European Journal of Trauma
Current Concepts of Polytrauma Management
Philip F. Stahel*, Christoph E. Heyde*, Wolfgang Ertel1
Abstract
In recent years, the implementation of standardized
protocols of polytrauma management led to a sig-
nificant improvement of trauma care in European
countries and to a decrease in posttraumatic mor-
bidity and mortality. As such, the “Advanced Trauma
Life Support” (ATLS®) protocol for the acute man-
agement of severely injured patients has been es-
tablished as a gold standard in most European
countries since the 1990s. Continuative concepts to
the ATLS® program include the “Definitive Surgical
Trauma Care” (DSTC™) algorithm and the concept of
“damage control” surgery for polytraumatized pa-
tients with immediate life-threatening injuries.
These phase-oriented therapeutic strategies ap-
praise the injured patient in the whole extent of the
sustained injuries and are in sharp contrast to pre-
vious modalities of “early total care” which advo-
cate immediate definitive surgical interventions.
The approach of “damage control” surgery takes the
influence of systemic posttraumatic inflammatory
and metabolic reactions of the organism into ac-
count and is aimed at reducing both the primary
and the secondary – delayed – mortality in severely
injured patients. The present paper shall provide an
overview on the current state of management algo-
rithms for polytrauma patients.
Key Words
Polytrauma · Management · ATLS® · Damage con-
trol · Multiorgan failure · Mortality
Eur J Trauma 2005;31:200–11
DOI 10.1007/s00068-005-2028-6
* Both authors contributed equally to this paper.
1
Department of Trauma and Reconstructive Surgery, Charité –
University Medical School Berlin, Campus Benjamin Franklin, Berlin,
Germany.
Received: February 27, 2005; accepted: March 7, 2005.
200
Focus on Polytrauma
Introduction
Trauma still represents the “major killing factor” in
young patients < 45 years of age in industrialized coun-
tries [1, 2]. In Germany alone, 4–5 million people suffer
traumatic injuries each year and > 20,000 severely injured
patients die every year [1, 3–5]. Trauma-related mortality
has three major causes [6]: (1) the immediate mortality at
the accident site (“sudden death”) due to lethal injuries
such as aortic rupture with free bleeding, lacerations of
the brain stem, or decapitating injuries; (2) early mortal-
ity within the first few minutes to hours (“golden hour”)
due to compromised airways, tension pneumothorax,
hemorrhagic shock as a consequence of intraabdominal
or intrathoracic bleeding and pelvic ring disruptions with
massive retroperitoneal hemorrhage, or due to severe
traumatic brain injury with acute cerebral edema or in-
tracranial hematoma; (3) late mortality within days to
weeks after trauma due to septic complications, multiple
organ failure and due to untreatable increased intracra-
nial pressure associated with cerebral edema.
Major improvements in the management strategies of
severely injured patients in the past decades have led to a
significant reduction of polytrauma-associated mortality
from about 40% in the 1970s to around 10% in the year
2000 [7]. This achievement is mainly owed to improved
standards of trauma care due to defined algorithms of pre-
and in-hospital trauma care which have been broadly
propagated and established in most industrialized and de-
veloping countries [6, 8–15]. Since the patients’ outcome is
directly related to the time interval from injury to properly
delivered definitive care, the optimization of preclinical
transportation times and the implementation of the con-
cept of patient transport to the closest appropriate – not
just to the closest – hospital (rule of “three R’s” by Donald
European Journal of Trauma 2005 · No. 3 © Urban & Vogel
Stahel PF, et al. Polytrauma Management
Trunkey: “get the Right patient to the Right hospital in the
Right time”) [16, 17], have led to minimized transportation
times and to shorter therapy-free intervals with overall im-
proved outcome of polytrauma patients [1, 4, 7, 13]. Fur-
thermore, the vast propagation of the “damage control”
concept for severely injured patients with immediate
life-threatening injuries, as well as the improvement of in-
tensive care strategies for polytraumatized patients have
further contributed to an increased level of trauma care
with reduced trauma-associated mortality [18–24].
Successful primary care of polytraumatized patients
(Box 1) is characterized by the demands of both therapeu-
tic and diagnostic measures. Since the time factor is of cru-
cial essence, validated concepts and algorithms have been
established in the past few years for the initial diagnosis
and treatment of severely injured patients. The updated
“Guidelines of the German Society of Trauma Surgery”
(DGU) for the diagnostics and treatment of polytrauma-
tized patients have recently been outlined in a compre-
hensive review article [25]. The “Advanced Trauma Life
Support“ (ATLS®) protocol of the American College of
Surgeons’ Committee on Trauma has been established as
a standard procedure algorithm for the initial assessment
and management of polytraumatized patients in the past 3
decades in > 30 countries worldwide and in twelve Euro-
pean countries [6, 14]. Based on the principle of the “gold-
en hour of shock”, injuries which would take a lethal
course if left untreated within the first minutes to few
hours after trauma are being cared for using standardized
diagnostic algorithms and validated therapeutic concepts
according to the ATLS® guidelines [6, 14, 26]. In blunt
polytrauma patients, this early phase of the “golden hour”
is not restricted to management within just the first 60 min
after injury only, but can be safely extended to the first
few hours after trauma [27]. Beyond the ATLS® concept,
the “Definitive Surgical Trauma Care“ (DSTC™) course
by the International Association for the Surgery of Trau-
ma and Surgical Intensive Care provides the standards of
emergency surgical procedures of patients with blunt and
penetrating injuries.
The concept of “damage control” orthopedic surgery
has evolved based on the observation that a prolonged
early definitive treatment of long bone fractures can be
Box 1. “Polytrauma” – definition according to Otmar Trentz (2000).
A syndrome of multiple injuries exceeding a defined severity (Injury
Severity Score [ISS] > 17) with consecutive systemic trauma reactions
which may lead to dysfunction or failure of remote – primarily not
injured – organs and vital systems [24].
European Journal of Trauma 2005 · No. 3 © Urban & Vogel
Figure 1. The “lethal triad” in the
pathophysiology of severely in-
jured patients leading to a vicious
circle and adverse outcome. This
implication constitutes the un-
derlying rationale for the concept
of “damage control” surgery [30].
detrimental for severely injured patients who are in a per-
sisting unstable physiological state despite adequate resus-
citative measures during the initial management phase [18,
19, 28–30]. In these patients, the early restoration of the
“lethal triad” of persistent metabolic acidosis, hypother-
mia, and coagulopathy represents the prime goal for sur-
vival [28–30] (Figure 1). Thus, polytrauma patients in ex-
tremis must be transferred to intensive care at the earliest
time point after stabilization of vital functions for restora-
tion of physiological parameters, and prolonged surgical
interventions must be avoided in order to prevent a lethal
“second hit” in these patients [24, 31–33]. The current un-
derstanding of “damage control” surgery involves four dis-
tinct phases of assessment and management [18, 34]: (1)
life-saving surgery with early recognition of those trauma
patients that warrant damage control (“ground zero” rec-
ognition phase); (2) salvage operation for control of hem-
orrhage and contamination (“OR phase”); (3) intensive
care management for restoration of physiological and im-
munologic baseline functions (“ICU phase”); (4) sched-
uled definitive surgery (“reconstructive phase”).
The present review shall provide an up-to-date
overview on established diagnostic and therapeutic al-
gorithms of preclinical and clinical management of poly-
traumatized patients.
Preclinical Management
During the prehospital period, emphasis in the manage-
ment of polytrauma patients should be placed on airway
maintenance, control of external bleeding, fluid resusci-
tation, immobilization of the spine, and immediate trans-
port to the closest appropriate clinic. Different algorithms
have been established to narrow the time window from
injury to definitive care and to optimize the preclinical
therapeutic strategies and determine the adequate target
facility for the individual trauma patients [6, 13, 35–37].
These defined algorithms should help prevent the under-
triage of trauma victims – a phenomenon which has been
shown to occur mainly in elderly patients [16, 17]. Thus,
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Stahel PF, et al. Polytrauma Management
the prime philosophy in the decision scheme suggested
by the American College of Surgeons’ Committee on
Trauma is: “When in doubt, take the patient to a trauma
center” [6]. The initial assessment of trauma victims at the
accident site is performed on the basis of vital functions
and a rough overview of the overall injury pattern. In the
case of a trapped person inside a car, the temporal course
of rescue and life-saving procedures must be coordinated
[6, 35]. According to established algorithms, the mea-
sures of extrication of trapped victims are in secondary
priority to securing the airway and protecting the cervical
spine [6, 35, 36]. Ensuring vital function according to the
A-B-C priorities of the ATLS® protocol comprises clear-
ing and securing the airway or establishing a patent air-
way by endotracheal intubation in the case of acute air-
way compromise [6, 13]. Supplemental oxygen is provided
to every trauma patient by an oxygen mask. The indica-
tion for endotracheal intubation at the accident site is es-
tablished liberally in cases of risk of airway obstruction or
aspiration (unconscious patients with Glasgow Coma
Scale [GCS] score ≤ 8, insufficient respiration with hyp-
oxemia due to severe thoracic trauma or flail chest), and
to prevent hypoxemia-induced secondary injury in severe
head trauma [6, 38]. In intubated patients, adequate anal-
gesia and sedation/relaxation are mandatory to prevent
pain and systemic secondary stress reactions leading to
increased intracranial pressure and adverse outcome
[39]. While assessing and managing the patient’s airway,
great care must be taken to prevent excessive movement
of the – potentially injured – cervical spine. During resus-
citative measures, the C-spine must be protected by
in-line immobilization to prevent hyperextension, hyper-
flexion, and rotation [6, 40]. Endotracheal intubation is
performed by standardized two-person maneuver ac-
cording to the ATLS® criteria with the helper holding the
cervical spine in slight axial in-line position while the sec-
ond person performs intubation [6, 40]. Although fiber-
scope-guided nasotracheal intubation has been shown to
be the safest measure with regard to limited cervical spine
motion during establishment of a patent airway [41], this
technique is not suited for intubation in an emergency
situation. For rapid-sequence induction, the use of an in-
tubating laryngeal mask (Fastrach) has been postulated
as a safe maneuver with limited cervical spine excursion
[42], however, the use of a laryngeal mask is not regarded
as a safe standard for establishing a patent airway in trau-
ma patients, according to the ATLS® criteria [6]. Thus,
these additional measures are not suited for emergency
intubation at the accident site. Appropriate immobiliza-
202
tion devices must be applied for stabilization of the entire
vertebral column during transport, since spinal injuries
must be assumed in all polytrauma patients until proven
otherwise. Based on the principle of “do no further harm”,
patients are immobilized with a cervical collar and evacu-
ated on a long spine board or a vacuum mattress. Based
on the National Acute Spinal Cord Injury Study (NAS-
CIS) guidelines, high-dose methylprednisolone therapy
(30 mg/kg bolus i.v.) should be initiated as early as possi-
ble in the case of neurologic impairment due to suspected
spinal cord injury, ideally at the accident site and impera-
tively within a time window of 8 h after trauma [43, 44].
Steroid therapy is continued in the clinic for further 24 h
with a maintenance dose of 5.4 mg/kg/h [43, 44]. In con-
trast to blunt spinal trauma, steroids are not recommend-
ed for penetrating spinal cord injury, such as gunshot in-
juries [45, 46]. In the latter case, the use of steroids has not
been shown to improve the neurologic outcome, but was
associated with a greater frequency of nonspinal compli-
cations [45, 46].
In parallel to airway management with cervical spine
protection, resuscitative measures for shock therapy are
initiated by fluid replacement via at least two large-cali-
ber peripheral venous accesses. An initial infusion vol-
ume of 2,000 ml crystalline solution or alternatively crys-
talloids and colloids at a ratio of 3 : 1 are recommended
as a standard [6, 13]. External bleeding sources are con-
trolled by local compression and sterile dressing in addi-
tion to fluid resuscitation. The use of surgical clamps and
tourniquets is obsolete and contraindicated due to iatro-
genic additional tissue damage. In the case of hemorrhag-
ic shock associated with massive internal bleeding due to
pelvic ring disruptions, initial hemorrhage control is es-
tablished by reduction of the pelvic ring by internal rota-
tion of both thighs and wrapping with wide bandages or
sheets [47, 48]. This simple technique can significantly de-
crease retroperitoneal bleeding associated with pelvic
ring disruptions – by diminishing the pelvic volume – dur-
ing the transportation phase.
Soft-tissue wounds and open fractures need to be
documented at the accident site and are covered by a
sterile dressing. No further inspection of the wound is
warranted until surgical exploration in the clinic [6]. At
no time should the wound be probed. If a fracture and an
open wound exist in the same limb segment, the fracture
has to be considered open until proven otherwise by the
surgical exploration. Concordantly, a wound over a joint
implies an open joint injury. In these cases, administra-
tion of tetanus prophylaxis and antibiotics by a sec-
European Journal of Trauma 2005 · No. 3 © Urban & Vogel
Stahel PF, et al. Polytrauma Management
Figure 2. Proposed algorithm for the initial assessment and manage-
ment of polytrauma patients.
ond-generation cephalosporin are warranted upon ar-
rival in the clinic [49]. Fracture-dislocations are reduced
in-line and fixed by temporary devices. Immediate trans-
fer to definitive care should not be retarded by any of
these additional measures [6]. When available, the rescue
helicopter should be used for fast and careful transport of
seriously injured patients to a verified level I trauma cen-
ter. Hereby, early notification of the receiving doctor at
the target hospital is of essential importance. All avail-
able information on the overall condition and estimated
injury pattern of the accident victim must be transmitted
ahead of time so that adequate equipment and manpow-
er can be arranged at the receiving hospital until admis-
sion of the patient to the emergency room [6].
Initial Assessment and Management
Upon arrival in the emergency room, the primary objec-
tive of the initial assessment and management of poly-
traumatized patients is survival. Thus, timing and pri-
orities have to be followed in tight adherence to defined
established algorithms which have been shown to im-
European Journal of Trauma 2005 · No. 3 © Urban & Vogel
prove the overall outcome of severely injured patients
(Figure 2) [4, 6, 18, 23–26, 50]. The established time-de-
pendent management phases for trauma patients in the
first 24 h (“day-1 surgery”) comprise:
(1) primary survey with baseline diagnostics and imme-
diate life-saving procedures and establishing access
to life-support systems according to the A-B-C algo-
rithm of the ATLS® protocol;
(2) damage control surgery in patients who are not re-
sponsive to the initial measures of resuscitation: surgi-
cal control for exsanguinating hemorrhage and de-
compression of body cavities (“life-saving surgery”);
(3) secondary survey in hemodynamically stable patients
with elaborate diagnostics including a “head-to-toe”
examination and further radiologic work-up (CT
scan, conventional X-rays, angiography, etc.);
(4) “delayed primary surgery”: decontamination, surgi-
cal exploration and management of non-immediately
life-threatening injuries, temporary fracture fixation.
Life-Saving Surgery and Damage Control
During the primary survey, the injured patient is rapidly
assessed according to the algorithm of the ATLS® pro-
tocol and life-preserving therapy is instituted simultane-
ously. The treatment priorities are based on the likeli-
hood of a patient to die within a short time from a
life-threatening injury, according to the “A-B-C-D-E”
mnemonic [6] (Table 1):
• Airway maintenance with cervical spine protection,
• Breathing and ventilation,
• Circulation with hemorrhage control,
• Disability: brief neurologic evaluation,
• Exposure with environmental control (protection
from hypothermia).
Using this algorithm during the primary survey, poten-
tial life-threatening conditions are identified and man-
aged simultaneously with a frequent reassessment of
the patient’s physiological status and response to re-
suscitative measures [6]. The key point of any success-
ful management of a severely injured patient concerns
the clear priority of “damage control” ahead of any
time-consuming diagnostic procedure. It has to be
pointed out, however, that the concept of “damage
control” – as outlined later in the paper – does not rep-
resent an integrated part of the original ATLS® proto-
col [6].
A – airway maintenance with cervical spine protection.
The first priority in the care of trauma victims is to ensu-
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Stahel PF, et al. Polytrauma Management
Table 1. Initial assessment and management principles according to the Advanced Trauma Life Support (ATLS®) algorithm [6]. FAST: focused
assessment sonography for trauma.
Assessment of vital functions
A Airway maintenance with cervical spine protection
• Inspection of upper airways, recognition of upper airway obstruction
(stridor, hoarseness, laryngeal hematoma/emphysema/dislocation,
dyspnea, tachypnea)
B Breathing and ventilation
• Clinical recognition of tension pneumothorax (!), massive hemothorax, • Puncture of second intercostal space in midclavicular line for acute
rib fractures, flail chest, subcutaneous emphysema
C Circulation with hemorrhage control
• Recognize clinical signs of shock (“three windows to the microcircu- • Aggressive volume resuscitation (3 : 1 rule of replacement)
lation”): cerebral, peripheral and renal perfusion, tachycardia
(> 100/min). Hypotension only in advanced state of shock with blood • “Damage control“ procedure for patients in extremis
loss of > 30–40%
• Recognize external and internal hemorrhage sources (clinical
examination, “FAST“, chest and pelvic X-ray)
D Disability: brief neurologic evaluation
• Glasgow Coma Scale (GCS) score and pupil evaluation
E Exposure with environmental control
• Completely undress the patient and “log-roll“ for posterior injuries
re an adequate airway. This implies the maintenance
of patent upper airways, if necessary by endotracheal
intubation or, in exceptional situations, by establishing
a surgical airway through cricothyroidotomy. Correct
positioning of the tube must be confirmed by ausculta-
tion, end-tidal CO2 monitoring, and a chest X-ray. In
addition, every trauma patient must receive supplemen-
tal oxygen (4–10 l/min via oxygen mask in nonintubated
patients and 50–100% FiO2 in intubated patients). The
need for exogenous oxygen in the trauma patient is il-
lustrated in the formula established by Nunn & Free-
man in 1964 [51]:
O2av = CO × SaO2 × Hb × 1.34.
This formula specifies that the oxygen available in the
tissue (O2av) is equal to the product of cardiac output
(CO in ml/min), arterial O2 saturation (SaO2 in %)
and hemoglobin concentration (Hb in g%), whereby
1.34 represents the O2-binding capacity of hemoglobin
(in ml/g). While the oxygen demand is satisfied under
physiological conditions, several of these variables may
be significantly compromised in seriously injured pa-
tients due to acute blood loss (Hb), pulmonary contu-
sion (SaO2) and myocardial contusion or pericardial
tamponade (CO), thus resulting in a severe deficit of
oxygen supply for the trauma patient [52].
204
Management
• Clearance of upper airways, suction, jaw-thrust or chin-lift maneuver,
oropharyngeal tube, “patent airway“ establishment by endotracheal
intubation with rapid-sequence induction or surgical airway by cri-
cothyroidotomy. Deliver supplemental oxygen. All measures must be
performed under C-spine protection (C-collar, in-line immobilization)!
decompression of tension pneumothorax, open placement of a chest
drain for hemo-/pneumothorax, flail chest, rib fractures in intubated
patients
• Surgical control of external and internal bleedings
• GCS ≤ 8: endotracheal intubation!
• Protection from hypothermia by warmed blankets, heating lamps and
application of preheated infusions
B – breathing and ventilation. In second priority to en-
suring an adequate airway, a tension pneumothorax
must be excluded based on clinical findings due to the
immediate threat to life [6]. The clinical symptoms in-
clude acute dyspnea with ipsilaterally decreased respi-
ratory sounds and hypersonoric percussion sound with
congested jugular veins. The clinical sign of congested
jugular veins may be absent in patients with hemorrhag-
ic-traumatic shock due to hypovolemia and circulatory
centralization. A tracheal deviation to the contralateral
side represents a late sign and may be detected by clini-
cal inspection of the neck. A tension pneumothorax
compromises ventilation and circulation dramatically
and acutely. Thus, if suspected by clinical findings, chest
decompression by puncture of the second intercostal
space in the midclavicular line with a large-bore needle
must be accomplished immediately without further im-
aging diagnostics [6]. This life-saving maneuver converts
the injury into a simple pneumothorax and must imme-
diately be followed by an open placement of a chest
drain in the fourth to fifth intercostal space in anterior
axillary line. The most frequent cause of tension pneu-
mothorax is mechanical positive pressure ventilation in
a patient with visceral pleural injury. Thus, insertion of
a chest drain is mandatory in every intubated trauma
European Journal of Trauma 2005 · No. 3 © Urban & Vogel
Stahel PF, et al. Polytrauma Management
patient with rib fractures due to thoracic trauma even in
absence of radiologic signs of a traumatic hemo-/pneu-
mothorax [6].
Aside from a tension pneumothorax, additional criti-
cal thoracic injuries include a flail chest with pulmonary
contusion, a massive hemothorax, and an open pneumo-
thorax, also referred to as a “sucking chest wound” [6, 53,
54]. The latter injury is treated by initial sterile occlusive
dressing which is left open on one side to allow a flut-
ter-type valve effect for prevention of aggravation into a
tension pneumothorax. The injury is then treated by
chest tube insertion and by surgical exploration of the
wound in the operating room after stabilization of vital
functions. Patients with a flail chest may be candidates for
early intubation and mechanical ventilation due to respi-
ratory distress and hypoxemia [6]. A traumatic hemotho-
rax is treated by chest tube drainage. This simple maneu-
ver resolves the problem in most cases of blunt thoracic
trauma [6, 53, 54]. However, the presence of a massive
hemothorax with continuous bleeding and/or the pres-
ence of a cardiac tamponade – both entities mainly due to
penetrating injuries – require surgical management by
resuscitative thoracotomy [6, 53–55].
C – circulation with hemorrhage control. In third prior-
ity, internal and external hemorrhages must be recog-
nized and the bleeding must be stopped, if necessary by
surgical measures. When assessing the extent of hemor-
rhage, attention should be paid to the fact that the indi-
vidual compensatory mechanisms can maintain a nor-
mal blood pressure for a limited time even in a critical
hypovolemic situation. In this regard, in case of an acute
blood loss of up to 30% (equivalent to 1.5 l blood loss in
a 70-kg patient), the systolic blood pressure can be kept
within a normal range by increasing the peripheral resis-
tance, thus “masking” the state of shock [6]. However,
cardiac output is reduced to up to half the normal value
which may lead to critical organ perfusion and subse-
quent metabolic acidosis with elevated serum lactate
and an increased lactate : pyruvate ratio in serum due to
the anaerobic metabolic situation [56]. Therefore, dur-
ing the primary survey, the main question to be ad-
dressed with regard to blood loss – “Is the patient in
shock?” – needs to be immediately resolved by clinical
findings of compromised tissue oxygenation [6]. The
clinical symptoms of shock are the “three windows to
the microcirculation” which can be assessed in terms of
inadequate organ perfusion [6]: (1) mental status/level
of consciousness (cerebral perfusion) – agitation, confu-
European Journal of Trauma 2005 · No. 3 © Urban & Vogel
sion, somnolence or lethargy; (2) peripheral perfusion
– cold and clammy skin, delayed capillary refilling,
tachycardia; (3) renal perfusion – oliguria (< 0,5 ml/kg/
h) or anuria. These clinical findings must help differen-
tiate in an early phase whether a patient is “hemody-
namically normal” or just apparently “hemodynamical-
ly stable” with the risk of deterioration. Based on the
response to initial resuscitative measures, the latter
group of patients are defined as either “transient re-
sponders” or “nonresponders” and are likely to require
a surgical intervention for hemorrhage control [6]. Ar-
terial blood gas analysis can furthermore help deter-
mine the extent of hemorrhagic shock in polytrauma
patients. In this regard, clinical studies have demon-
strated that lactate levels and base deficit represent
highly sensitive parameters for recognition of “hidden
shock” in traumatic hemorrhage [56–59]. A base deficit
below the cutoff at –6 mEq/l in the initial blood gas anal-
ysis has been shown to be associated with significantly
increased transfusion requirements, posttraumatic com-
plications and increased mortality [58, 59]. A base defi-
cit < –10 mEq/l has been associated with a high mortal-
ity of 40–70% [58, 59]. By contrast, mortality in patients
with normal base deficit or base excess (+2 to –2 mEq/l)
was as low as about 6% [58, 59]. In addition, the lactate
level on admission represents a sensitive parameter re-
flecting the extent of traumatic-hemorrhagic shock [57].
The time frame of normalization of lactate levels below
a cutoff at 2 mmol/l was shown to correlate significantly
with survival [57]. While polytrauma patients with re-
fractory lactate acidosis (> 2 mmol/l) for > 48 h after in-
jury had a mortality of 85%, those patients where lac-
tate levels normalized within the first 24 h had a low
mortality of around only 1% [57].
In parallel to aggressive volume resuscitation, the
main bleeding sources must be screened according to
standardized protocols during the primary survey [6].
This includes a focused assessment sonography for trau-
ma (“FAST”) and anteroposterior radiographs of chest
and pelvis as a gold standard. The further algorithms for
diagnosis and management of intrathoracic and intraab-
dominal bleedings and of retroperitoneal hemorrhage
associated with pelvic ring disruptions are provided in
the paragraph on damage control (see below).
D – disability: brief neurologic evaluation. After stabili-
zation of vital functions, a brief evaluation of the level of
consciousness (GCS) and of pupil symmetry and reac-
tion is performed. The presence of traumatic brain in-
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Stahel PF, et al. Polytrauma Management
jury must be recognized early in order to take preven-
tive measures for the development of secondary brain
injury due to hypoxemia and hypotension [38, 39]. These
parameters are crucial for the outcome after head injury
due to propagation of a massive intracerebral inflam-
matory response leading to development of brain ede-
ma with increased intracranial pressure and decreased
cerebral perfusion pressure, ultimately contributing to
delayed neuronal cell death [60, 61]. For this reason, an
appropriate resuscitation of the “A-B-C” parameters
represents the crucial basis for avoidance of secondary
brain injuries after trauma [38]. The severity of traumat-
ic brain injury is classified according to the GCS as mild
(14–15 points), moderate (9–13 points), and severe (3–8
points). Endotracheal intubation for securing a patent
airway is mandatory at a GCS ≤ 8, since these patients
are comatose per definition [6, 39]. Patients with a GCS
≤ 13 must be admitted to a trauma center with available
neurosurgical capabilities. In these patients, a cranioce-
rebral CT scan is mandatory due to the significantly in-
creased likelihood of intracranial hematoma as com-
pared to patients with mild head injury (GCS 14 or 15)
[39].
E – exposure with environmental control. Every trauma
patient must be completely undressed for thorough in-
spection and examination under protection from hypo-
thermia by warm blankets and preheated infusions and
heating lamps. A “log-roll” maneuver is mandatory in
all patients for inspection of the back side for potential
hidden injuries. A continuous reassessment of vital pa-
rameters must be performed in order to recognize dete-
rioration and to initiate according resuscitative mea-
sures [6].
The Concept of “Damage Control”
Since the first description of the concept of abbreviated
laparotomy with intraabdominal packing in patients
with massive hemorrhage more than 2 decades ago [62],
this concept of “damage control” surgery has had a
worldwide dispersion in all major surgical disciplines
[18]. The rationale behind the concept of abbreviating
standard surgical procedures lies within the aim of an
early transfer of critical patients to the intensive care
unit (ICU) for restoration of physiological “endpoints
of resuscitation” [24] in order to improve the overall
outcome of critically injured patients in severe traumat-
ic-hemorrhagic shock [22, 28]. The presence of the “le-
thal triad” of hypothermia, coagulopathy, and acidosis
206
(Figure 1) represents a major risk factor for deteriora-
tion and adverse outcome of polytrauma patients [29,
30]. The underestimation of the extent of traumatic
hemorrhage and of the patient’s physiological condition
and reserves may be detrimental due to prolonged sur-
gical interventions which exacerbate this vicious circle
and contribute to increased posttraumatic mortality [18,
28–30]. Thus, in recent years, the “classic” orthopedic
concept of “early total care” for the unstable multiply
injured patient has been abandoned in favor of the new
concept of “damage control orthopedic surgery” (DCO)
which has led to an increased overall survival of poly-
trauma patients [20, 31, 33, 48, 63, 64].
According to the “damage control” concept, life-pre-
serving measures are first priority while other prolonged
surgical interventions must be avoided at all costs in or-
der to decrease the systemic pathophysiological “load” to
the injured organism and to breach the vicious circle of
the “lethal triad” (Figure 1). The two major surgical steps
of damage control procedures include the acute decom-
pression of body cavities and the control of exsanguinat-
ing hemorrhage, as outlined below.
Decompression of body cavities. Pathologically in-
creased pressure in body cavities requires immediate
emergency surgical management. This involves the
acute decompression of a tension pneumothorax and
the drainage of a traumatic hemo-/pneumothorax, as
described for the ATLS® protocol above [6]. In addi-
tion, a suspected cardiac tamponade must be immedi-
ately resolved by subxiphoideal puncture and/or open
decompression in case of required emergency thoracot-
omy [6, 53–55]. Furthermore, the presence of a peracute
epidural hematoma requires immediate decompression
by burr hole evacuation and/or craniotomy [39, 65].
These surgical measures have utmost priority due to the
acute life-threatening implication of these injury pat-
terns.
Control of exsanguinating hemorrhage. During the pri-
mary survey, the presence of hemorrhagic shock must be
diagnosed and treated simultaneously. The basic man-
agement principle is to stop the bleeding and to replace
the volume loss. Volume replacement is performed ac-
cording to the 3 : 1 rule, which means that one unit of lost
blood must be replaced by three units of fluid due to loss
into the third compartment [6]. Thus, for illustration, the
management of a simple femoral shaft fracture associat-
ed with up to 1,500 ml blood loss requires about 4,500 ml
European Journal of Trauma 2005 · No. 3 © Urban & Vogel
Stahel PF, et al. Polytrauma Management

fluid replacement for adequate resus-

citation. The potential requirement
of surgical hemorrhage control must
be determined during the early resus-
citative phase. Significant external
hemorrhages are temporarily stopped
by external compression and sterile
dressing in the emergency room fol-
lowed by surgical wound manage-
ment in the operating room.
Major internal bleeding sources
which require immediate surgical
control are:
• massive hemothorax: initial man-
agement by open chest drain place-
ment. Requirement of urgent tho-
racotomy in cases of penetrating
trauma and/or after blunt trauma
with massive bleeding via chest tube
(> 1,500 ml immediately or continu- Figures 3A to 3D. Case example of a 21-year-old female patient involved in a motorcycle crash
ing hemorrhage of > 200 ml/h in the with applied “damage control” procedure due to severe polytrauma with central liver lacera-
later phase) [6, 53–55]. tion, intracranial hematoma and multiple long bone fractures (A). The Injury Severity Score
• intraabdominal hemorrhage: indi- (ISS) was 50 points. Damage control surgery was performed by “crash”-laparotomy, Pringle ma-
neuver and intraabdominal packing (B) and external fracture fixation. The abdominal wall was
cations for urgent laparotomy in- not closed – in terms of a provisional laparostoma (C) – for avoidance of abdominal compart-
clude hemodynamically unstable ment syndrome and further staged procedures including changes of packings within 24–48 h.
patients with blunt abdominal trau- The postoperative CT scan (D) shows the “packed” liver with the central laceration (arrow).
ma and positive ultrasonography
and patients with penetrating abdominal injuries [6]. explorative laparotomy with pelvic “packing” is war-
Patients “in extremis” with severe multiple injuries ranted in order to achieve surgical hemorrhage control
have a significantly increased chance of survival if the [20, 33, 47, 48, 68]. It is crucial to know that > 80% of
surgical procedure is abbreviated and definitive repair hypotensive patients due to pelvic hemorrhage are
of intraabdominal injuries is delayed in terms of a staged “nonresponders” [69]. The hallmark of these patients’
procedure (crash-laparotomy, “packing”, laparostoma/ survival is a rapid recognition and surgical control of
temporary Ethizip® closure), as compared to patients hemorrhage, since mortality in pelvic fracture-associat-
with early total care [28–30, 66, 67] (Figure 3). Defini- ed hemorrhage is still as high as 50–60% [70]. Interven-
tive surgery is followed within 24–48 h after stabiliza- tional measures like angiography and embolization are
tion of vital parameters in the ICU. obsolete for the management of these patients, since
• pelvic ring disruption with massive retroperitoneal hem- arterial bleeding sources are present in < 10% of all
orrhage: unstable pelvic injuries with posterior pelvic cases and successful embolization can be performed in
ring disruption are associated with massive uncon- < 2% [69, 71]. In addition, angiography has several dis-
trolled retroperitoneal bleeding of up to 5,000 ml due to advantages due to the necessity of transporting a hemo-
lacerations of the presacral and paravesical venous dynamically unstable patient and the average time of
plexus and cancellous bone bleeding [47]. These pa- about 2.5 h until angiography is performed in a level I
tients require immediate closed reduction of the pelvic trauma center, which extends way beyond the “golden
ring in the emergency room and fixation with a pelvic hour” [69, 71]. According to the ATLS® algorithm, per-
“C-clamp” (posterior pelvic ring) and/or external fix- forming extended diagnostics, such as angiography, is
ator (anterior pelvic ring) [20, 33, 47, 48, 68]. If these part of the secondary survey and is therefore obsolete
measures – in combination with aggressive volume re- for early hemorrhage control in the initial phase [6].
suscitation – cannot achieve hemodynamic stability, The propagated “damage control” procedure for he-

European Journal of Trauma 2005 · No. 3 © Urban & Vogel 207

Stahel PF, et al. Polytrauma Management
modynamically unstable patients Table 2. Timing and priorities of operative interventions in polytrauma patients depending on
with pelvic ring disruptions includes the physiological status [24].
closed reduction and external fixa- Physiological status
tion with explorative laparotomy,
pelvic “packing” and provisional Compromised vital functions 씮 Life-saving surgery
closure of the abdomen with surgi- Stable vital functions
®
cal zippers (Ethizip ) [20, 33, 47, 48, Highly unstable/in extremis
68]. This therapeutic modality has Hyperinflammation
”Window of opportunity“
been shown to lower mortality from
Immunosuppression
pelvic bleeding from 50–60% [70]
Recovery
to about 20–25% [20, 33]. Change
of packings has to be performed
within 24–48 h and definitive surgery is to follow during
the “time window of opportunity” from the 5th to 10th
day after trauma (Table 2).
• intracranial bleeding sources: aside from acute epidu-
ral hematoma from arterial bleeding sources (see
above), dural sinus bleeding may represent a major
source of intracranial hemorrhage requiring immedi-
ate surgical intervention by trepanation and cranioto-
my [65].
• penetrating and blunt vascular injuries, “mangled ex-
tremity”: arterial injuries with clinical signs of limb
ischemia due to blunt or penetrating trauma require
immediate surgical management without further di-
agnostics [72–74]. The “Mangled Extremity Severity
Score” (MESS) has been established as a guideline
for early determination whether limb salvage is
achievable as opposed to early amputation, with an
established “cutoff” level of the MESS at 7 points
[75–79].
Secondary Survey
The phase of the secondary survey can only begin after
the resuscitative measures of the primary survey are
completed according to the A-B-C-D-E algorithm and
the patient has been hemodynamically stabilized and
demonstrates normal vital functions [6]. The secondary
survey comprises an extended anamnestic evaluation of
concomitant diseases and events associated with the
mechanism of injury and a complete and thorough
“head-to-toe” examination including a full neurologic
status. Diagnostic adjuncts to the secondary survey in-
clude a multislice polytrauma CT scan which nowadays
represents a fast and highly sensitive “gold standard”
for further evaluation of hemodynamically stable poly-
trauma patients [80, 81]. The multislice CT has been
shown to be a highly sensitive tool also for detecting
aortic rupture, whereby a normal CT scan of the aorta
208
Operative procedures Timing
씮 Delayed primary surgery Day 1
씮 Damage control surgery
“Second looks” only! Day 2–4
Scheduled definitive surgery Day 5–10
No surgery!
Secondary reconstructive surgery After 3 weeks
was shown to unequivocally exclude an aortic rupture
[80–84]. An aortography or transesophageal echocar-
diography are nowadays only indicated in rare cases
with equivocal findings in the CT scan [80, 82]. Conven-
tional X-rays of extremities and spine series are per-
formed during the secondary survey according to the
individual injury pattern [6].
Delayed Primary Surgery (“Day-1 Surgery”)
Surgical interventions which are not immediately re-
quired for resolving life-threatening conditions are per-
formed after further evaluation of the stabilized patients
in the secondary survey. Hereby, the term “delayed” re-
fers to primary surgical interventions within the first
24 h (“day-1 surgery”). These operations are aimed at
reducing the “antigenic load”, saving injured limbs and
joints at risk, decompressing the spinal cord, and opti-
mizing the therapeutic modalities on the ICU [21, 22,
24, 85].
Such interventions in the context of “day-1 surgery”
include:
• decompression of compartments under pressure in
non-immediately life-threatening conditions: unstable
vertebral fractures with spinal stenosis, subdural he-
matoma, compartment syndromes of the extremities;
• laparotomy for hollow viscus injuries;
• revascularization of vascular injuries;
• debridement of contaminated soft tissue and open
fractures/joint injuries;
• external fracture fixation of long bones;
• dorsal fixation of unstable vertebral fractures by inter-
nal fixator.
These operative measures should take as little time as
possible to avoid an iatrogenic “second hit” [86] which is
associated with adverse outcome in polytrauma pa-
tients, particularly in the presence of concomitant head
injury [31, 64, 65, 87, 88].
European Journal of Trauma 2005 · No. 3 © Urban & Vogel
Stahel PF, et al. Polytrauma Management
Intensive Care and Scheduled Definitive Surgery
Following the operative interventions, subsequent
transfer to the ICU is aimed at the earliest time point
possible for further stabilization of the polytrauma pa-
tient and for restoration of the following “endpoints of
resuscitation” [21, 22, 24]:
• stable hemodynamics without need for vasoactive or
inotropic stimulation;
• no hypoxemia, no hypercapnia;
• serum lactate ≤ 2 mmol/l;
• normal coagulation;
• normothermia;
• urinary output > 1 ml/kg/h.
The pathophysiological phase of hyperinflammation
between days 2–4 after trauma (Table 2) is a time period
of enhanced susceptibility to a “second-hit” injury and
thus does not allow any surgical intervention [24, 86].
Exceptions are short operations such as sterile change
of dressing, exchange of tamponades and “second-look”
operations for further debridement of necrotic tissue
and avoidance of bacterial contamination [24, 89]. These
measures are necessary to reduce the overall stress to
the organism through necrotic tissue and inflammatory
mediators (“antigenic load”) and to avoid infectious
complications and the development of sepsis and organ
failure [90, 91].
The next management phase takes into account
the presence of a physiological “window of opportu-
nity” between days 5–10 after trauma, which corre-
sponds to the interval between the early hyperinflam-
matory phase and the period of immunosuppression
which follows the 2nd week after trauma (Table 2)
[24]. Thus, during the “time window of opportunity”,
the fully resuscitated patient is a candidate for changes
in operative strategies and definitive scheduled surgi-
cal procedures. These include the change from exter-
nal to internal fixation of long bone and pelvic ring
fractures, the definitive osteosynthesis of joint injuries,
completing ventral spondylodesis for unstable verte-
bral fractures, and definitive soft-tissue coverage by
skin grafting and/or secondary wound closure [24, 31,
64, 87–89, 92].
During the phase of immunosuppression (Table 2)
no surgery should be performed due to the high sus-
ceptibility to a “second-hit” injury with an increased
risk of complications such as developing sepsis and
multiple organ failure [24, 86]. Only after the 3rd week
should further reconstructive operations be performed,
if required. These include secondary cancellous bone
European Journal of Trauma 2005 · No. 3 © Urban & Vogel
grafting and definitive orthopedic reconstructive inter-
ventions aimed at restoring a good functional long-term
result.
Conclusion
The complex management of polytraumatized patients
can be optimized by standardized and validated ap-
proaches using well-established algorithms, such as the
ATLS® program. In addition, new concepts in recent
years have demonstrated that highly critical polytrauma
patients in extremis have a significantly improved overall
outcome, if surgical procedures are abbreviated for the
benefit of an early transfer to intensive care. This notion
– which is in sharp contrast to the classic concept of “ear-
ly total care” – has been defined as ”damage control” sur-
gery. The kinetics of the physiological response to severe
injury must be taken into account for the timing and pri-
orities of surgical interventions in the further course after
trauma. As such, the “time window of opportunity” for
scheduled definitive surgical interventions lies between
the 5th to 10th day after injury, whereas the time of hy-
perinflammation (day 2–4) and immunosuppression
(2nd–3rd week) are associated with a high susceptibility
to iatrogenic “second hits” induced by prolonged surgical
interventions, leading to adverse outcome due to devel-
opment of sepsis and multiorgan failure. This golden bal-
ance between mandatory primary and secondary mea-
sures and the knowledge of the pathophysiological
reactions in adherence with established diagnostic and
therapeutic algorithms will help improve the overall out-
come of polytrauma patients.
Acknowledgment
Dr. Stahel is supported by grants from the German Research Founda
Ztion (DFG) No. STA 635/1-1, 635/1-2, and 635/2-1.
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Address for Correspondence
PD Philip F. Stahel, MD
Klinik für Unfall- und Wiederherstellungschirurgie
Charité – Universitätsmedizin Berlin
Campus Benjamin Franklin
Hindenburgdamm 30
12200 Berlin
Germany
Phone (+49/30) 8445-645270, Fax -4464
e-mail: pfstahel@aol.com
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