Polytrauma Care
Milton T. M. Little, MD, FAAOS, FAOA
Geoffrey S. Marecek, MD, FAAOS, FAOA
Dr. Little or an immediate family member serves as a paid consultant to or is an employee of DePuy, a Johnson & Johnson Company and Globus Medical. Dr. Marecek or an immediate family member has received royalties from Globus Medical; serves as a paid consultant to or is an employee of BoneSupport AB, Globus Medical, NuVasive, restor3d, Smith & Nephew, Stryker, Synthes, and Zimmer; has stock or stock options held in restor3d; and serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma Association and the Western Orthopaedic Association.
ABSTRACT
Patients with polytrauma are uniquely challenging and require orthopaedic surgeons to interact with general surgeons, neurosurgeons, and other specialists to provide timely and effective treatment. Surgeons play an important role in the evaluation, resuscitation, and early treatment of these patients. It is necessary to understand the pathophysiology of trauma and how different injuries affect the timing and extent of interventions. The concepts of damage-control orthopaedics and early appropriate care have evolved to provide a framework for delivering timely and potentially lifesaving care to these patients.
Keywords: damage control; femur fracture; pelvic fracture; polytrauma; resuscitation
Introduction
All orthopaedic surgeons should be familiar with treatment of patients with polytrauma. This is the rare opportunity where direct action (or inaction) can affect a patient’s survival. Understanding Advanced Trauma Life Support principles is an essential first step in evaluating patients and managing the early stages of care. Surgeons must understand patient resuscitation and the specific interventions that aid in resuscitation. Familiarity with the management of nonorthopaedic injuries and their effect on the timing of orthopaedic care is important because it will help the surgeon determine when to employ early appropriate care or damage-control orthopaedics (DCO). These concepts have expanded how physicians think about care of the polytrauma patient and expedited care for patients with pelvic, acetabular, spine, and femoral fractures.
Initial Assessment and Management
The initial management of the patient with polytrauma uses a team-based approach and the Advanced Trauma Life Support manual’s principles of a primary, secondary, and tertiary survey for a systematic assessment of the patient.1,2,3,4 The primary survey identifies immediate life-threatening injuries that require life-sustaining interventions. The secondary survey identifies additional injuries that may cause disability, blood loss, or affect hemodynamic stability.3 The tertiary survey is critical to finding additional injuries once the patient’s mental status has improved and distracting injuries have been stabilized.5 This systematic approach is essential to avoid missing potentially significant injuries at every step of the survey.
Primary Survey
The primary survey uses the ABCDEs (airway, breathing, circulation, disability, exposure), a stepwise algorithm to systematically assess the patient to prevent a fatal outcome. This assessment occurs simultaneously with resuscitation described in the next paragraphs.
Airway
Confirmation of a patent airway is critical to appropriate patient oxygenation. Patients must be immediately assessed for airway obstruction or inability to maintain their airway (ie, intoxication, head injury, waning consciousness, facial trauma) in the field and upon arrival to the trauma bay.3,4 If concerns arise regarding airway protection, the patient should be intubated immediately, and mechanical ventilation should be initiated. Cervical
precautions should be maintained, and a team approach to intubation should be performed.3,6 The Glasgow Coma Scale (GCS) provides a compressive assessment of patient consciousness7 (Table 1). Patients with a GCS score of 8 or lower should be intubated immediately.
precautions should be maintained, and a team approach to intubation should be performed.3,6 The Glasgow Coma Scale (GCS) provides a compressive assessment of patient consciousness7 (Table 1). Patients with a GCS score of 8 or lower should be intubated immediately.
Table 1 Glasgow Coma Scale | ||||||||||||||||||||||||||||||||||||
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Breathing
The trauma team must confirm appropriate lung oxygenation by assessing bilateral breath sounds with or without intubation. All patients should receive supplemental oxygen and pulse oximetry to monitor oxygen saturation.4 Chest injuries (ie, tension pneumothorax, simple/open pneumothorax, and pulmonary contusions) may prevent appropriate ventilation.8 During the primary survey, an AP chest radiograph can identify these injuries, whereas occult injuries may be identified later with CT of the chest, abdomen, and pelvis in stable patients.
Circulation
Blood pressure and heart rate are criteria used to assess shock in patients with polytrauma9 (Table 2). Systolic blood pressures should be maintained above 90 mm Hg, and inability to do so is commonly due to decreased blood volume or hypovolemic shock2,3,4,6 (Table 3). Two critical steps are necessary to maintain appropriate circulation: identification of and stopping the cause of the hypotension and rapid volume replacement. When necessary, blood products should be used for resuscitation at a 1:1:1 ratio for red blood cells, fresh-frozen plasma, and platelets to prevent dilutional hypocoagulability.2,10 Fluid should be warmed or administered in a warming device to prevent hypothermia because core hypothermia <35°C is an independent predictor of mortality.2
Table 2 Borderline Patient Criteria for Borderline Trauma | ||||||||||||||||||||||||
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Circulatory compromise can occur as a result of decreased blood volume or inadequate cardiac output.4 Five potential sources of major bleeding are large skin lesions, chest injuries, abdominal injuries, pelvic fractures, and additional lower extremity fractures.2 Chest injuries and blunt abdominal trauma are common sources of exsanguination and mortality.8,11,12 A plain AP radiograph of the pelvis can identify severe vertical shear or volume-expanding anteroposterior compression injuries (68% sensitive for all fractures).2,4,13
Stabilization of these injuries can be accomplished with internal rotation of the lower extremities, circumferential sheeting, or pelvic binder application during the primary survey.3,13,14,15,16 Femoral fractures, multiple open fractures, or mangled extremities are sources of significant bleeding, and unrecognized blood loss may lead to underestimates in the patient’s resuscitation needs.2,17
Stabilization of these injuries can be accomplished with internal rotation of the lower extremities, circumferential sheeting, or pelvic binder application during the primary survey.3,13,14,15,16 Femoral fractures, multiple open fractures, or mangled extremities are sources of significant bleeding, and unrecognized blood loss may lead to underestimates in the patient’s resuscitation needs.2,17
Table 3 Hemorrhagic Shock Classification | ||||||||||||||||||||||||||||
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Simultaneous performance of a Focused Assessment with Sonography for Trauma, or FAST, examination can identify free abdominal fluid and/or organ injury and as little as 20 mL of fluid in the chest cavity.4,8,11 Hemodynamically unstable patients with a positive FAST examination should undergo emergent surgical exploration.3,4
Disability
Neurologic status is assessed with the GCS, which classifies a patient’s eye, motor, and verbal responsiveness and determines the patient’s level of dysfunction4,7,9 (Table 1). Patients with severe dysfunction or a GCS score of 3 to 8 should be intubated immediately because they are unable to protect their airway.3,4 Severe head injury is a major determinant of mortality in polytrauma patients and can increase mortality twofold to threefold.18 Neurologic injuries leading to neurogenic shock present as hypotension and bradycardia unresponsive to fluid resuscitation and may require vasopressors to maintain systolic blood pressure >90 mm Hg and cerebral perfusion.6
Exposure
The patient should be disrobed and examined from head to toe upon arrival to identify areas of trauma and possible sources of bleeding. Following thorough evaluation of all areas including the patient’s spine using logroll precautions, the patient should be covered with warm blankets immediately. Hypothermia can exacerbate coagulopathy by inactivating certain coagulation proteins.1,2,19 Avoiding the lethal triad of hypothermia, coagulopathy, and acidosis is essential to avoid devastating effects to the patient. Infusion of cold fluids/blood products, increased exposure, and surgical interventions can increase lactate production and cause metabolic acidosis.1,2,4,20
Secondary Survey
After the primary survey has been completed and the patient’s hemodynamic instability has begun to stabilize, the secondary survey should be performed. This includes the patient’s history and physical examination and a more thorough head-to-toe assessment of all body parts.4 Assessment of the spine with an accompanying motor/sensory and rectal examination for open injuries and tone should be performed. In hemodynamically stable patients, CT will provide additional information because it is more sensitive for assessment of intra-abdominal, chest, head, and spinal injuries.6,8,11
Tertiary Survey
The tertiary survey is performed 24 to 48 hours after the patient is stabilized and may identify missed injuries (present in approximately 10% of patients).5 Major risk factors for missed injuries are lower GCS, intensive care unit (ICU) admissions, and high Injury Severity Scores. Approximately 63% of missed injuries are discovered during admission after the first tertiary examination, but up to 15% are found after hospital discharge.5 Multiple tertiary surveys should be performed by the orthopaedic team because extremity injuries are the injuries most often missed.5,21
Resuscitation
The act of resuscitation is critically important in the early stages of polytrauma care. Many of these patients arrive in hypovolemic shock; it is necessary to both restore the patient’s oxygen delivery capacity and to stop ongoing bleeding from various sites. Employing alternative techniques (such as tranexamic acid [TXA], circumferential pelvic wrapping, interventional angiography, and use of the retrograde endovascular balloon occlusion of the aorta [REBOA]) can all help stop ongoing bleeding.
Historically, large-volume crystalloid resuscitation was the standard for patients in hemorrhagic shock, but it can cause acute traumatic coagulopathy and resuscitation-associated coagulopathy.1 More recently, reducing the volume of fluid administered in favor of blood products using a 1:1:1 ratio of plasma, platelets, and red blood cells has improved survival and reduced complication rates.10,22
Thromboelastography is a measure of the efficacy of coagulation. According to a 2020 study, thromboelastography-guided resuscitation has been shown to reduce mortality, the quantity of blood products given, and interventions for hemorrhage control.23 Prompt and effective resuscitation is important in avoiding acute respiratory distress syndrome (ARDS).24 Serum lactate has been proposed as a marker of the adequacy of resuscitation, particularly as it applies to the timing of surgical intervention.1,24
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