1 Introduction

Polytrauma is defined as a syndrome of multiple injuries that exceeds an Injury Severity Score (ISS) of 17 points with consecutive systemic reactions that may lead to dysfunction or failure of remote-primarily, uninjured organs and vital systems [1]. Polytrauma is a systemic disease rather than a combination of local injuries. Most deaths occur either at the scene, during the first 24 hours after admission, or in the second and third week (“trimodal mortality”) ( Fig 1.4-1 ). Although the mortality at the scene can only be influenced by preventative measures, mortality due to hemorrhage during the first 24 hours after admission and late mortality from multiple organ failure can be influenced significantly through appropriate emergency management and treatment algorithms. Fractures of the “central bones” (pelvis, spine, or femur) frequently occur in patients with high-energy trauma. Pelvic fractures happen in patients with blunt multiple trauma in 10–20% of cases and represent a significant source of morbidity and mortality [2–5]. The pelvis as a central part of the skeleton possesses exceptional inherent strength because of its strong ligaments and bony structures. Major forces are required to disrupt the normal pelvic ring. In this light, pelvic ring disruption—more than any other fracture of a bone structure of the body—can lead to severe complications. Exsanguinating hemorrhage represents the most dreaded acute complication of pelvic fractures due to the proximity of the iliac vascular system to the pelvic ring. The pelvis also protects several organs that may be injured due to fracture displacement. Neurological injury to the lumbosacral plexus or sciatic nerve may lead to complications that significantly increase the total trauma impact of the multiply injured patient with a pelvic injury. The unstable, untreated pelvis enforces immobility and does not allow appropriate nursing care of those patients with chest and brain injuries, which further complicates their care.

The importance of the pelvic fracture varies with its severity, both in terms of how severely the patient is otherwise injured and how much compromise is caused by the fracture itself. In general, pelvic disruption with sacrogluteal arch (posterior) displacement presents a more serious problem, both for patient management and pelvic fracture care. The mortality rate approximates 50% if the fracture is open or associated with major vessel injury [6, 7].

Interestingly, in the multiply injured patient with an associated pelvic fracture, the outcome is more related to associated organ injuries and complications rather than the pelvic fracture. Poole et al [8, 9] found more deaths in those patients owing to head injury or nonpelvic hemorrhage. The pelvic fracture was responsible for only one-seventh of the deaths. Similar results are reported by various groups [10–15] with pelvic injury-related mortality between 7% and 18% in multiply injured patients. Studies from our own group revealed that parameters predicting mortality were age, ISS, and the existence of severe hemorrhage rather than the type of pelvic ring injury or the APACHE II score at admission [16]. Although this may be surprising, it is clear that the severity of pelvic ring disruption reflects the total trauma impact, as well as contributes to severity of hemorrhage.

Most treatment concepts previously reported have focused on isolated pelvic ring disruption. They are widely accepted and include a rapid evaluation, identification, and control of the source of major blood loss, as well as reduction and primary fixation of the pelvis. Because additional injuries require a more variable scheme of diagnostic and therapeutic approaches, the order of emergent treatments, the procedures of bleeding control, and the time point of pelvic fixation in multiply injured patients are different, compared with the isolated pelvic ring injury. Therefore, the general diagnostic and treatment algorithm of the polytrauma patient are reviewed, and the interactions of pelvic fracture management with associated injuries are discussed.

2 General principles

The primary objective in the initial care of the multiply injured patient is survival with normal cognitive function. The understanding of the pathophysiological alterations occurring after severe injury is mandatory for a successful outcome ( Fig 1.4-2 ). The host reacts to a severe injury (the first hit) with a systemic host defense response, which represents the physiological response to tissue injury, hypotension, hypoxemia, pain, and stress (antigenic load). If the emergency treatment does not rapidly eliminate or at least significantly decreases the antigenic load, the host defense response converts to the host defense failure disease. Poorly planned surgical intervention in the acute treatment phase may also overload the host defense response and lead to a failure in host response (the second hit). This pathophysiological response of the host results in permanent morbidity or even death.

Therefore, rapid and adequate resuscitation and treatment of life-threatening injuries with thoughtful surgical intervention, if necessary, has the highest priority over precise reconstruction of fractures [1, 16]. The stepwise approach and the close interaction between diagnostic and emergency procedures to save the patient′s life depend predominantly on the structure and the experience of the emergency team. This can be successfully achieved with a trauma leader who is experienced in both trauma and orthopedic surgery or a multidisciplinary approach with the presence of the attending trauma or orthopedic surgeon, along with anyone else deemed necessary by the trauma team leader, in the emergency department [17]. The evolution of a multidisciplinary pathway coordinating the resources of a level 1 trauma center and directed by joint decision making between trauma surgeons and other subspecialty traumatologists has resulted in significantly improved patient survival [17]. It is recommended that the involved specialties establish a sitespecific protocol for the acute management of a patient with a pelvic ring disruption along with other injuries.

The first hour (golden hour) after admission to the emergency department is most critical in terms of survival and reduction of morbidity. The planned treatment protocol for multiply injured patients is important but must allow a flexible approach in the presence of specific injuries. Multiply injured patients must have simultaneous immediate evaluation of their vital organ functions and resuscitation, the use of focused rapid diagnostic procedures, and appropriate surgical treatment, including damage control followed by stabilization of their vital organ functions in the intensive care unit (ICU), which occurs following the acute resuscitation phase [1].

The trimodal pattern of mortality in the multiply injured patient clearly indicates the importance of emergency treatment of exsanguination and severe head injury during the first 24 hours. After admission, isolated or multiple organ failure become responsible for the late mortality ( Fig 1.4-1 ). Based on these data, the fundamental objectives of the primary treatment are rapid recognition and control of severe hemorrhage as well as the acute evacuation of intracranial hematoma. ln this light, a stepwise algorithm, including diagnostic and therapeutic procedures to maximize vital organ functions while rapidly diagnosing life-threatening injuries in the shortest time possible has been developed ( Fig 1.4-3 ) [1, 16]. In the case of acute circulatory and/or pulmonary failure, the diagnostic procedures have to be stopped immediately and the patient transported to the operating room for damage control, which includes decompression of body cavities as well as control of hemorrhage and contamination.

2.1 Principles of resuscitation

Resuscitation of the multiply injured patient starts at the accident scene. Early intubation, aggressive fluid replacement, and rapid transport to an appropriate hospital are mandatory ( Fig 1.4-4 ). After admission to the emergency department, simultaneous resuscitation that combines restoration and maintenance of vital functions with damage-control procedures rather than sequential care is the hallmark of a proper trauma system. Many algorithms have been published recently, but the best is that of the American College of Surgeons’ Advanced Trauma Life Support (ATLS) program [18].

2.1.1 Primary survey

Ideally, the trauma team consists of a trauma leader experienced in all injury patterns, or a trauma surgeon, orthopedic surgeon, anesthesiologist, two nurses, and any other subspecialist required by the trauma team leader. The primary survey should take 3–5 minutes. In multiply injured patients with signs of torrential hemorrhage or absence of viral signs, resuscitation has to be carried out simultaneously with the primary survey ( Fig 1.4-5 ).

Airway and breathing

A patent airway is the most urgent priority, and the respiratory system must be assessed from the lips to the alveoli. First, the patency of upper airway must be determined from the lips to the larynx. The patient′s upper airway can be most expeditiously cleared by a jaw thrust or chin lift. The mouth should be inspected for foreign bodies or vomitus, suction applied and foreign bodies removed. At this point, it is important to stress that excessive movement of the cervical spine should be avoided because as many as 15% of unresponsive patients may have an unstable cervical spine injury. The lower respiratory system is assessed next by exposing the chest and checking the adequacy of ventilation. Adequate air entry and exchange must be ensured.

The chest must be palpated meticulously to identify lesions such as fractured ribs, fractured sternum, flail segments, or costochondral separations. Fractured ribs in a patient who is ventilated or requires ventilation are an indication for a chest tube. If chest tubes are already in place, one must be sure that they are functioning and that there are no technical problems, such as an inadequate seal or a tube fenestration outside the chest.

Cardiovascular system

In most multiply injured patients, hypovolemic shock resulting from bleeding is the most common cause of circulatory collapse. Assessment, including vital signs, is performed clinically and simultaneously. The quality of the carotid, femoral, and peripheral pulses, together with tissue perfusion assessed by capillary refill and pulse oximetry are performed. Obvious external sites of bleeding are controlled by direct pressure. The judicious use of tourniquets to control severe extremity hemorrhage may be considered [19].

The key problem in young patients with multiple injuries is their ability to tolerate > 30% loss of their blood volume without obvious signs of hemorrhage such as significant hypotension and tachycardia. Moreover, if the interval between the time of injury and the admission to the emergency department is short, the decrease of hemoglobin and hematocrit level does not correlate with the true blood loss [18]. This can lead to underestimation of the real hemodynamic status of the patient with fatal consequences. The rapid detection of the so-called “hidden shock” can be achieved easily by using blood gas analysis and assessing either the base deficit or blood lactate levels. Studies [20–23] of critically ill and severely injured patients suggest that the ability to maintain lactate at normal levels correlates with the true state of hypovolemia and consequently with the probability of survival. Pathophysiologically, lactate production is increased as pyruvate oxidation decreases during tissue hypoxia. The amount of lactate produced is believed to correlate with the total oxygen debt, which is dependent on the magnitude of hypoperfusion and severity of hemorrhagic shock [22]. Therefore, blood lactate levels seem to better correlate with hypovolemia-induced tissue perfusion changes and local oxygen debt than hemoglobin and hematocrit levels [24]. As well as blood lactate or base deficit, physical examination of the pelvic area and in particular the perineal area looking for rapid expanding hemorrhage or scrotal or labial hematomas are clues that there is a major pelvic disruption and ongoing blood loss.

Central nervous system

Rapid neurological assessment is carried out at this stage, including assessment of pupillary reaction and determination of the Glasgow Coma Scale (GCS) [25]. A more detailed neurological assessment is contraindicated at this stage. The GCS obtained in the emergency department must be compared with those values registered at the scene and during transport of the patient, if there is suspicion of intracranial lesions, rapid computed tomography (CT) is mandatory, especially in the presence of unequal pupillary reactions between both eyes with a hemodynamically stable patient.

Exposure

The primary survey should include a complete exposure of the patient by cutting off clothes in a standard pattern on the patient′s arrival.

2.1.2 Acute resuscitation

The resuscitation period should take 10–15 minutes, or significantly less depending on the urgency of the situation ( Fig 1.4-5 ). Although the treatment options are described in a sequential fashion, as far as possible these maneuvers should be carried out simultaneously.

Airway

Impaired pulmonary gas exchange through severe chest injury and circulatory shock results in decreased oxygen delivery to injured organs, aggravates the hypoxic tissue damage, induces the release of cytokines with a subsequent activation of macrophages and neutrophils, precipitates pulmonary and systemic microvascular alterations, and leads to the development of multiple organ failure. Acute respiratory distress syndrome is frequently the precursor of multiple organ dysfunction syndrome, suggesting that altered pulmonary function has a key role in subsequent organ failure. In the presence of a severe head injury, persistent, untreated hypoxemia and/or hypotension are responsible for secondary brain damage with high mortality ( Table 1.4-1 ) [26, 27].

Table 1.4-1 Influence of systemic hypotension on the outcome after severe traumatic brain injury.

	N	Death or vegetative state (GOS* 1–2), %	Favorable outcome (GOS* 4–5), %
No hypotension	307	17	64
Early hypotension (from injury through resuscitation)†	248	55	40
Late hypotension (in the intensive care unit)†	117	66	20
Early and late hypotension†	39	77	15
* GOS stands for Glasgow Outcome Score. † Systemic blood pressure < 90 mm Hg. (Source: Chesnut RM, Marshall SB, Piek J. et al. Early and late systemic hypotension as a frequent and fundamental source of cerebral ischemia following severe brain injury in the Traumatic Coma Data Bank. Acta Neurochir Suppl (Wien). 1993;59:121–125.)

Most upper airway problems can be managed in the primary survey phase. Endotracheal intubation is warranted in most multiply injured patients. There are three essential indications: (1) impairment of pulmonary gas exchange and/or respiratory mechanics; (2) presence of hypovolemic shock; and (3) presence of central nervous system disorders associated with severely altered airway reflexes. In addition, early intubation reduces stress and allows adequate analgesia. In the presence of a potentially unstable cervical spine, nasotracheal intubation is the safest way to secure the airway because there is less need to position the head and cervical spine. Obviously, a degree of expertise is essential before attempting this method, and this can best be gained by the use of an intubation mannequin. In about 1% of patients, surgical control of the airway is necessary. The recommended method is cricothyrotomy because it is the simplest and surest way to secure an airway surgically. Tracheostomy should be deferred to more elective circumstances.

As far as the lower airway is concerned, 90% of blunt chest trauma can be managed with chest tubes. They are indicated whenever there is a reasonable suspicion of the presence of air or blood in the pleural space. Using a scalpel, a Kelly forceps, and the finger, a single large-bore (32–36 French) chest tube should be inserted into the fourth or fifth interspace in the midaxillary line. Trocars for insertion of chest tubes are contraindicated because they are dangerous. The chest tube should be connected to underwater drainage and the drainage monitored. Immediate drainage of 1,000 mL, a total drainage exceeding 1,500 mL, or more than 250–300 mL/h of blood for 4 hours are all indications for thoracotomy to control bleeding. Continuous bubbling or failure of the lung to expand may indicate a bronchopleural fistula that requires surgical repair.

Cardiovascular system

The first step in managing hypovolemia, the most common cause of shock in the trauma patient, is the insertion of at least two large-bore needles for intravenous infusions (ie, 16-gauge or larger). They should be placed distally, one above and one below the diaphragm, and not in a limb with a proximal fracture. Failure to achieve percutaneous insertion after two attempts should lead to a venous cutdown at both ankles or central access. Initially, a combination of crystalloid and colloid solutions with a ratio of 3:1 in favor of crystalloids should be run at the maximum capacity of the intravenous line [28]. Hypovolemic shock should not be treated by vasopressors or sodium bicarbonate.

In the presence of severe or even heavy hemorrhage, universal donor blood should be used immediately. Type-specific blood may be used if available; beyond that, crossmatched blood may be given. Each center must develop a massive transfusion protocol such as 2–3 units of fresh frozen plasma and 7–8 units of platelets for every 5 L of volume replacement the patient receives. The coagulation status of the patient must be monitored, including the partial thromboplastin time, prothrombin time, platelet count, and tests for fibrin-split products. Intravenous fluids should be warmed through appropriate devices to avoid hypothermia. Continuing acidosis documented through a persistent elevation of lactate levels represents inadequate fluid replacement and persisting cellular hypoxia and should be treated as such.

Simultaneously, blood samples should be drawn for appropriate tests, including cross-matching for a minimum of 6 units of blood, hemoglobin, hematocrit, white cell count, blood glucose, urea nitrogen, and serum electrolytes. Preferably, tests should also include serum creatinine level and arterial blood gases, the latter being an invaluable aid for initially assessing the degree and longevity of shock, and subsequently monitoring the patient.

Cardiogenic shock in injured patients is either caused by cardiac tamponade, compression of the pericardium from tension pneumothorax, or cardiac contusion with extended myocardial infarction. If the origin of pump failure is a tension pneumothorax or cardiac tamponade, tube thoracostomy or pericardiocentesis should be carried out immediately. Administration of drugs with positive inotropic action may be effective in the case of myocardial contusion with significant reduction in blood pressure.

Spinal shock occurs in injured patients with a fracture of the spine and compression or disruption of the spinal cord. In the management of injured patients with spinal shock, in which significant blood loss into the areas of injury surrounding the cord is often found, a balanced therapy of fluid administration and vasopressors is recommended.

2.1.3 Diagnostics and secondary survey

At this point a systemic review of all vital systems should be done ( Fig 1.4-3 , Fig 1.4-5 ). The diagnostic algorithm is always performed simultaneously with ATLS rather than sequentially. However, each diagnostic procedure and especially procedures that need transport of the multiple-injured patient have to be carefully evaluated with regard to the vital functions of such a patient.

The diagnostic algorithm ( Table 1.4-2 ) for a multiply injured patient is divided into primary and secondary diagnostic procedures. Although primary diagnostic procedures can be rapidly performed in the emergency department within minutes, for secondary diagnostic procedures the patient has to normally be transported to specific areas within the hospital. Additionally, those procedures are time-consuming and do not allow quick access to surgery in a life-threatening failure of vital organ functions.

Table 1.4-2 Primary and secondary diagnostic procedures.

Primary procedures	Secondary procedures
Mandatory Physical examination Blood gas analysis (lactate, base deficit) Ultrasound Chest and pelvis x-ray Computed tomography of the head, if high suspicion for compressive lesion	Computed tomography (with contrast) Angiography
Dependent on specific injuries Electrocardiogram Transesophageal echocardiography Retrograde urethrogram

The importance of blood gas analysis for evaluation of hemorrhagic shock has been described in section 2.1.

Chest x-ray is performed to detect hemoperitoneum, hemothorax, and hemopericardium. For detection of abdominal free fluid, ultrasound of the abdomen is recommended. Diagnostic peritoneal lavage (DPL) is still used in some centers for this indication, although ultrasound has become the standard test in expert hands. Due to obesity or subcutaneous emphysema, DPL may be helpful to detect blood in the peritoneal cavity. In case of free abdominal fluid (> 500 mL) and stable hemodynamics, a CT of the chest, abdomen, and pelvis is recommended. Clues, such as anterior rib fractures or sternal injuries, are potential indicators of myocardium contusion. If so, an electrocardiogram should be performed. An area of contused myocardium can compromise cardiac function. Myocardial contusion is a relatively common yet often unrecognized complication in trauma.

In the presence of significant hemoperitoneum (> 1,000 mL) on ultrasound examination and hemodynamic instability, it is recommended to transfer the patient immediately to the operating room for abdominal exploration and bleeding control. It is important at this stage that a surgeon knowledgeable in pelvic fracture assessment is available, as urgent application of external fixation or pelvic packing may be indicated.

Clinical examination and anteroposterior pelvic x-ray are used to determine whether the patient has an unstable bony pelvic injury. It is important to emphasize that the pelvic x-ray obtained in the emergency department often does not allow precise evaluation of posterior ring injury except in the presence of gross displacement. If confirmed, the pelvic volume is closed by a circumferential pelvic compression device applied around the pelvis at the level of the greater trochanters, along with taping the slightly flexed knees and ankles together with the lower extremities internally rotated. There are several commercially available compression devices but the use of a folded bed sheet is also just as effective ( Fig 1.4-6 , Fig 1.4-7 ). If posterior and/or vertical displacement is recognized, 9–13 kg of skeletal traction through a femoral traction pin is extremely helpful.

The single most reassuring sight for the trauma leader is copious amounts of clear urine. Under such circumstances, one feels that “urine is gold.” Importantly, a lower urinary tract injury must be ruled out before passing a urinary catheter. If there is any blood at the urethral meatus following milking of the urethra in men, a retrograde urethrogram is warranted. An urethrogram is also indicated if there is a high-floating prostate upon rectal examination, perineal hematoma, or an unstable pelvic fracture. If time does not permit these maneuvers, catheterization should be deferred and central venous pressure (CVP) used to monitor cardiac output. With pelvic fractures, there is a 13% incidence of bladder or urethral injury. In women, bladder injury is more frequent, whereas in men urethral injury—usually of the membranous urethra—is more common. As far as the upper urinary tract is concerned, the presence of hematuria is an indication for CT scan of the kidneys (see Chapter 1.13).

A CT scan and angiography represent the gold standard for diagnosis of organ injuries and arterial bleeding, respectively. Interventional angiography also can be used for bleeding control. Despite major advances in technology with the introduction of spiral CT and angiography, the patient has to be transferred to the radiology department in most hospitals. A CT scan is used if there is suspicion of head, chest, abdominal, and/or pelvic injury. With the possibility of spiral CT technology, a rapid examination of all body cavities in less than 40 seconds can be achieved. Moreover, an evaluation of grossly displaced spine and extremity fractures, especially articular injuries, is possible.

Recently the diagnostic value of contrast-enhanced CT in localizing arterial bleeding has been demonstrated [29]. Contrast found in the gluteal region usually means superior gluteal arterial bleeding ( Fig 1.4-8 ), whereas contrast in the obturator area indicates obturator artery bleeding. Therefore, the simple addition of contrast to the CT protocol significantly alerts the clinician to the presence of pelvic arterial bleeding that, in turn, may lead to earlier intervention such as embolization. The routine use of arterial angiography for either diagnostic and/or the therapeutic purpose of hemorrhage control is controversial because < 10% of all bleeding sources is generated from injury of named pelvic arteries but rather caused by bleeding from the pelvic venous plexus or cancellous bone. It can be helpful to use angiography if ultrasound and/or CT does not reveal free fluid or does not allow localization of the bleeding source, but the patient requires ongoing blood transfusion. Note that a patient with signs of severe hemorrhagic shock should not be transported for any diagnostic procedure.

3 Principles of damage control

Damage control is a term coined by Rotondo et al in 1993 and has been most often used for devastating abdominal injury [30]. By using this philosophy, only major injuries resulting in significant blood loss are addressed at the time of initial laparotomy. Intestinal injuries are stapled, and packing is often used as an adjunct for hemostasis. The patient is then immediately transferred to the ICU for rewarming, monitoring, and ongoing resuscitation. Generally 24–48 hours later, when the patient is adequately resuscitated, euthermic, and has a normal coagulation profile, he or she is taken back to the operating room and unpacked. Gastrointestinal reconstruction can be performed at that time. This principle of care can be used for injuries outside of the abdomen as well. Applying this concept to the multiply injured patient with a pelvic injury and severe hemorrhage, acute stabilization of the pelvic ring by external means and longitudinal traction should be done to minimize the operative time and to prevent heat and blood loss ( Table 1.4-3 ). Following this, the patient should then be taken to the ICU. Once resuscitated, he or she is returned to the operating room for more elective, definitive fracture fixation.

Resuscitative thoracotomy has become an established treatment for patients with acute cardiopulmonary arrest after severe injury. It should be performed only in trauma patients with absent vital signs either at the moment of admission or when in proximity to the hospital under rapid transportation. The knowledge of the mechanism of trauma and signs of major injuries may help to decide the right course of action. The best survival rates are seen in penetrating trauma, whereas the outcome in patients with blunt trauma is still disappointing.

3.1 Decompression of body cavities

3.1.1 Tension pneumothorax

The presence of a tension pneumothorax should already have been recognized during the primary survey and must be immediately decompressed.

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1.2 Biomechanics and methods of internal fixation 1.1 Anatomy of the pelvic ring 1.3 Pathoanatomy, mechanisms of injury, and classification 1.5 Defining the injury: assessment and principles of management of pelvic ring fractures 1.8.5 Internal fixation of lateral compression fractures (type B2) 2.23 Results of treatment for fractures of the acetabulum

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