Evolving concepts and strategies in the management of polytrauma patients

Abstract

Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.

1. Introduction

The term “polytrauma” is used frequently in trauma practice and literature. Conventionally it refers to multiple injuries that involve multiple organs or systems. In the absence of a unified nomenclature for a patient with multiple trauma-related injuries, the panel of experts from all over the world initiated the step to develop an improved, database-supported definition for the polytraumatized patient.¹ Subsequently the comprehensive definition was proposed and has been labeled as ‘Berlin definition’.²

Management of polytrauma patients with orthopaedic injuries have undergone many changes in the last 4 to 5 decades. These changes have been introduced and have evolved as advancement in understanding the physiologic changes in response to injury, surgery, resuscitative measures, surgical methods, and perioperative management strategies have occurred. Complication rates have decreased owing to improvement in factors related to the safety of passengers in motor vehicle accidents and clinical management of polytrauma patients.3, 4, 5, 6, 7

Trauma remains a major public health concern due to the high cost, loss of productive life, and societal dependency due to disability. Baker et al. have proposed that the trimodal distribution of deaths is observed following road traffic accidents. The first peak occurs at the scene of injury, the second peak in the emergency department (ED), and the third peak during hospitalization.⁸ Recently, Santry et al. have proposed a quadri modal distribution of deaths with the fourth peak occurring after the discharge of the patient.⁹

Apart from predicting patients who would develop complications during management, improvement in the clinical result of polytrauma patients with fractures may be attributed to the staged fracture fixation and individualized treatment strategies.^10,11

Golden hour is a very well-known term used by trauma surgeons. Conventionally, it refers to the first hour after injury in which a patient should receive definitive care to decrease morbidity and mortality.¹² However, considering the limitations of the transport of injured victims to a definitive center, the timing may be extended based on the clinical assessment of the patient.

We provide a narrative review of current models of trauma care with a focus on three pillars of managing polytrauma which include resuscitation, damage control orthopaedics, and trauma-related coagulopathy. A detailed search was done by two authors from Pubmed/Medline, Embase, and Google scholar databases till September 20, 2020. The keywords used for the search included ‘polytrauma’, ‘resuscitation’, damage control orthopaedics’, and ‘trauma related coagulopathy’. These articles were checked for their suitability to be considered for this review. Manuscripts were further checked in the bibliography for any missing publications and these were manually retrieved from databases. This review included prospective, retrospective, randomized, non-randomized, and observational studies.

2. Evolving models of polytrauma care

2.1. Definition of polytrauma

The definition and classification of ‘Polytrauma’ has evolved over the last few decades. The first formal definition of ‘Polytrauma’ in English literature was by Border et al., in 1975 wherein a polytrauma patient was defined as having two or more significant injuries.¹³ Tscherne et al., in 1984 added the concept of ‘‘significant injuries,’’ with polytrauma defined as two or more injuries, among which at least one injury or the sum of all injuries is life-threatening to the original definition.¹⁴ Since then anatomical and physiological definitions of polytrauma have been proposed, predominantly based on Injury Severity Score (ISS) with modifications.¹⁵ Till a long time, an ISS >15 has been used as the definition of polytrauma.¹⁶ The Abbreviated Injury Score (AIS) which specifies the involvement of more than one ISS body region-gained in acceptance with polytrauma as injury with AIS >2 in at least two ISS body regions allowed us to capture the greatest percentage of worst outcomes.¹⁷ Despite well described shortcomings, the AIS scale and the ISS continued to be the most relevant scales to assess injury severity.¹⁸ To provide an objective assessment to include both anatomical and physiological elements of polytrauma, an international panel of experts from all over the world initiated a step to develop an improved, database-supported definition for the polytraumatized patient which is now called the ‘Berlin Definition’.¹ (Table 1).

Table 1.

Evolution of Definition and classification of Polytrauma.

Authors	Year/Decade	Definition of polytrauma
Border JR et al	1975	Polytrauma patient was defined as having two or more significant injuries
Baker SP et al	1974	Proposed anatomical based injury score -The injury severity score (ISS).
Tscherne et al	1984	Added the concept of ‘‘significant injuries’’- where one of the injury is life threatening.
Pape HC et al	2000	Highlighted an ISS ≥18 as a definition of polytrauma
Butcher N et al	2012	Suggested AIS >2 in at least two body regions: a potential new anatomical definition of polytrauma
“Berlin Definition”	2014	Polytrauma is defined as “a significant injury of 3 or more points in 2 or more body regions with one or more variables from five physiological parameters namely age, consciousness, hypotension, coagulopathy and acidosis".

Abbreviations: ISS= Injury Severity score; AIS = Abbreviated Injury Score.

2.2. Berlin definition

As per new ‘Berlin definition’, Polytrauma is defined as “a significant injury of 3 or more points in 2 or more body regions with one or more variables from five physiological parameters namely age, consciousness, hypotension, coagulopathy and acidosis".

2.3. Models of care and fracture fixation guidelines

Definitive fixation of fracture is still a controversial topic. Many management protocols have evolved [19] (Table 2). In the 1970s, early fracture fixation was advocated to prevent fat embolism syndrome. Multiple studies had shown decreased pulmonary complications and improved patient outcomes after early fracture fixation in polytrauma patients.^20,21

Table 2.

Evolution and characteristics of models of Polytrauma care.

	Concepts	Early Total Care (ETC)	Damage Control Orthopaedics (DCO)	Early Appropriate Care (EAC)	Safe Definitive Surgery (SDS)	Prompt individualized safe management (PRISM)
1	Year	1989	2000	2013	2015	2017
2	Philosophy	Early fixation of long bones as soon as possible prior to 48–72 h ‘at risk’ period. Early Stabilization Aggressive resuscitation	Involves staged management - - ‘Definitive’ management after physiology improves to avoid ‘Second Hit’ to the patient during vulnerable period. Hemostatic Resuscitation	Fracture definitive fixation guided by laboratory parameters such as lactate and pH.	Definitive surgery in stable patients and DCO in unstable patients.	Doing no further harm. No need to assign a protocol to patient. Individualized treatment to each patient. Use of different physiological parameters to assess patient’s condition and then proceed accordingly.
3	Advantages	Decrease in pulmonary complications. Reduce Fat Embolism Syndrome Facilitates nursing care	Prevents blood loss and hypothermia, less operative time.	Physiological and Biochemical rationale	Same as DCO and prevents two surgeries in some patients	Considers the local healthcare resources available in each hospital/country. Assessment of the patient in great details with age, gender, co-morbidities and pregnancy into consideration. Consider On-going response to resuscitation and evaluation. No timeline cut offs is used ie 24 and/or 36 h. Use of inflammatory mediators and Intra-operative reassessments
4	Disadvantages	Led to exacerbation of ‘Second Hit’ in a subset of patients with haemodynamic instability e.g. Extremely high ISS	Two surgeries are required, increased cost of treatment and hospital stay.	–	–	-

Abbreviations: ISS= Injury severity score.

2.4. Early total care (ETC)

In 1989, Bone LB et al. conducted a randomized controlled trial to evaluate the concept of Early Total Care (ETC) in which definitive fracture fixation of long bone was carried out within 24 h of injury. This study showed a decrease in pulmonary complications such as fat embolism, acute respiratory distress syndrome (ARDS) and sepsis-related mortality with the integration of ETC.²² However, subsequently, it was observed that ETC was associated with “second-hit” in patients with hemodynamic instability, head, and/or chest injuries. It was noticed that the rate of intraoperative complications was increased, and patients had a lower Glasgow coma score at discharge in polytrauma patients when fracture fixation was carried out early compared to those patients in whom it was delayed.²³ It was postulated that early fracture fixation may be harmful to those patients who are more severely injured.

2.5. Damage control orthopaedics (DCO)

In this concept, the priority was given to the improvement in the physiology by supportive interventions as per assessment before definitive trauma management is initiated. It replaced the earlier concept of ETC because patients were “too sick not to operate”. The concept of damage control came to the medical field from the United States (US) naval war term of the same name. The purpose of damage control in the US navy in wartime was to keep the ship afloat at all costs after taking fire, to return to the port safely and then perform the definitive repair. Rotondo et al., in year 1993 applied this concept to the management of penetrating abdominal injuries and later Scalea et al., in 2000 extrapolated this to fracture fixation management. They postulated that external fixation of bony injuries initially would require less operative time, prevent blood loss and hypothermia, and potentially would prevent patients from ‘second hit’ of definitive surgery; trauma being the first hit.^24,25

Certain parameters like Injury Severity Scale (ISS) > 40 (without thoracic trauma), ISS >20 with thoracic trauma, Glasgow Coma Scale (GCS) of 8 or below, multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs, hypothermia <35 °C, head injury with Abbreviated Injury Scale (AIS) of 3 or greater, IL-6 values above 500 pg/dL were the important parameters for DCO. Even with the emergence of this concept, the most optimal timing for definitive fixation remained controversial. It was observed that patients of trauma had an acute inflammatory period of 2–5 days after inflicting trauma and remained at increased risk of ARDS, multi-organ failure. In view of these concerns, it is suggested to provide definitive management only to patients who have potentially life-threatening injuries like an unstable pelvic fracture, compartment syndrome, fractures with vascular injuries, unreduced dislocations, traumatic amputations, unstable spine fractures, Cauda equina syndrome, and open fractures. The emerging concept of the damage control resuscitation (DCR) along with coagulopathy assessment, its optimization, and lactate clearance has improved overall surgical outcome. This has avoided overzealous untimely definitive surgeries and thus avoiding adverse outcomes (Fig. 1).26, 27

Fig. 1.

Flow chart depicting concepts of Early Total Care and Damage Control Orthopaedics.

3. Early appropriate care (EAC)

EAC has emerged as a safer concept with identifying and triaging the need of the patients with regards to the need for definitive care vs an attempt for optimization of physiology before attempting definitive care. EAC emphasized managing the most time-critical orthopaedic injuries only and others after optimal resuscitation to minimize secondary inflammatory response. Vallier HA et al. recommended EAC in which fracture was definitively fixed once lactate levels were ≤4 mmol/L, pH i ≥ 7.25, or base excess ≤5.5. It is thus like ETC with an emphasis on metabolic acidosis.²⁸ Correcting base abnormalities, the goal has been to definitively treat spine, pelvis, femur, and acetabulum fractures within 36 h of injury. This is expected to decrease delay to surgery complication rates.

4. Safe definitive surgery (SDS)

Pape et al., in 2015 introduced a new and dynamic concept for fracture fixation in polytrauma patients. They proposed to divide patients into 3 groups based on primary trauma assessment-borderline, unstable, and extremis based on clinical grading system (CGS). CGS was based on shock (blood pressure, transfusion requirement, lactate levels, base deficit and urine output), temperature, coagulation (platelet count, factor II and V, fibrinogen and D-Dimer level) and soft tissue injury (chest trauma score, abdominal trauma, pelvic and extremity trauma). Once resuscitation was started, the secondary assessment was done and patients were divided into 4 groups-stable (Grade I), borderline (Grade II), unstable (Grade III), and extremis (Grade IV) based on CGS. In a stable group, SDS was done on and DCO was applied to other groups. These patients were routinely assessed multiple times and when they became stable, definitive surgery was planned in whom DCO was applied previously.^27,29

5. Prompt individualized safe management (PRISM)

Giannoudis PV et al., in 2017 proposed the PRISM philosophy. They emphasized that each patient reacts differently to trauma and healthcare resources are differently distributed in different countries. So, to categorize the patients into specific protocols, the individualized treatment may be overlooked. They proposed that surgeons may apply different strategies and remain flexible in management to suit best to patients. Authors proposed to use physiological parameters (such as hemoglobin, pulse rate, blood pressure, pH, lactate levels, lung function, etc.), injury patterns, age, and comorbidities to get a complete picture of the status of the patient and then proceed for the individualized treatment plan – be it ETC or DCO.³⁰ The key decision is required for the appropriate timing of major fracture care in polytrauma patients.³¹

6. Resuscitation

The “Airway, Breathing, Circulation, Disability, Exposure (ABCDE)" approach of management by Advanced Trauma Life Support (ATLS) increases efficiency and quality of care in polytrauma patients. The priority remains the identification and stabilization of potentially life-threatening injuries. In patients with polytrauma, the resuscitation of vital functions should be started with the primary survey. The compromised airway being the biggest and fastest killer, it needs to be assessed and managed at the earliest followed by breathing, circulation, and neurological insults. Patients with severe head injury with a Glasgow Coma Score (GCS) of 8 or less also necessitates the need for a definitive airway for the purpose of its protection from aspiration and at times, for ventilator support as well. Injury to the chest with subsequent hemothorax and or pneumothorax should be identified.³²

The identification of hemorrhage, rapid, and accurate assessment of hemodynamic status, and controlling them appropriately is important. Definitive control of hemorrhage is essential rather than aggressive and continued volume resuscitation as this can increase mortality and morbidity. A study by Ley et al. concluded that “evaluated trauma patients receiving fluid in the emergency found that crystalloid resuscitation of more than 1.5 L independently increased the odds ratio of death".³³

So, to avoid the risk for coagulopathy, in such a situation after fluid therapy due to blood loss and dilutional coagulopathy, it is prudent to consider the transfusion of appropriate blood products. The concept of transfusion of blood products as 1:1:1 of blood: plasma: platelets are reported. Another important step is to prevent hypothermia and thus the ED temperature should be controlled accordingly.

Physiological parameters such as pulse rate, blood pressure, pulse pressure, ventilatory rate, arterial blood gas (ABG) analysis, body temperature, and urinary output should be checked as they reflect the adequacy of resuscitation. The patient is said to be resuscitated if stable hemodynamic, no hypoxemia, normal coagulation, normothermia, normal urine output, serum pH toward normal. The trends towards normal physiology indicate effective resuscitation. The aim is to prevent the lethal triad of coagulopathy, hypothermia, and acidosis.

7. Trauma associated coagulopathy

7.1. Types

Coagulopathy associated with trauma together with hypothermia and academia form constituents of the “triad of death”. Coagulation abnormalities in polytrauma patients present in 2 forms- Acute coagulopathy of trauma (ACT) and Resuscitation associated coagulopathy (RAC). It has been seen that traumatic coagulopathy relates to continued hemorrhage and resuscitative measures (intravenous fluids and massive blood transfusion); however, some trauma patients can present with an established coagulopathy. This Acute Coagulopathy of Trauma Shock (ACoTS) has been associated with four times more likelihood of death, acute renal injury, multi-organ failure, and longer intensive and hospital inpatient stay.³⁴

7.2. Acute coagulopathy of Trauma Shock (ACoTS)

ACT which develops after an injury and before any resuscitative efforts have been made. Trauma patients with a combination of Injury severity score (ISS) ˃25, pH ˂7.10, temperature ˂34 °C, and systolic blood pressure ˂70 mmHg have a 98% likelihood of developing life-threatening coagulopathy.^35,36

7.2.1. Mechanism of ACoTS/Physiological basis of ACoTS

The mechanism by weights ACoTS is not well known but appears to be due to activation of the protein C pathway.³⁷ Other proposed mechanisms for this acute coagulopathy include “activation of protein C, endothelial glycocalyx disruption, depletion of fibrinogen, and platelet dysfunction".³⁸ It is postulated Protein C dysfunction and acidemia is precipitated due to hypothermia.

7.3. Factors influencing ACoTS-

1. ISS is well correlated with coagulopathy and its severity seen in trauma victims.^39,40

2. Shock with tissue hypoperfusion is another leading contributor to the development of ACoTS. The base deficit is associated with prolonged clotting times. Higher ISS and shock thus are associated with an increasing incidence and severity of ACoTS.³⁹

3. Generous fluid administration in the trauma victim leads to hemodilution (dilutional coagulopathy), detrimental effect on clotting function, or direct impairment of clot formation or strength. These all factors lead to increased blood loss and impediment to definitive surgery as well.^40,41

4. Hypothermia after injury may be another cause for the initiation of ACoTS.³⁸

7.3.1. Early identification of ACoTS and the role of dynamic coagulation tests

It is necessary to reduce mortality and morbidity. Early identification of coagulopathy in trauma victims in ED itself helps in decision making for further management and the outcome.³⁵ Platelet counts activated partial thromboplastin time (APTT), the prothrombin time (PT), International normalized ratio (INR) are the standard parameters to diagnose coagulation abnormalities. However, these tests only assess the initial phase of blood coagulation.⁴² Though these classical tests, evaluating components of ‘clotting cascade’ do act as a baseline, they do take time to process, hence point of care coagulometers could be used to expedite the processing time in a dynamic changing situation of ACoTS.⁴³ Tests such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) have been developed to dynamically assess the coagulation function in patients.^44,45 Despite the increase in the clinical use of these dynamic tests, a systematic review has found no to little evidence for the accuracy of these tests while others found that there is limited evidence to support these tests for diagnosing ACT.^46,47 However, the European Task Force for Advanced Bleeding Care in Trauma has a strong recommendation for the routine use of viscoelastic tests along with conventional tests to monitor and diagnose coagulopathy in polytrauma patients.⁴⁸

7.4. Resuscitation associated coagulopathy (RAC)

Resuscitation coagulopathy complicates acute traumatic coagulopathy due to rapid infusion of crystalloid and colloids can lead to a dilution of procoagulant factors. Further crystalloid transfusion causes endothelial injury leading to a reduction in circulating clotting factors. The other factor which causes RAC is hypothermia acidosis and reduced ionized calcium (Ca2+) concentration. (Fig. 2). Viscoelastic testing (VET) such as ROTEM and TEG, a monitoring tool in many trauma centers helps in the comprehensive depiction of the coagulation process.⁴⁹ The aim of DCR should minimize any resuscitation-induced coagulopathy and correction of any existing coagulopathy. The key elements of DCR include control of hemorrhage, permissive hypotension, hemostatic resuscitation, prevention/correction of acidosis, hypothermia, and correction of hypocalcemia. Most recent guidelines suggest that a balanced transfusion ratio consists of fresh frozen plasma: platelets: RBCs in a ratio of 1:1:1 strategy and early administration of tranexamic acid should be started immediately.^48,50 In some European trauma facilities, the use of various agents like fibrinogen concentrate or prothrombin complex concentrate as part of hemostatic management has been advocated.⁴⁹

Fig. 2.

Pathophysiology of Trauma associated coagulopathy.

7.5. Major hemorrhage protocol guidelines

National Health Service (NHS), mid and south Essex hospital groups provide applicable guidelines for the management of Major Hemorrhage (MH). Activation of the MH protocol and information to the Blood Transfusion Department for MH is described.⁵¹

Recommendations include:

• •Maintenance of oxygen saturation followed by the establishment of a minimum of 2 large-bore intravenous access points and infusion of 1–2 L (or if a child 10–20 mL/kg) of crystalloid or colloid.
• •Blood products in 1:1:1 ratio as soon as possible.
• •The use of cell salvage to reduce the requirement for bank blood.
• •Use of Prothrombin Complex Concentrate (PCC); clotting factor concentrates (factor VIIa) where appropriate.
• •In both adult and paediatric patients’ appropriate doses of intravenous tranexamic acid.
• •Mechanical control of hemorrhage by the external compression by sheet or binder, C- Clamp, anti-shock iliosacral screw, angiography, pelvic packing, and Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA) may be tried simultaneously to reduce the bleeding source.

8. Patient outcomes from clinical studies

The following section highlights patient related factors, interventions, and outcomes in polytrauma from some recent studies.

8.1. Early coagulation support (ECS)

Includes prompt infusion of tranexamic acid, fibrinogen concentrate, and packed red blood cells helps in reducing blood product consumption compared to the massive transfusion protocol for initial resuscitation of major trauma patients.⁵²

8.2. Psychosocial rehabilitation

Due to the improvement in philosophy of trauma care from early total care to prompt individualized safe management, use of early advanced trauma life support, improved quality in healthcare services, advancement in management options and more stringent traffic rules and safety, the overall survival rates after polytrauma are increasing. However long-term and short-term burden such as problems in mobility, self-care, activity of daily living, work-related disability continues to have impact on socioeconomic and quality-of-life in many patients. Recovery from these trauma-related problems is dependent upon severity of the injury as well as psychosocial factors. Although psychosocial intervention did not change the recovery of physical function; these interventions should not be abandoned because the greatest gains in function occurs early in recovery after trauma, which is the key time in transition to home placement.⁵³

8.3. Obesity

Early mobilization is required to gain mobility and minimize morbidity especially in obese patients as higher Body Mass Index (BMI) increases the risk of longer hospital stays and systemic complications in polytrauma patients.⁵⁴

8.4. Polytrauma in older patients

A recent analysis of Dutch trauma registry data of more than 25,000 polytrauma patients showed that older patients had poor outcome and are at a higher risk of morality than younger patients despite sustaining less high-energy accidents. Patients older than 75 years showed a unique trimodal distribution of mortality with a later onset of events by one week following the initial trauma. Medical optimization of comorbid conditions during trauma hospitalization is increasingly important. Development of a multidisciplinary dedicated trauma service is associated with increased trauma team activation rate as well as better survival rates in geriatric trauma patients.^55,56

8.5. Independent predictors of mortality in polytrauma patients

Evaluation of predictors of mortality across all stages of trauma care, from the pre-hospital phase to the emergency room, surgical center, ICU and thirty days after hospital discharge reveals arterial oxygen saturation, diastolic blood pressure, lactate level, Glasgow Coma Scale, infused crystalloid volume and presence of traumatic brain injury are independent early mortality predictors.⁵⁷

8.6. Malnutrition and outcomes in polytrauma

The nutritional status of trauma patients should be routinely and carefully monitored as in hospitalized patients. Malnutrition is an independent risk factor for complications, mortality, prolonged hospital length of stay with declined quality of life.⁵⁸

8.7. Gender and polytrauma

Recent studies demonstrated that the women are at risk for a prolonged in-hospital rehabilitation time after major trauma though there is an overall lower in-hospital mortality rate and increased likelihood for ICU admission.^59,60

9. Conclusion

The evolving models of polytrauma care have highlighted the need for early identification and appropriate timely management of key parameters like hypothermia, coagulopathy, and intervention of potentially life-threatening injuries before the definitive management of the trauma is initiated. The concept of damage control resuscitation, dynamic analyses of coagulopathy, and lactate clearance as critical pillars in the management of polytrauma. Optimal resuscitation, transfusion protocols, and balanced timely surgical care will help the management of polytrauma patients to improve outcomes.

Author’s contributions

VJ and KPI involved in Conceptualization, literature search, review, and editing. GKU and RG involved in literature search, writing, editing, drafting, RV writing, editing, drafting of the manuscript. All authors have read and agreed on the final draft submitted.

Disclosure

None.

Funding of the study

No funding was involved in this study.

Declaration of competing interest

The authors declare No conflict of interest.