Management of the
Multiply-Injured Patient
Jomelle Gem E. Justiniani
Outline
Definition
Incidence, Epidemiology, Mortality
Trauma Scoring Systems
Pathophysiology and Immune Response
Initial Evaluation and Management
Radiologic Investigations
Standard Care for Treatment of Skeletal Injuries
Rehab
Take Home Points
Polytrauma
Subgroup of injured patients who
have sustained injuries to more than
one body region and organ with at
least one of the injuries being lifethreatening
Epidemiology
Occurs in 15-20% in overall trauma
population
MVA accounts for 37.9% of all cases
Falls account for 30.2%
Blunt trauma accounts for 86.2%
Penetrating trauma 11.1%
Burns 1.7%
Epidemiology
Risk Factors:
Alcohol use (BAC > 0.08%)
Failure to wear a seat belt
Failure to have an air bag
Failure to wear a helmet
Trauma Scores
Anatomic
AIS
ISS
Physiologic
TS
RTS
Combination
TRISS
ASCOT
Trauma Scores
AIS
Trauma Scores
AIS
Trauma Scores
ISS
To calculate an ISS for an injured person, the body is
divided into six ISS body regions. These body regions
are:
1. Head or neck - including cervical spine
2. Face - including the facial skeleton, nose, mouth, eyes
and ears
3. Chest - thoracic spine and diaphragm
4. Abdomen or pelvic contents - abdominal organs and
lumbar spine
5. Extremities or pelvic girdle - pelvic skeleton
6. External
Trauma Scores
RTS
Pathophysiology and Immune
Response
Ebb (shock)
Flow up to 2 weeks
Recuperation lasts up to several
months
Pathophysiology and Immune
Response
Neuroendocrine system:
Adrenocortical response:
Release of adrenocorticosteroids and
catecholamines
Increased heart rate, respiratory rate, fever, and
leukocytosis
Pathophysiology and Immune
Response
Pathophysiology and Immune
Response
Initial Management
Reanimation Period (1 to 3 hours)
Time of admission to control of lifethreatening conditions
Primary Stabilization Period (1 to 48
hours)
Complete stability of respiratory,
hemodynamic, and neurologic systems
Major extremity injuries are managed
Initial Management
Secondary Regeneration Period (2-10
days)
Patient stabilized and monitored
Tertiary reconstruction and
rehabilitation period (weeks)
Final reconstructive measures
Initial Management
Respiratory Function Assessment
Management of Hemorrhagic Shock
Assessment of capillary refill time,
conjunctiva color, urine output
Frequent sources of hemorrhage:
Abdomen
Thorax
Pelvis
Initial Management
Neurologic Status Assessment
Initial Management
Neurologic Status Assessment
Initial Management
Staging:
Stable have physiologic reserve to
withstand prolonged operation
intervention
Borderline stabilized in response to
initial resuscitative attempts but have
clinical features, or combinations of
injury
Initial Management
Staging:
Borderline:
Initial Management
Staging:
Unstable remain hemodynamically unstable
despite initial intervention; at greatly increased
risk of rapid deterioration, subsequent multiorgan failure, and death
In Extremis very close to death; having
suffered severe injuries, often with ongoing
uncontrolled blood loss
Deadly triad:
HYPOTHERMIA
ACIDOSIS
COAGULOPATHY
Early Radiologic
Investigations
Radiography:
Chest AP
Cervical spine
pelvis
Early Radiologic
Investigations
Ultrasound:
Early Radiologic
Investigations
Ultrasound:
Arteriography
For traumatic aortic and vascular
injuries
Early Radiologic
Investigations
Ultrasound:
Arteriography
For traumatic aortic and vascular
injuries
Surgical Strategy and Decision
Making
Damage Control Orthopaedics
Seeks to control but not to definitively
repair the trauma-induced injuries early
after trauma
Attempts to reduce the biological load of
surgical trauma in the alreadytraumatized patient
Surgical Strategy and Decision
Making
Damage Control Orthopaedics
FIRST STAGE: early temporary
stabilization of unstable fractures and
the control of hemorrhage
SECOND STAGE: resuscitation of
patients in ICU with optimization of their
condition
THIRD STAGE: delayed definitive fracture
management
Priorities in Fracture Care
Consideration of progressive soft
tissue damage : tibia, femur, pelvis,
spine, and upper extremity
Immobilization of shaft fractures
Priority of treatment dictated by
extent of bone and soft tissue
damage femoral head fractures and
talar fractures
Closed Fracture
Open Fracture
Reconstructive versus
Amputation
Rehabilitation
has to start during the immediate
postoperative period mobilization
under the supervision of a trained
physiotherapist
Take Home Points
