POLYTRAUMA
ISMAIL SALIM, MD
ORTHOPEDIC & TRAUMA SURGEON
Objectives
Definition
How to asses polytrauma patient
Pathophysiology
Timing & Priorities of surgery
Algorithm of polytrauma
Management of polytrauma
Definition
PoliTrauma (AO Trauma): A syndrome of multiple injuries that affects
more than one organ system that can lead to organ dysfunction or
organ failure with ISS (Injury Severity Sore ) score more than 16
ATLS Primary Survey
The Injury Severity
Score (ISS)
ISS Body region:
Head or neck – including cervical spine
Face – including the facial skeleton, nose, mouth, eyes and ears
Chest – thoracic spine and diaphragm
Abdomen or pelvic contents – abdominal organs and lumbar spine
Extremities or pelvic girdle – pelvic skeleton
External Calculation
square each AIS code and add the three squared
numbers for an ISS (ISS = A2 + B2 + C2 where A, B, C
are the AIS scores of the three most injured ISS
body regions)
Abbreviated Injury
Scale (AIS)
The Injury Severity
Score (ISS)
Region Injury Description AIS Square Top
Three
Head & Neck Subdural Hematoma 3 9
Face No Injury 0
Chest Flail Chest 4 16
Abdomen Minor Contusion of Liver
Complex Rupture Spleen 5 25
ISS
Extremity Fractured femur 3 3 – 8 Minor
External No Injury 0 9 – 15 Moderate
16 – 24 Serious
Injury Severity 50 24 – 39 Severe
Score (ISS) 40 – 74 Critical
75 Maximum
The New Injury Severity
Score (ISS)
Sums of squares of the 3 highest AIS scores
regardless of body region
AIS Score Region
ISS vs NISS example
Multiple abrasions 1 External
Deep laceration tongue 2 Face
Subarachnoid hemorrhage 3 Head/Neck
Major kidney laceration 4 Abdomen
Major liver laceration 4 Abdomen
ISS = (4)2 + (3)2 + (2)2 = 29
NISS = (4)2 + (4)2 + (3)2 = 41
PATHOPHYSIOLOGY
Phases in Polytrauma
TIMING & PRIORITIES OF
SURGERY
Timing Surgical Physiologic
Intervention Status
Day 1 Response poor life saving Unstable
Response transient damage control Neutral
Response mild delayed primary Stable
surgery
Day 2-3 “second look” surgery only Hyperinflamation
Day 5-10 Definitive surgery Window of oppurtunity
Week 2-3 NO SURGERIES IMMUNOSUPRESSION
Week 3+ Reconstructive surgeries Anabolic Phase
MANAGEMEN
T OF
POLYTRAUMA
Work As A Team
MANAGEMENT
ETC vs DCO
Algorithm Trauma
Management/ Hannover
Protocol
Clinical condition
Stable Borderline Unstable In Extrimis
Grade I Grade II Grade III Grade IV
hemorraghe control and/or decompression
(thorax)in the emergency room (ER)
(ATLS criteria)
OR OR
Reevaluation (ER) : ABG,SBP coagulation,FAST ICU
urine output (inflammatory response) Ex-Fix
(distractor)
Stable Uncertain
OR OR
ETC ETC DCO DCO DCO
(Pape et al. J Trauma 2003)
Borderline Criteria
End Points
Resuscitation
HOT-UCIL
Stable Hemodynamics
Stable Oxygen saturation
Normal Temperature
Urinary output > 1 ml/kg/h
No Coagulopathy
No Inotropics
Lactate < 2 mmol/l
Pelvic and acetabular fractures, are rare, account
for approximately 3% - 8% of all fractures.
High risk of associated injuries, therefore DCO is
the most suitable therapeutic option.
Retroperitoneal cavity can hold up to 4 L of
Pelvic blood.
Ring Mortality of polytrauma patients with pelvic
Injuries fracture and unstable haemodynamic reportedly
50%.
FAST – extended focused assessment
sonography for trauma, to identify the source of
haemorrhage.
Every effort should be aimed at the stabilization
of the fracture.
Purpose : reduce the volume of the open pelvic
ring, and to dab the venous bleeding.
Method :
Pelvic
• Pelvic binder / pelvic wrapping
Ring
Injuries • Pelvic C-clamp
• Pelvic external fixation
• Pelvic packing
If the patients remain hemodynamically unstable,
angiographic embolization must be performed.
Pelvic Binder
Placement
Pelvic Binder on Patient
Pelvic C-clamp
CONCLUSION
Polytrauma is a concept of management of a
multiple organ injury that need fast assessment,
right treatment in the right time and a good team
work.
References
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