Severely injured patients: modern management strategies

Abstract

Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors. The spectrum of injuries and their severity is quite extensive, which dictates a clear understanding of the existing nomenclature. What is defined nowadays as polytrauma or major trauma, together with other essential terms used in the orthopaedic trauma literature, is described in this instructional review. Furthermore, an analysis of contemporary management strategies (early total care (ETG), damage control orthopaedics (DCO), early appropriate care (EAC), safe definitive surgery (SDS), prompt individualised safe management (PRISM) and musculoskeletal temporary surgery (MuST)) advocated over the last two decades is presented. A focused description of new methods and techniques that have been introduced in clinical practice recently in all different phases of trauma management will also be presented. As the understanding of trauma pathophysiology and subsequently the clinical practice continuously evolves, as the means of scientific interaction and exchange of knowledge improves dramatically, observing different standards between different healthcare systems and geographic regions remains problematic. Positive impact on the survivorship rates and decrease in disability can only be achieved with teamwork training on technical and non-technical skills, as well as with efficient use of the available resources.

Keywords: damage control; early appropriate care; major trauma; management; polytrauma; review.

Figure 1

The ‘Leeds Major Trauma Risk Phaseout’ represents a graphic representation of the gradual decrease in the risk of death/disability following major trauma. These risks, at the time of the accident/’first hit’, increase significantly. All patients rely on the subsequent healthcare response to gradually restore their general state ideally to the preinjury levels (blue line). The causes of death/disability at the first stages are mostly associated with airway obstruction, severe brain injury and/or massive haemorrhage. Subsequently, complications relevant to the innate immune response to the ‘first hit’ and the magnitude and timing of surgical interventions (’second hit’) may be fatal due to multiorgan failure, infections and later pulmonary embolism. In all different phases of modern trauma care, a number of different protocols, interventions, drug therapies and surgical procedures aim to reduce the risk of death/disability (pointing-down arrows). A well-coordinated individualised strategy of management following the ‘Leeds PR.I.S.M.’ appears as a sensible model to follow. (30) ABs, antibiotics; ARDS, acute respiratory distress syndrome; ATLS, advanced trauma life support; CARS, compensatory anti-inflammatory response syndrome; CXR, chest x-ray; DCO, damage control orthopaedics; DCR, damage control resuscitation; DCS, damage control surgery; ED, emergency department; FAST, focused assessment with sonography for trauma; HAI, hospital-acquired infection; IR, interventional radiology; LRTI, lower respiratory tract infection; MOF, multiple organ failure; MTP, massive transfusion protocol; O.R., operation room/theatres; PE, pulmonary embolism; PR.I.S.M., prompt individualised safe management strategy; REBOA, resuscitative endovascular balloon occlusion of the aorta; RSI, rapid sequence induction of anaesthesia; SIRS, systemic inflammatory response syndrome; TBI, traumatic brain injury; TICU, trauma intensive care unit; TQ, tourniquet; TXA, tranexamic acid.

Figure 2

Example of the ‘Code Red theatre’ checklist used at one of the UK’s major trauma centres.