Definition of Polytrauma

Within the field of rehabilitation medicine, polytrauma has been defined as “two or more injuries, one of which may be life threatening, sustained in the same incident that affect multiple body parts or organ systems and result in physical, cognitive, psychological, or psychosocial impairments and functional disability.” Given the nature of the exposure (motor vehicle collision, blast, fall, blunt trauma, assault, etc.) it is likely that traumatic brain injury (TBI) occurred and in severe cases could dictate the entire course of rehabilitation. Thus, there has been increased focus on intracranial injuries as part of polytrauma. Other conditions commonly seen as part of polytrauma include amputations, wounds, spinal cord and musculoskeletal injuries, burns, acute and chronic pain (general prevalence of 81.5% in Iraq and Afghanistan veterans), auditory or visual impairments, post-traumatic stress disorder (general prevalence of 68.2% in Iraq and Afghanistan veterans), and other mental health diagnoses. Because of the heterogeneity of injuries and potential causes, it is difficult to estimate the true incidence of polytrauma. However, both military and civilian settings TBI tracking systems have been established and for the former, the US Department of Defense (DoD) has found that over 370,000 TBI of different severities have been diagnosed since the year 2000. Many of the individuals who sustained a TBI will have other associated traumatic injuries, so a better understanding of the incidence and prevalence of polytrauma will continue to emerge.

TBI is a heterogeneous condition spanning from experiencing a brief episode of confusion after external trauma all the way to catastrophic injury and death (see Chapter 148 , Chapter 163 ). Table 146.1 demonstrates the formal definitions of TBI based on 2016 VA/DoD Clinical Practice Guidelines; however, it is important to note that these definitions relate to immediate metrics (such as duration of loss of consciousness) and are not representative of current level of function. Should the patient meet criteria in more than one category of severity, the higher severity level is assigned.

History of Polytrauma System of Care

Coordinated national trauma care systems are quite rare, with only nine documented systems existing in high-income countries. Military trauma care in the United States has been greatly accelerated in the past decade, producing efforts to establish a national trauma care system pairing military and civilian organizations to develop common best practices, data standards, research, and workflow across the continuum.

As service members began returning from the war in the early 2000s, it became apparent that a comprehensive rehabilitation system would be needed to ensure these individuals were returned to their maximum level of function and quality of life. These patients presented with complex medical, rehabilitation, and psychosocial needs that proved challenging to meet in the existing DoD and VA rehabilitation system. Legislation enacted in 2004 directed the Veterans Health Administration (VHA) to establish a continuum of care centered around TBI and other conditions associated with war exposures including extremity injuries/amputations, vision loss, and psychological conditions. This collectively became known as the Polytrauma System of Care (PSoC) in 2005, composed of 5 inpatient rehabilitation centers (Polytrauma Rehabilitation Center or PRC), 5 transitional rehabilitation centers (Polytrauma Transitional Rehabilitation Program), 23 specialty outpatient clinics (Polytrauma Network Sites), 87 support outpatient clinics (Polytrauma Support Clinic Team), and 39 designated contacts for referral to care (Polytrauma Points of Contact) ( Fig. 146.1 ). The PSoC has been integrated across all VHA Medical Centers and has come to function as a hub for research, training, resources, and sharing of best practices.

Distribution of Veterans Health Administration polytrauma/traumatic brain injury system of care centers.

Image Courtesy of the Department of Veterans Affairs. Polytrauma facilities. 2017. https://www.polytrauma.va.gov/system-of-care/care-facilities/ .

The PSoC is the only published national system centered upon rehabilitation of polytrauma injuries with inpatient, transitional, and outpatient integration to provide long-term care for these individuals. Notably, Canada set out to create “The Canadian Forces Physical Rehabilitation Program” in 2008, also focusing on injuries sustained during the Afghanistan war through a hybrid civilian-military rehabilitation model.