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A18. Critical care of polytrauma victims

Polytrauma is most simply defined as the presence of multiple injuries when the effects of these injuries are multiplied and more complicated to treat than the sum of the isolated injuries. It's an epidemic, and it’s the leading cause of death for people under 40. Shock, SIRS, and MODS can occur. Often, saving all the functions of the victim is impossible and so compromises must be made. It’s important to keep in mind the saying “life before limb”, meaning that one should amputate a limb if it could save the life.

Pre-hospital care

The goal of pre-hospital care is to stabilise the patient sufficiently for the transport to the hospital.

ABCs are the priority on scene, after ensuring the safety of the environment first. The patient should be stabilised with pain management and fluid resuscitation if needed. It’s important to not give fluids too aggressively, as that will cause haemodilution, which dilutes the clotting factors, predisposing to more bleeding. Hypothermia should be prevented. Pain management decreases O2 demand of the body.

During transport, it’s essential that the patient is adequately fixated to prevent secondary injury, especially of the cervical spine. Fixation can be accomplished with boards, splints, cervical collar, etc.

Hospital care

In hospital, the ABCs are repeated immediately to further stabilise the patient for surgery. The patient should be intubated if there are indications for it. Give blood products if the blood loss is severe (> 30%). eFAST to check for internal bleeding. CT if the patient is stable enough for it. Administration of O2 is esssential.

When the patient is stable enough, they’re taken to the operating room, where the first priority of the trauma surgeons is to treat life-threatening injuries, most notably intracranial, intrathoracic, or intraabdominal bleedings. This is the first operative phase, during which only those injuries which make stabilisation of the patient’s vitals impossible should be treated. Surgical treatment of less urgent injuries, like injuries threatening a limb, occurs later.

Following this, the first stabilising phase starts, in which one uses stabilising measures and monitoring to stabilise the patient’s vitals, including urine output, acid-base status, gas exchange, and blood volume.

After only a few hours of stabilising, the second operative phase starts. Here, potential life-threatening injuries, injuries that may threaten a limb, and other injuries which make care of the patient difficult, must be treated. One should not attempt to save a limb if it may risk the patient’s life.

Then, the second stabilising phase starts, where similar goals as the first stabilising phase are important. This phase ends when the patient no longer requires organ support and intensive therapy. The patient continuously monitored in the ICU for late-onset complications like sepsis, SIRS, or MODS.

After the patient no longer requires intensive care, the third operative phase starts, where non-life threatening injuries are treated.

Damage control surgery

When possible, polytrauma patients should have definitive surgery (surgery aimed to permanently fix the problem) as early as possible as this improves survival. However, on the other hand, prolonged surgery on haemodynamically and vitally unstable patients decreases survival. For these patients, damage control surgery is the alternative.

Damage control surgery refers to surgery which is necessary to stabilise (but not definitively treat) life-threatening conditions in the acute phase of polytrauma. In case of severe fractures, for example, this could be to fixate the fractures with minimally invasive external frames as a temporary solution until the patient is more stable for definitive fracture fixation after the patient has stabilised, usually a few days later. The core principles of damage control surgery are:

  • Control the source of bleeding as early as possible
  • Treatment of coagulopathy
  • Acidosis prevention/correction
  • Hypothermia prevention/treatment
  • Cause minimal iatrogenic injury (haemodilution by administering too much fluid)

Damage control surgery is indicated in:

  • Pelvic and long bone fractures which cause haemodynamic instability
  • Compartment syndrome
  • Large soft tissue defects
  • Occipito-cervical dissociation
  • Ustable spinal fracture
  • Penetrating injury of the chest or abdomen

Damage control resuscitation

Polytrauma patients are prone to developing trauma-induced coagulopathy (TIC), which worsens haemorrhage, something polytrauma patients are usually already at risk of. Damage control resuscitation refers to those actions aimed at achieving haemostasis early and rapidly, to prevent TIC. Damage control resuscitation involves:

  • Massive transfusion protocol (in which one transfuses 10 units of packed RBCs, platelets, and fresh frozen plasma in a 1:1:1 ratio)
  • Permissive hypotension (maintaining systolic BP < 90 mmHg to decrease bleeding)
  • Tranexamic acid

Indications for damage control resuscitation include sign of haemorrhagic shock and positive eFAST.