A polytrauma is the simultaneous injury of several body regions, whereby according to Tscherne’s definition at least one of these injuries is life-threatening. According to the “Injury Severity Score”, a patient is considered to be boyltraumatized with an ISS >16 points. 80% of all polytraumas occur as a result of a traffic accident (motorcycle, car and pedestrian).
But falls from great heights can also lead to polytrauma. Thanks to significantly improved primary care and diagnostics, mortality has decreased significantly over the last 20 years. The prognosis is directly related to the time interval between the accident event and the definitive care of the patient.
The longer the time interval, the worse the prognosis. The guidelines of the professional associations state that a patient with polytrauma should be admitted to the clinic no later than 60 minutes after the accident event. This is the so-called “golden hour of shock“.
The patient should be operated on at the latest 90 minutes after the emergency call has been received. As soon as these times are significantly longer, the probability of survival of the accident victim decreases rapidly. Since the prognosis depends directly on the time interval until the definitive therapy, the therapy should start at the accident site.
Polytraumatized patients often develop hemorrhagic shock due to massive blood loss, either internally or externally. Since internal bleeding is difficult to detect, care must be taken to centralize the circulation. This is manifested by very cold and pale extremities, since in the case of centralization only the vital organs are supplied with oxygen.
In addition, polytrauma often results in an oxygen deficiency (hypoxia) and a too high concentration of carbon dioxide (hypercapnia). The causes for this are
- Collapsed lung parts
- Relocation of airways and
- Disturbance of the central respiratory regulation
Multi-center studies have shown that early intubation, volume administration and ventilation for the prevention of shock lung as well as appropriate pain therapy have a significant impact on the survival of polytraumatized accident victims. In order to make the therapy on site as efficient as possible, there is a list of appropriate therapy measures that should be initiated before transport to the clinic: 1. intubate as early as possible to avoid shock lung If possible, the head should not be overstretched (reclinched) backwards in order to avoid possible injuries to the cervical spine.
2. place several large-lumen intravenous accesses and fix them well. This will provide sufficient volume to avoid a shock situation. In any case, the patient should be treated for pain and sedated, possibly also anaesthetised.
3. if there is a tension pneumothorax, this is relieved on site, 4. immobilize and fix fractures on site. 5. avoid cooling of the patient, cover him with a rescue blanket and then take him to a suitable hospital as quickly and gently as possible, possibly by helicopter. A polytrauma patient should always be registered before arriving at the hospital so that the shock room team can prepare for the patient and all necessary doctors, nurses and equipment are ready.
The clinic must also work as efficiently as possible in a short period of time. A well organized shock room team is a prerequisite for this. This team usually consists of surgeons and anesthetists, or, depending on the case, additional specialists such as neurologists, pediatricians, etc.
To avoid confusion, a shock room leader is appointed to coordinate the therapies and procedures. In order to initiate the therapy as quickly as possible, the shock room team is ready to help when the patient arrives. The treatment phases are then divided into two phases.
1. acute phase Here, the vital functions of the patient are ensured according to the ATLS protocol and a short “body check” is performed to get an overview of the injuries. The ATLS protocol (Advanced Trauma Life Support) is a standard concept of American trauma surgeons and is considered the standard procedure for the treatment of severely injured patients in the acute phase: The shock room team follows the ABCDE rule: 2nd stabilization phase (primary phase) In this phase the patient is further stabilized. Large-lumen accesses and a central venous catheter (ZVK) are inserted.In addition, the patients are treated with pain therapy and sedation, a large ECG (12-channel ECG) is written and an acidosis of the patient is corrected.
The volume must be administered very carefully in order to avoid an increase in intracranial pressure. In addition to isotonic solutions, blood preparations are also used to compensate for the large volume loss. In this primary phase, early operations are also performed, if necessary.
The first operation should take place as soon as possible, at most 90 minutes after the emergency call. Since the lethality of polytrauma patients is significantly increased by the presence of the lethal triad, the operations should be kept as short as possible. This is because these parameters can significantly worsen the above-mentioned factors and thus further endanger the survival of the patient.
Various studies have helped to establish a priority order of operations:
- A= Airway = securing the airways
- B= Breathing = Ventilation if necessary
- C= Circulation = volume and bleeding control
- D= Disability = neurological status
- E= Exposure = complete undressing under control of a cooling
- Hypothermia (hypothermia)
- Hyperacidity (metabolic acidosis) and
- Increased coagulation (coagulopathy)
1. stopping bleeding in the abdominal cavity, such as injuries to large vessels, spleen, liver, kidneys, etc. In the case of mass bleeding, the bleeding is initially treated by packing with numerous abdominal cloths and then continued in a more stable condition. 2. hemostasis in the thoracic region or a tension pneumothorax.
The thorax is only opened if a drainage insert is not sufficient or if large vessels such as the heart and aorta are affected. 3. bleeding in the case of pelvic fractures, these occur frequently in traffic accidents and lead to massive blood loss into the pelvis, which is not visible externally for a very long time. Hemostasis in the pelvis is only possible by external stabilization with pelvic forceps or surgical treatment with an internal/external fixator.
4. increase in intracranial pressure due to bleeding. The only helpful and quick therapy is the relief of the hematoma by means of a drilling or opening of the skull. Severely injured patients who remain unstable even after emergency treatment are transferred to the intensive care unit under the principle of “damage control”.
The primary goal is to restore physiological parameters such as: Once the patient is stable enough to survive an operation, further surgical treatment is initiated. After the operations, there is often a long stay in the clinic and possibly further operations and rehabilitation measures.
- Oxygen saturation
- Coagulation
- Blood gases
- Excretory function of the kidney
- Blood pressure and
- Temperature
A polytrauma is always an acutely life-threatening situation for the patient and requires above all rapid and controlled action.
The emergency physician at the scene of the accident is under great pressure to ensure that the patient is admitted to the appropriate hospital as quickly and correctly as possible. In the clinic, the survival of the patient then depends on the competence, efficiency and the controlled and well-organized treatment of the shock room team. For this purpose, precise guidelines are established to ensure that the acute emergency therapy in the shock room is carried out as routinely as possible.
In order to avoid confusion or misunderstandings, a shock room leader is appointed to control the activities of the other doctors and to keep an overview. This shock room phase is followed by the early operative phase. The motto here is: “As much as necessary, as little as possible.
“Since every operation is a further burden for the patient, only life-threatening injuries should be treated as quickly and effectively as possible in the early surgery. The further, final operations follow as soon as the patient is in a better and more stable condition. These include above all temperature, oxygen supply, volume, kidney function and blood gases.
Due to the numerous studies and guidelines for the treatment of polytrauma patients, the survival rates have now increased significantly. Nevertheless, all patients initially suffer life-threatening injuries and many can no longer be helped.The surviving patients often have a long period of hospitalization and rehabilitation ahead of them before they can return to normal everyday life.
