identify any missed injuries and any clinical signs of prior operations or diseases. The re-evaluation of medications, allergies, and any relevant medical history is critical in elderly patients and should be performed as soon as possible. 

Intensive Care Unit

One of the most important aspects of the clinical pathway of the polytrauma patient during the phase when survival is critical is management in the ICU environment. This is when the patients’ vital organs require support and pharmacologic treatment strategies are implemented in order to regulate the hosts’ response to injury. 

Ventilation Strategies

Multiple trauma patients often present with blunt thoracic trauma and suffer from a variable degree of respiratory insufficiency. Management strategies for these patients should begin upon arrival at the trauma center. The objective is to initiate treatment early in order to minimize the risk of development of atelectasis and/or parenchymal damage. Mechanical ventilation should facilitate alveolar recruitment and enhance intrapulmonary gas distribution. Modern ventilation strategies with low tidal volume (4 to 8 mL/kg), best PEEP, low airway pressures (<35 cm H2O) and an inspiratory oxygen concentration of 55% to 60% are often ideal. Hypercapnia may be allowed up to a certain degree. This is known as permissive hypercapnia (PHC).420 It is well tolerated in patients with ARDS and a pCO2 of 60 to 120 mm Hg. Clinical experience shows that pressure controlled ventilation with inverse ratio ventilation (I:E [1:1 to 4:1]), low tidal volumes (4 to 8 mL/kg), frequencies of 10 to 15/min, PHC (pCO2 ∼ 70 mm Hg) an individual PEEP of 5 to 12 cm H2O, a high oxygen concentration (FiO2 < 0.5) and a high airway pressure can prevent the lung from further ventilation damage.448 Early experiences using other ventilation strategies, such as bilevel positive airway pressure (BIPAP), demonstrate that they are also feasible, although there may be problems with BIPAP in cases where long-term sedation is required. One of the most recent concepts developed for the prevention of pulmonary failure is the recruitment of alveoli by a temporary increase in positive end expiratory pressure (open-lung concept).2 It does not cause sustained cardiovascular side effects and also does not lead to the development of bronchopleural fistulae. However the clinical relevance of this new concept has still to be proven in larger series.263 
Recently, a new study compared an established low–tidal-volume ventilation strategy with an experimental strategy based on the original “open-lung approach,” combining low tidal volume, lung recruitment maneuvers, and high positive end expiratory pressure. The authors concluded that for patients with acute lung injury and acute respiratory distress syndrome (ARDS), a multifaceted ventilation strategy designed to recruit and open the lung resulted in no significant difference in hospital mortality or barotrauma compared with an established low–tidal-volume ventilation strategy. This “open-lung” strategy did appear to improve secondary endpoints related to hypoxemia and the use of rescue therapies.253 

Adult Respiratory Distress Syndrome

Acute lung injury can be caused by severe pneumonia or trauma and ARDS is its most critical form. In ARDS, the lungs become swollen with water and protein, and breathing becomes impossible, leading to death in 3% to 40% of the cases. Activated blood cells, cytokines, toxins, cell debris, and local tissue damage facilitate endothelial cell damage leading to decompensation of lymph drainage and pulmonary interstitial edema. Patients with ARDS have higher hospital mortality rates and reduced long-term pulmonary function and quality of life. ARDS is treated with mechanical ventilation, which can provide life support but often at the expense of further lung injury. Ventilation that employs a low tidal volume inhaled in each breath reduces the risk of death in patients who are critically ill with ARDS. The use of steroids has been controversial despite the fact that published trails support the administration of low to moderate dose corticosteroids in the treatment of early and late phase ARDS.89 The impact of clinical risk factors in the conversion from acute lung injury to acute ARDS in severe multiple trauma patients has also been evaluated. It has been shown that the impact of pulmonary contusion, the APACHE II score and disseminated intravascular coagulation may help to predict the conversion of acute lung injury to ARDS in severe multiple trauma.450 Historically, three phases of ARDS have been differentiated, the third leading to a state of scarring of pulmonary tissue and often irreversible loss of organ function. Currently, we believe that the formation of scar tissue is often the result of high intra-alveolar pressures due to inadequate ventilation techniques. Because of the improved ventilation strategies described above, the later form is usually no longer seen.323 

Multiple Organ Dysfunction Syndrome

MODS is the result of an inappropriate generalized inflammatory response of the host to a variety of insults. Currently, it is believed that in the early phase of MODS, circulating cytokines cause universal endothelium injury in organs. In the later phase of MODS overexpression of inflammatory mediators in the interstitial space of various organs is considered a main mechanism of parenchymal injury. The difference in constitutive expression and the upregulation of adhesion molecules in vascular beds and the density and potency of intrinsic inflammatory cells in different organs are the key factors determining the sequence and severity of organ dysfunction.411 The sequence of organ failure is variable. The most commonly reported sequence is pulmonary failure followed by hepatic and intestinal failure.91,102 

Rehabilitation

The aftercare of polytrauma patients has to start during the immediate postoperative period. This requires mobilization of the extremities during the course of the intensive care treatment. Passive continuous motion may be used but mobilization of all major joints must be performed and should be part of a standardized rehabilitation program. Once the patient has been returned to the normal ward these measures must be maintained and they may be accompanied by active exercises by the patient. These should be performed under the supervision of a trained physical therapist. The modes of mobilization and the degree of weight bearing should be carefully discussed between the treating surgeon and the physical therapist. Patients tend to be cautious about mobilization and there is often a particular fear about weight bearing. This can often be explained by the severe psychological impact induced by the traumatic insult. Reassurance of the patient is an important additional factor if adequate mobilization is going to be achieved. These factors are important not only with regard to the maintenance of joint mobility, but also to prevent osteoporosis induced by immobility. It is crucial that patients realize the importance of muscular activity, joint mobility, and weight bearing with reference to neuromuscular function and the maintenance of an optimal osseous microstructure. 

Patients with Head Trauma

When treating patients who have had significant head trauma special care must be taken to avoid the development of secondary brain damage. These patients also benefit from early rehabilitation measures. An appropriate transfer to a rehabilitation center is advisable. Although it may be considered appropriate to commence treatment in the primary center the patients are often still under the influence of sedative drugs or undergoing withdrawal symptoms from these drugs. In this situation a thorough work-up cannot be performed and cognitive training is useless. In an ideal situation, transfer to a specialized facility may overlap with the normalization of the withdrawal symptoms and thus forms the basis of a timely beginning of the rehabilitation program. 

Late Outcome after Polytrauma

Evaluation of the effectiveness of trauma care was traditionally focused on mortality rates, the incidence of preventable deaths, complication rates, in-hospital morbidity, and length of hospital stay.38,354 However, due to the advances of acute trauma management and the increased survival rates over the last few decades, the long-term functional recovery, health-related quality of life, return to work, and patient satisfaction have been added to the classic trauma evaluation endpoints. 
The long-term outcome of major trauma reflects the result of multiple phases and factors including diagnostic procedures, therapeutic interventions, inherent characteristics of the patient, and the effectiveness of the trauma services over a long period of time this being from the time of the accident until rehabilitation or even later. It is the end result of this multifactorial and complicated system that is of most concern to the patient. In the last two decades the importance of the patient’s point of view and their perception of health outcomes has been acknowledged, and has led to the development of a large number of functional and patient-related outcome scores.37 
However, the increasingly high priority of assessing the long-term functional outcome of trauma cannot only be based on patients’ concerns as proper assessment facilitates the development and improvement of management guidelines, discharge and rehabilitation planning, and the optimal allocation of resources. In addition, the long-term outcome of trauma management has significant social and economic implications.37 
Recovery following polytrauma is often prolonged and thus the appropriate time interval for assessment of long-term outcomes is usually longer than the customary time frame of 2 years. In particular, social rehabilitation including return to work or hobbies and change of occupation or retirement appears to be a long-term process. This suggests that the evaluation of the functional outcome following polytrauma should be based on a lengthened follow-up period by which time surgical outpatient review is sporadic if it is still occurring at all. This fact together with the complexity of parameters associated with the outcome of polytrauma explains the difficulty of long-term assessment and the scarcity of comprehensive clinical studies and adequate data. 
Currently, the long-term outcome evaluation of trauma care encompasses parameters related to quality of life, return-to-work or sports, persistent physical or psychological complaints, and restrictions and acquired disabilities. The term “quality of life” entered Index Medicus in 1977.144,455 In order to apply its concept in the specific clinical setting of trauma four basic areas should be considered these being physical function, psychological function, social function, and symptoms.416 The unique character of this outcome assessment is that it relies largely on subjective variables judged by the patients themselves. 
A large number of validated scoring systems are used to quantify outcome after mainly isolated injuries in almost all anatomic areas. In the case of polytrauma they are often utilized to objectively quantify the anatomical and physical components of the final outcome. Examples are the Lysholm and Merle d’Aubigne scores. For patients with multiple musculoskeletal disorders patient-assessed scales have been developed that describe self-reported complaints and subjective parameters. In addition, numerous scoring systems have been developed to determine psychological outcome after trauma. 
In most of the large series it is musculoskeletal injuries of the lower extremity below the knee372,412,435 together with injuries of the spine,124,161,221 the pelvis308,410 and brain injury222,237 that are identified as those most influencing the long-term functional outcome of polytrauma patients.393 According to most published series, they seem to determine a major proportion of the patient’s quality of life with respect to functional status and pain. 
Predictors of disability such as mechanism of injury, gender, injury severity, sociodemographic status, social support, and psychological sequelae have also been reported.49,173,177 Clinically relevant psychological impairments such as anxiety, depression, and post-traumatic stress disorder have been reported especially within the first year after injury when they have a prevalence of 30% to 60%. In succeeding years the prevalence drops and has been reported to be 7% to 22%.260 The importance of psychological outcomes, particularly post-traumatic stress disorder (PTSD), has been highlighted in many series.359,394 It is described as an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. 

Upper Extremity Injuries

Publications addressing the long-term outcome of upper extremity injuries are rare. Usually studies focus on isolated upper extremity fractures.104 These results are likely to be different from those of multiply injured patients who have sustained high-energy trauma. Superior long-term results were reported in patients with upper extremity injuries in contrast to outcomes after lower extremity fractures.53,235 However studies show that associated vascular and neurologic injuries negatively affect the long-term functional outcome.190 An analysis of the musculoskeletal recovery after 5 years in 158 multiply injured patients treated between 1989 and 1990 has shown that approximately 50% of patients with shoulder girdle injuries had functional impairment and persistent disability.265 In addition, 45% of trauma victims with shoulder girdle fractures and 62% of patients with upper extremity fractures reported chronic pain.265 Displaced and intra-articular fractures, or a combination of shoulder girdle and diaphyseal fractures, were associated with poor long-term results. In the Hannover Rehabilitation Study a total of 637 multiply injured patient (ISS >15) were evaluated with a follow-up of 10 years (mean 17.5 years).227 This study showed worse long-term results in patients who had combined intra-articular and diaphyseal upper extremity fractures. One possible explanation for this might be the complexity inherent in the reconstruction of intra-articular and multiple trauma. Moreover, concomitant injuries may interfere with the rehabilitation process and deleteriously affect the long-term outcome. 

Pelvic Fractures

Pelvic injuries are usually the result of high-energy trauma and are often associated with multiple co-existing injuries.113,408 Whether it is the accompanying injuries or the pelvic injuries that mainly lead to the poor long-term results is difficult to know. Research has shown that the presence of associated injuries and the stability or instability of pelvic fractures contribute to poor long-term outcomes.325 In particular chronic pain and neurologic impairment have been shown to influence outcome.326 Pohlemann et al.324326 have documented chronic pain in all pelvic fracture classification groups. They showed that 45% of patients with type A fractures had chronic pain compared with 59% of patients with type B fractures and 63% of patients with type C fractures. Furthermore, neurologic sequelae such as peripheral nerve lesions, incontinence, and sexual dysfunction have been shown to correlate with poor long-term results and were identified as a principal reason for work disability.400 

Lower Extremity Fractures

Fractures of the lower extremity are often associated with significant long-term impairment and loss of function.53,372 Trauma patients with these injuries have been shown to have the lowest rates of full recovery and overall satisfaction.265,292 In the LEAP study, a prospective multicenter lower extremity assessment project33,233,234 the long-term functional outcome of 601 patients with high-energy trauma below the distal femur was studied. The results demonstrated comparable outcomes in patients who had limb salvage and those who had an amputation. Only 58% of those working prior to their injury were able to return to work within 7 years. There was also no significant improvement in outcomes at the 7-year follow-up when compared to the 2-year follow-up. 
The Hannover Rehabilitation Study, in a 10-year follow-up, has shown that 30% to 50% of patients have chronic pain and 10% to 30% report impaired range of motion. Patients with femoral shaft fractures had superior long-term results compared with those who had intra-articular fractures and proximal femur fractures.319 Patients who sustained fractures below the knee had worse results compared with patients with fractures above the knee joint. The thin soft tissue envelope and restricted blood supply were suggested as possible factors leading to an inferior outcome (Table 9-10).453 
Table 9-10
Functional Long-term Outcome of the Lower Extremities’ Fractures following Polytrauma
Acetabulum N = 20 (%) Prox. Femur N = 20 (%) Femoral Shaft N = 107 (%) Kneea N = 48 (%) Tibial Shaft N = 34 (%)
Persistent pain 50 45 32.7 43.8 26.5
Abnormal gait 35b,c 20b 3.7 8.3 14.7b
Work disability 27.8b,d,e 10 7.6 19.8 8.8
Successful rehabilitation 70 60b 80.4 56.3b 67.7
 

Pfeifer R, Zelle B, Kobbe P, et al. Impact of isolated acetablar and lower extremity fractures on long-term outcome. J Trauma Acute Care Surg. 2012;72(2):467–472.

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Notwithstanding the differences in injury pattern, severity of injury, trauma management practices, and rehabilitation there is strong evidence that the quality of life and overall outcome is significantly impaired after major trauma. In the past, the principal aim of treatment was the prevention of late organ failure and death. In contrast, nowadays the ultimate goal of trauma care is to restore patients to their previous functional status and role in society. The exact measurement of functional outcome still lacks accuracy but the results of a number of studies reporting on the functional outcome after multiple trauma are shown in Table 9-11.8,111,171,172,192,210,305,316 The commonly used functional outcome scores are shown in Table 9-12.134,186,392,434 We anticipate that in the near future there will be better assessment of the outcome of the treatment of the multiply injured patient. 
Table 9-11
Studies Focused on Long-term Outcome of Major Trauma Patients
Authors, Origin, Year Number of Patients ISS—Follow-up Outcome Parameters Conclusions
Bull,125 Birmingham, UK, 1975 1,268 N/a—on discharge
  •  
    Disability—5-point scale
  •  
    Of the 1,268 cases 264 suffered some residual disability
  •  
    The ISS rating may be a useful measure of likely disabilities when applied to groups of cases, but should be used with great caution in forecasting the outcome of an individual patient
MacKenzie et al.,429 Baltimore, USA, 1986 473 N/a—6 months
  •  
    Activities of daily living (ADL)
  •  
    Instrumental activities of daily living (IADL)
  •  
    Mobility
  •  
    AIS of the most severe extremity and spinal cord injury carry considerably more weight when predicting functional status than do the AIS scores of injuries to any other body region
Horne and Schemitsch,145 Wellington, New Zealand, 1989 90 Mean ISS 23.3—mean 3.2 years
  •  
    Modified Glasgow scale
  •  
    Correlation between outcome and the severity of brain injury, the severity of skeletal injuries and the ISS
  •  
    ISS < 24 no physical impairment
  •  
    ISS of 25–30 slight impairment
  •  
    ISS > 30 at least one moderate impairment
Gaillard et al.,16 Creteil, France, 1990 250 Mean ISS 25—minimum 2 years
  •  
    Long-term survey
  •  
    There was no parallelism between objective sequelae and duration of work stop and gravity of lesions ISS
Jurkovich et al.,339 Seattle, Baltimore, Nashville, USA, 1995 329 N/a—12 months
  •  
    Sickness impact profile (SIP)
  •  
    48% had some form of disability even at 12 months
  •  
    Disability was present for a wide spectrum of activities of daily life, including ambulation, psychosocial health, sleep, home management, and return to work and leisure activities
  •  
    Need for psychological intervention and social support long into the recovery period of patients who might not at first seem to require them
Ott et al.,188 Nurnberg, Germany, 1996 73 PTS ≥ 40—range 1–13 years
  •  
    Aachen long-term Outcome Score (ALOS)
  •  
    Spitzer index (SI)
  •  
    Self-assessment.
  •  
    Return to work
  •  
    Predominantly, handicaps resulted from permanent physical disability, in particular the lower extremities
  •  
    Head injuries, extremity trauma, severity of injury and increasing age correlated with worse outcome
Anke et al.,416 Oslo, NOR, 1997 69 Mean ISS 25 (range 17–50)—35 ± 4 months
  •  
    Checklist on social network
  •  
    Occurrence of impairments and disabilities
  •  
    (74%) had physical impairments, about one-third (32%) of the subjects had cognitive impairments.
  •  
    significant correlation between ISS and degrees of impairments
  •  
    high prevalence of impairments after severe multiple trauma
Holbrook et al.,29 San Diego, USA, 1999 780 Mean ISS 13 +/- 8.5—18 months
  •  
    Quality of well-being (QWB) scale
  •  
    Functional disability score
  •  
    Center for Epidemiologic Studies Depression (CES-D) scale
  •  
    Impact of events scale
  •  
    Depression, post-traumatic stress disorder and serious extremity injury play an important role in determining outcome
  •  
    A prolonged and profound level of functional limitation after major trauma was identified at 12-month and 18-month follow-up
Korosec-Jagodic et al.,378 Celje, Slovenia, 2000 98 APACHE II 14.3 ± 6.6—2 years
  •  
    EuroQol 5D questionnaire
  •  
    Health-related quality of life (HRQOL)
  •  
    Trauma patients had a tendency toward anxiety and depression
  •  
    Survival and quality of life after critical illness are independent
Holbrook et al.,361 San Diego, USA, 2001 1,048 Mean ISS 13.5—18 months
  •  
    Quality of well-being (QWB) scale
  •  
    Center for Epidemiologic Studies Depression (CES-D) scale
  •  
    Impact of events scale
  •  
    Gender may play a strong and independent role in predicting functional outcome and quality of life after major trauma
  •  
    Functional outcome and quality of life were markedly lower in women compared with men, as measured by the QWB scale
Stalp et al.,406 Hannover, Germany, 2002 254 Mean ISS 24 ± 6—mean 2.1 years ± 0.1
  •  
    Hannover score for polytrauma outcome (HASPOC)
  •  
    Musculoskeletal function assessment (MFA)
  •  
    12-item health survey (SF-12)
  •  
    Functional independence measurement (FIM)
  •  
    Glasgow outcome scale
  •  
    Evaluation of specific body regions
  •  
    The most severe impairment in functional outcome occurs after injuries of the lower extremities, spine and pelvis
  •  
    The main problems in patients with multiple injuries with skeletal injuries 2 years after trauma were secondary to injuries of the lower extremity below the knee, the spine, and the pelvis
Tran and Thordarson,401 Los Angeles, USA, 2002 24 Mean ISS 17—minimum 12 months
  •  
    36-item health survey (SF-36)
  •  
    AAOS lower limb
  •  
    Foot and ankle score
  •  
    Significant negative impact on outcome in multiply injured patients who have also sustained a foot injury
  •  
    Multiply injured patients with foot injuries had significantly more limitations in physical and social activities, increased bodily pain
Zelle et al.,365 Hannover, Germany, 2005 637 Mean ISS 20.7 ± 9.7—mean 17.5 (range 10–28)
  •  
    Hannover score for polytrauma outcome (HASPOC)
  •  
    12-item health survey (SF-12)
  •  
    Self-reported requirement for medical aids and devices
  •  
    Self-reported requirement for inpatient rehabilitation
  •  
    Self-reported length of rehabilitation
  •  
    Retired because of injury
  •  
    Psychosocial factors play a major role for the recovery following polytrauma
  •  
    Workers’ compensation patients were significantly more likely to use medical aids and devices, be retired because of their injury, and have inpatient rehabilitation
  •  
    The workers’ compensation status has a significant impact on the long-term subjective and objective outcome following polytrauma
Zelle et al.,176 Hannover, Germany, 2005 389 Mean ISS 20.2 ± 4.3
mean PTS 29.5 ± 13.3—mean 17.3 ± 4.8 years
  •  
    Lower extremity specific outcome measurements
  •  
    The Hannover score for polytrauma outcome (HASPOC)
  •  
    12-item health survey (SF-12)
  •  
    Tegner activity score
  •  
    The inability to work
  •  
    Injuries below the knee have a major impact on the functional recovery following polytrauma
  •  
    The analysis of general outcome and lower extremity specific outcome measurements suggests that patients’ fractures above the knee joint achieve superior outcomes than patients with fractures below the knee joint
Pape et al.,411 Hannover, Germany, 2006 637 Mean ISS 20.7 (range 4–54)—mean 17.5 years (range 0–28)
  •  
    Lower extremity specific outcome measurements
  •  
    General outcome measurements
  •  
    12-item health survey (SF-12)
  •  
    Inability to work
  •  
    Subjective outcome questionnaires
  •  
    The injury most often responsible for physical disability was head trauma, followed by injuries to the lower extremities
  •  
    A high percentage of patients can be recruited for follow-up even after 10 years after polytrauma
X
Table 9-12
Commonly Used Functional Outcome Scores in the Clinical Setting of Polytrauma
Name—Abbreviation Characteristics Range of Values Studies Where Used
Quality of well-being scale—QWB scale 1 symptom scale and 3 function scales (mobility, physical activity, social activity) 0–1.0
Death—asymptomatic full function
29,361
Glasgow Outcome Score—GOS 5 item score 1–5
Dead—good recovery
145,288,406
Activities of daily living scale—ADL scale 21 items of basic capacities of self-care (BADL) and higher levels of performance (IADL) 0–21
Worst–best
418,429
Sickness impact Profile—SIP 12 categories physical and psychosocial 0–210
Worst–best
313,339
Functional independence measurement—FIM 13 motor items and 5 cognitive items 1–7 Total assist–complete independence 406
Hannover score for polytrauma outcome—HASPOC score Part 1 (113 questions) patient questionnaire (HASPOC-subjective) and Part 2 (191 questions) physical examination (HASPOC-objective) 5–411 points
Best–worst
98,176,406
Health survey short form 36 or 12 item—SF-36/12 36/12 health related aspects 0–100 points 176,411,436
EuroQol 5D questionnaire—EQ-5D Part I—descriptive system
Part II—visual-analogue scale
Part III—EuroQol 5D Index
−0.11–1
Worse than death–perfect health
378
X

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