2.9.1 Introduction

Trauma is the fourth most common cause of death for all age groups and the most common cause of death for young adults. Polytrauma is the subgroup of injured patients who have sustained injuries to at least two of the following six-body regions:

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  head, neck, and cervical spine

  
  
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  face

  
  
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  chest including thoracic spine

  
  
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  abdomen including lumbar spine

  
  
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  limbs including bony pelvis

  
  
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  skin

The cumulative severity of this trauma load on the patient’s anatomy and physiology is often expressed as an injury severity score (ISS) of 16 or above and represents 15–20% of the overall trauma population. The ISS is calculated from the degree of injury severity to the three most severely injured body regions. Polytrauma patients have significantly greater mortality and morbidity and require complex multidiscipline medical management, prolonged hospitalization, rehabilitation, and recovery periods. The social and economical implications for the patient, his/her family, and society in general, are immense.

The pathway of clinical interventions of patients with multiple injuries is complex and involves input from a variety of medical disciplines. The different steps of the pathway are as follows: initial management at the scene of the injury and transport to a medical facility, resuscitation room, diagnostics (radiological investigations), operating room, intensive care unit, ward care, in-hospital rehabilitation, and discharge home (Fig 2.9-1). The clinical management of the patient, however, continues even after hospital discharge as many patients require additional rehabilitation and further reconstructive procedures involving considerable input for a substantial period. The clinical input and the decision-making process in each step of this pathway can be critical for minimizing long-term morbidity and mortality.

2.9.2 Initial assessment—resuscitation room

The prehospital care of the multiple-injury patient is outside the scope of this chapter and varies considerably from country to country. Once in hospital, the initial assessment of the injured patient must have a stepwise approach with planned diagnostic and operative tactics to avoid mistakes that could affect the patient’s prognosis. The clinical course of the patient can change rapidly and management plans must be adapted accordingly.

The advanced trauma life support (ATLS) course has had a great impact on providing a common language for all who care for the injured patient. It has established an organized and systematic approach for the evaluation and treatment of patients and has had a positive influence on the care provided worldwide. Details of the ATLS protocol are not presented here, but to summarize it comprises a primary survey to rapidly diagnose and treat immediate life-threatening conditions, followed by a careful secondary survey to ensure all of the patient’s injuries are identified and subsequently treated.

2.9.3 Immediate life-threatening conditions of the multiple-injury patient

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  Airway obstruction or injury and asphyxia (eg, laryngeal trauma)

  
  
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  Tension pneumothorax or hemothorax

  
  
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  Open thoracic injury and flail chest

  
  
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  Cardiac tamponade

  
  
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  Massive internal or external hemorrhage

The routine of A (airway with cervical spine control), B (breathing), C (circulation), D (disability, a brief neurological assessment), and E (exposure of whole patient) is designed to assess and treat any life-threatening conditions, and to avoid obvious or dramatic but less dangerous secondary lesions distracting the resuscitation team from identifying hidden but immediately life-threatening problems.

Once life-threatening problems are diagnosed and treated, a full systematic head-to-toe “secondary survey” of the patient’s condition must be undertaken. This may need to be delayed until after initial surgery has been performed and the patient is stable, but it should never be omitted. Comparatively minor injuries, if missed, may receive suboptimal treatment causing long-term loss of function and considerable morbidity.

The tertiary survey consists of a repeated head-to-toe evaluation of the patient and provides another opportunity to evaluate any newly discovered physical findings and diagnose any missed injuries. It also involves daily laboratory data and new radiological examinations in the form of plain x-rays, computed tomography (CT), or magnetic resonance imaging (MRI) with a low threshold for imaging any unexplained or suspicious clinical signs. Repeated thorough physical examination is vital and contributes favorably to the patient’s long-term outcome.