POLYTRAUMA
I MADE ARYA SUSILA
DEFINITION
Syndrome of multiple injuries exceeding a defined severity (ISS > 16) with
sequential systemic traumatic reactions which may lead to dysfunction or
failure of remote organs and vital systems, which had not themselves been
directly injured.
International consensus (2014) : presence of two injuries that are greater or equal to 3 on
the Abbreviated Injury Scale (AIS) and one or more of the following additional conditions:
• Hypotension (systolic blood pressure ≤ 90 mm Hg)
• Unconsciousness (Glasgow coma scale [GCS] score ≤ 8)
• Acidosis (base deficit ≤ 6.0)
• Coagulopathy (partial thromboplastin time ≥ 50 seconds or International Normalized
Ratio ≥ 1.4)
• Age (70 ≥ years)
INJURY SEVERITY SCORE (ISS)
• The Injury Severity Score (ISS) is an established medical score to assess
trauma severity.
• It correlates with mortality, morbidity and hospitalization time after
trauma.
• The AIS Committee of the “Association for the Advancement of Automotive
Medicine” (AAAM) designed and improves upon the scale.
• It is used to define the term major trauma. A Polytrauma is defined as the
Injury Severity Score being greater than 16.
• Interpretation ISS >16 associated with mortality of 10%
• It is the :
– first scoring system to be based on anatomic criteria
– defines injury severity for comparative purposes
• To calculate an ISS for an injured person, the body is divided into six ISS body
regions :
– 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
INJURY SEVERITY SCORE
Abbreviated Injury Score (AIS)
Score to measure the severity of a trauma
1 Minor
Measure 6 regions of body 2 Moderate
3 Serious
• Head & neck
• Face 4 Severe
• Chest 5 Critical
• Abdomen
• Extremity 6 Unsurviveable
• External ISS
Each regions is measured with abbreviated injury score (AIS) 1-8 Minor
9-15 Moderate
The score is the sum of the square of 3 highest score 16-24 Serious
25-49 Severe
Ranges from 1 to 75
50-74 Critical
≥75 Maximum
If one of the region has a score of 6 → ISS = 75
INJURY SEVERITY SCORE (ISS)
• ISS = sum of squares for the highest AIS grades in the three most
severely injured ISS body regions
• ISS = A² + B² + C²
• where A, B, C are the AIS scores of the three most severely injured
ISS body regions
• Range from 1-75 (If an injury is assigned an AIS of 6 (unsurvivable
injury), the ISS score is automatically assigned to 75)
• Minor < 9, Moderate 9 - 16, Serious 16 - 25, Severe Injury > 25
Hemorrhage: unstable pelvic ring injuries, femoral shaft fractures,
multiple long-bone fractures, and open injuries.
Contamination: open fractures must always be considered as
contaminated
IMPORTAN Dead, ischemic tissue with a hypoxic zone at the margin: in unstable,
displaced open fractures, especially after high-energy impact, a
CE OF radical soft-tissue debridement is necessary as soon as possible to
remove this source of pro-inflammatory mediators.
FRACTURE
Ischemia-reperfusion injury: prolonged hypovolemic shock and
S compartment syndrome related to fractures with or without vascular
injuries are prone to ischemi are perfusion injury with microvascular
damage due to oxygen radicals.
Stress and pain: unstable fractures cause pain and stress which, via
afferent input to the central nervous system, stimulate a
neuroendocrine, neuroimmunological, and metabolic reflex arcs.
Interference with intensive care: unstable fractures prevent effective
patient postures (eg, upright chest), and pain-free patient
movement.
Control
Control of
contamination
hemorrhage
sources
AIM OF
FRACTURE Prevention of
MANAGEMENT ischemia- Pain relief
reperfusion injury
Facilitate
ventilation,
nursing, and
physiotherapy
TIMING AND PRIORITIES OF
SURGERY
First priority is resuscitation to ensure
adequate perfusion and oxygenation
of all vital organs → intubation,
ventilation, and volume replacement.
Decompression of body cavities
(tension pneumothorax, cardiac
tamponade, epidural hematoma).
If not successful → immediate life-
saving surgery
Control of exsanguinating hemorrhage
(massive hemothorax or
hemoperitoneum, crushed pelvis,
whole limb amputation, “mangled
Control of hemorrhage and
extremity”).
contamination, irrigation, packing,
provisional closure of the wound or
abdominal cavity, and stabilization of
the physiological systems in the
intensive care unit (ICU) may be
followed by definitive surgery after 6–
12 hours.
ALGORITHM FOR INITIAL ASSESSMENT,
LIFE SUPPORT, AND DAY-1-SURGERY
CRITERIA AND STRATIFICATION
• Definitive osteosynthesis as “day-1-surgery” is advisable only when all
the endpoints of resuscitation have been accomplished
Damage control can be used in two circumstances:
• Reactively: “bail-out” surgery, which means aborting invasive procedures
in a patient at imminent risk of death.
• Preemptively: calculated early decision to accomplish definitive repair in
staged sequential procedures due to inadequate resuscitation or a high
risk of physiological deterioration.
If there is a positive response to
resuscitation, the phase of
delayed primary surgery can
start.
Conditions should be treated
with high priority:
Limb-threatening and disabling injuries Long bone fractures (especially femoral
(including open fractures) require at shaft fractures), unstable pelvic
least “damage control”: debridement, injuries, highly unstable large joints,
fasciotomies, reduction, fixation, and and spinal injuries require at least
revascularization. provisional reduction and fixation.
Between the fifth and tenth day post trauma there exists an
immunological window of opportunity when the phase of
hyperinflammation decrease → definitive surgery of long bone fractures
shaft and articular can be performed in relative safety.
Period of immunosuppression (about 2 weeks) → secondary
reconstructive procedures can be planned for the third week post
trauma
PRIORITY SURGERY TIMING
CONCLUSION
Algorithms are meant to
optimize the physiological
Polytrauma must be state of patients prior to
The primary objective is
considered as a systemic non-lifesaving surgery and
survival of the patient
surgical disease to provide procedures
which are safe, simple,
quick, and well executed
REFERENCE :
Buckley, R.E., Moran, C.G. and Apivatthakakul, T., 2017. AO Principles of Fracture
Management: 3rd Ed. Thieme
Eftekhari, A. 2019. The Most Common Tools to Measure Trauma Severity: A
review Study. 2, 115–123.
Dario, N. & Ramirez, G. 2016. Trauma severity scores. Colombian Journal of
Anesthesiology, 44, 317–323
THANK YOU
