“Damage Control” in Severely Injured Patients

Abstract The concept of “damage control” is established in the management of severely injured patients. This strategy saves life by deferring repair of anatomic lesions and focusing on restoring the physiology. The “lethal triad” hypothermia, coagulopathy, and acidosis are physiological criteria in the selection of injured patients for ”damage control”. Other criteria, such as scoring of injury severity or the time required to accomplish definitive repair, are also useful in determining the need for ”damage control”. The staged sequential procedures of ”damage control” include, after the selection of patients (stage 1), “damage control surgery” or “damage control orthopedics” (stage 2), resuscitation in the intensive care unit (stage 3), “second–look” operations or scheduled definitive surgery (stage 4), and the secondary reconstructive surgery (stage 5). The concept of ”damage control” was carried out in a third of 622 severely injured patients in our division. Although level I evidence is lacking, the incidence of posttraumatic complications and the mortality rate were reduced. However, better understanding of the significance and kinetics of physiological parameters including inflammatory mediators could help to optimize the “damage control” concept concerning the selection of patients and the time points of staged sequential surgery.     

Aktuelle Konzepte des Polytraumamanagements: Von ATLS zu „Damage Control“

In recent years, the implementation of standardized protocols for polytrauma management has led to a significant improvement in trauma care as well as to a decrease in post-traumatic morbidity and mortality. As such, the "Advanced Trauma Life Support" (ATLS) protocol of the American College of Surgeons for the acute management of severely injured patients has been established 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 patients with immediate life-threatening injuries. These phase-oriented therapeutic strategies appraise the injured patient of the whole extent of the sustained injuries and are in sharp contrast to previous modalities of "early total care" which advocate immediate definitive surgical intervention. The approach of "damage control" surgery takes into account the influence of systemic post-traumatic inflammatory and metabolic reactions of the organism and is aimed at reducing both the primary and the secondary, delayed, mortality in severely injured patients. The present paper provides an overview of the current state of management algorithms for polytrauma patients, with a focus on the standard concepts of ATLS and "damage control".     

Timing of intervention for spinal injury in patients with polytrauma

ObjectiveThe optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores.MethodsA narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995–2020) based on the keywords – polytrauma OR multiple trauma AND spine fracture AND timing, present in “All the fields” of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed.ResultsSpine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, “damage control” internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay.ConclusionRecognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.     

ATLS? and damage control in spine trauma

Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patient's immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS^? polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS^? protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient.     

ATLS® and damage control in spine trauma

Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patient's immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS^® polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS^® protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient.     

European Trauma Course

The growing appreciation that good trauma care makes a difference in survival and the increasing complexity of the care process have generated an international demand for multidisciplinary trauma education, which is not being met at present. Therefore, the European Trauma Course (ETC) was developed on behalf of the European Resuscitation Council (ERC), the European Society of Trauma and Emergency Surgery, the European Society of Emergency Medicine and the European Society of Anaesthesiology. The ETC was officially launched during the ERC biennial conference 2008 in Ghent. As ATLS^® (?Advanced Trauma Life Support^®“) represents the standard of trauma education to date, the ETC is the first internationally recognised and certified training course for the initial care of the severely injured with a strong focus on team training. Its modular design allows for adaptation to the differing regional European environments.     

Current updates in management of extremity injuries in polytrauma

Injury-related morbidity and mortality have been one of the most common causes of loss in productivity across all geographic distributions. It remains to be a global concern despite a continual improvement in regional and national safety policies. The establishment of trauma care systems and advancements in diagnostics and management have improved the overall survival of severely injured. A better understanding of the physiopathological and immunological responses to injury led to a significant shift in trauma care from “Early Total Care” to “Damage Control Orthopedics.” While most of these algorithms were tailored to the philosophy of “life before limb,” the impact of improper fracture management on disability and societal loss is increasingly being recognized. Recently, “Early Appropriate Care” of extremities has gained importance; however, its implementation is influenced by regional health care policies, available resources, and expertise and varies between low and high-income countries. A review of the literature was performed using PubMed, Embase, Web of Science, and Scopus databases on articles published from 1990 to 2020 using the Mesh terms “Polytrauma,” “Multiple Trauma,” and “Fractures.” This review aims to consolidate on guidelines and available evidence in the management of extremity injuries in a polytraumatized patient to achieve better clinical outcomes of these severely injured.     

Impact of trauma societies on the clinical care of polytrauma patients

Introduction

Trauma societies have an influence on the management and outcome of polytrauma. Its contributions include setting up standard definitions, trauma registries, evidence-based medicine guidelines, and the creation of educational tools such as specific courses of trauma care and decision-making.

Methods

Literature and web-based search of definitions and available information.

Results

The history of and accomplishments of trauma societies in the above-mentioned domains are reviewed, including the major trauma registries (Major Trauma Outcome Study, National Trauma Data Bank, The American Pediatric Surgical Association, the American Burn Association trauma, and the German Trauma Society trauma registries). Several learned societies in the field of trauma have created recommendations and/or guidelines concerning polytrauma (the Eastern Association for the Surgery of Trauma, The Society of Critical Care Medicine, and the German Trauma Society, Brain Trauma Foundation, and the Essential Trauma Care (EsTC) Guidelines). Several practical, hands-on courses and scoring systems for improving the quality of management of polytrauma patients have been founded and implemented in the past 35?years, including the Advanced Trauma Life Support (ATLS^?) Course of the American College of Surgeons, the Definitive Surgical Trauma Care (DSTC^TM) Course, the National Trauma Management Course (NTMC^TM Course,) the Advanced Trauma Operative Management (ATOM) Course, and the European Trauma Course (ETC).

Conclusions

Trauma and emergency care societies have made an elaborate, substantial contribution by developing trauma registries and creating specific guidelines courses on trauma care and decision-making.     

Metabolic changes after polytrauma: an imperative for early nutritional support

Major trauma induces marked metabolic changes which contribute to the systemic immune suppression in severely injured patients and increase the risk of infection and posttraumatic organ failure. The hypercatabolic state of polytrauma patients must be recognized early and treated by an appropriate nutritional management in order to avoid late complications. Clinical studies in recent years have supported the concept of "immunonutrition" for severely injured patients, which takes into account the supplementation of Ω-3 fatty acids and essential aminoacids, such as glutamine. Yet many aspects of the nutritional strategies for polytrauma patients remain controversial, including the exact timing, caloric and protein amount of nutrition, choice of enteral versus parenteral route, and duration. The present review will provide an outline of the pathophysiological metabolic changes after major trauma that endorse the current basis for early immunonutrition of polytrauma patients.     

Response of fingertip circulation to local warming in the injured hand—A study using laser doppler flowmetry

A laser Doppler flowmeter was used to assess the fingertip circulation serially in 41 patients with various hand injuries. The “flux value” measures the flow of red cells across the site of assessment and the “fluctuation” represents the pulsatile peak-trough difference in flux value with each cardiac contraction. Local temperature at the fingertip was raised stepwise by a special heater-thermostat from 36 to 44°C. Compared to the normal hand both the flux value and fluctuation in the injured hand are smaller at lower temperatures. The differences narrow down at higher temperatures and the trend reverses above 42°C and remains so on cooling. This may represent abnormal sympathetic tone in the injured hand.     

Initial management of the polytrauma patient

Trauma is the leading cause of death among those aged less than 40 years in the UK. This article highlights the management principles for treating the multiply injured patient, based on the algorithm devised by the American College of Surgeons Committee on Trauma called the Advanced Trauma and Life Support^® guidelines. These guidelines focus on the ABCDE approach, which stands for Airway and cervical spine control, Breathing, Circulation, Disability/neurological status and Exposure. The algorithm was devised to create a common structured approach to managing any patient involved in trauma. It also ensures that life-threatening injuries are identified and treated first, before moving on to treat limb-threatening injuries. The final aim is to identify all the injuries. The principles of treating the multiply injured can be divided into four phases: primary survey (ABCDE) and resuscitation, re-evaluation, secondary survey (full head-to-toe examination) and transfer to definitive care. Using these principles, problems are identified and addressed in a stepwise manner in a sequence that allows all injuries to be identified. Should the patient's condition deteriorate at any stage, the attending team must restart the primary survey at A (airway) once again.     

Management of polytrauma patients in the UK: Is there a ‘weekend effect’?

Background/purposeIt has been suggested that hospital admission during weekends poses a risk for adverse outcomes and increased patient mortality, the so-called ‘weekend effect’. We undertook an evaluation of the impact of weekend admissions to the management of polytraumatised patients, in a Level I Major Trauma Centre (MTC) in the UK.Materials and methodsA retrospective review of prospectively documented data of polytrauma patients (injury severity score (ISS) > 15), admitted between April 2013 and August 2015 was performed. Exclusion criteria included patients initially assessed in other institutions. All patients were initially managed at the emergency department (ED) according to ATLS^® principles and underwent a trauma computed tomography (CT) scan, unless requiring immediate surgical intervention.ResultsDuring the study period 1735 patients (pts) were admitted under the care of the MTC. Four hundred and five pts were excluded as they were transferred from other institutions and 300 pts were excluded as their ISS was less than 16. Overall 1030 patients met the inclusion criteria, out of which 731 were males. Comparing the two groups (Group A: weekday admissions (670), Group B: weekend admissions (360)), there was no difference in pts gender, mechanism of injury, GCS at presentation, need for intubation and time to CT. Patients admitted over the weekend were younger (p < 0.01) and presented with haemodynamic instability more frequently (p = 0.02). Time to operating room was also lower during the weekend, but this did not reach statistical significance (p = 0.08). Mortality was lower in Group B: 39/360 pts (10.8%) compared to Group A: 100/670 pts (14.9%) (p = 0.07). The relative risk (RR) of weekend mortality was calculated as 0.726 (95% CI: 0.513–1.027).Discussion/conclusionWeekend polytrauma patients appear to be younger, more severely injured and present with a higher incidence of haemodynamic instability (shock). Overall, we failed to identify a “weekend effect” in relation to mortality, time to CT and time to operating room. On the contrary, a lower risk of mortality was noted for patents admitted during the weekend.     

Damage control orthopaedics in polytraumatized patients- current concepts

The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable polytraumatized patients with head, chest, abdomen or pelvic injuries, with blood loss followed by immediate fracture fixation (Early Total Care -ETC) may be associated with secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). Development of SIRS is typically a function of the type and severity of the initial injury (the “first hit”). Immediate Fracture fixation, using reamed nails or plates, in such unstable patients with multiple injuries is subsequently defined as the “second hit” and may be associated with development of acute respiratory distress syndrome (ARDS) and multiple organ failure (MOF), with relatively high morbidity and mortality.The other alternative for long bone fracture fixation in unstable polytraumatized patients is based on immediate treatment of life threatening conditions related to the injuries, followed by the initial use of minimally invasive modular external frames for long bone fractures and is called Damage Control Orthopedics (DCO) and is widely accepted. In order to refine the DCO concept and to avoid an overuse of external fixation, the “Safe Definitive Surgery” (SDS) concept has been introduced, which is a dynamic synthesis of both strategies (ETC and DCO). The SDS strategy employs clinical parameters and includes repeated assessment of patients. The following paper is going to summarize historical backgrounds and recent concepts in treatment of polytraumatized patients.     

Iatrogenic Ureteric Injuries: Incidence,Aetiological Factors and the Effect of Early Management on Subsequent Outcome

Objective: To investigate the changing pattern in incidence, aetiological factors and the effect of early diagnosis and surgical treatment on the outcome of iatrogenic ureteric injuries in our Urology Unit over a 5 year period. Patients/Methods: All patients with ureteric injuries caused as a result of any surgical procedures (iatrogenic ureteric injuries) were studied during a 5 year period (1998–2002). Data collected and analysed included yearly incidence of injury, aetiological factors, modalities of treatment and the outcome of management of the injuries. During the study period, our general surgical colleagues had a policy of requesting “J” stent insertion prior to major abdominopelvic surgical procedures. During the same period, in nearly all difficult cases of ureteroscopy (URS) + lithoclast lithotripsy±Dormia basket, a ureteric catheter or “J” stent was prophylactically inserted by urological surgeons. Results: There were 82 iatrogenic ureteric injuries in 75 patients over the 5 year period. The total number of iatrogenic ureteric injuries declined from 26 (31.7%) in 1998 to 10 (11.8%) in 2002. Urological, obstetrics and gynaecological and general surgical procedures were involved in 69(84.1%), 7(8.7%), and 4(4.9%) of the injuries respectively. The commonest types of injuries encountered were; injury to ureteric mucosa post URS or lithoclast calculi disintegration 34 (41.5%), complete ureteric perforation 15 (18.3%) and false passage 15 (18.3%). The most severe complications encountered were complete ureteric avulsions 3 (3.75%) and loss of ureteral segment 2 (2.4%). The commonest treatment options used were “J” stent insertion or ureteric catheter placement (48, 59.4%), percutaneous nephrostomy (17, 20.7%), laparotomy and removal of suture on tied ureters (5, 6.1%). Two (2.4%) nephrectomies were performed because of poor renal function in one patient and severe damage to a functioning renal unit during a difficult retroperitoneal surgery in another patient. Recognition and treatment of ureteric injuries at the time of surgery was associated with less morbidity compared to those in whom the diagnosis was delayed. The overall successful resolution of ureteric injuries in this series was 77/82 (93.9%). There was no mortality attributable to these ureteric injuries. Conclusion: In our Unit, the incidence of significant iatrogenic ureteric injuries has shown a decline over a 5-year period. We attribute this trend to the prophylactic use of “J” stents or ureteric catheter placement and good surgical technique during major abdomino-pelvic surgeries in our hospital. Endourological procedures are the commonest causes of ureteric injuries. Prompt diagnosis and institution of appropriate corrective surgical procedures often result in a very satisfactory outcome in about 94% of cases.     

Emergency Treatment of Multiply Injured Patients with Unstable Disruption of the Posterior Pelvic Ring by Using the “C–Clamp”

Abstract Purpose: Evaluation of the therapeutic usefulness of the “pelvic C–clamp” (PCC) during emergency treatment of multiply injured patients with unstable disruption of the posterior pelvic ring. Patients and Methods: The data of 28 patients with polytrauma in combination with an unstable fracture of the posterior pelvic ring (average Injury Severity Score [ISS]: 49 points; average Polytrauma Score [PTS]: 41 points) were retrospectively analyzed from the moment they were admitted to the emergency room until 48 h after admittance. The PCC was used immediately for primary stabilization of the pelvis after clinical diagnosis of the unstable pelvic fracture. Main outcome measurements: development of mean blood pressure, development of oxygenation level, period of time until the PCC was placed, number of blood units needed, period of time until circulatory stabilization occurred. Results: The PCC was applied in all cases within an average of 64.7 min after trauma. Seven patients (25%) died within the first 45 min after admission. The surviving patients showed:• an increase in mean blood pressure of 25% 20 min after application of the PCC,• a hemodynamic stabilization 6 h after application of the PCC,• a stabilization of the oxygenation level 6 h after application of the PCC,• a decrease in the number of required blood units 6 h after application of the PCC. Conclusion: The present study shows, that the application of the PCC to critically injured patients with unstable pelvic fractures leads to stabilization of the vital parameters within a short period of time.     

Polytraumadefinition im G-DRG-System 2006

INTRODUCTION: Severely injured patients represent a relevant financial cost factor in the health system especially for high level trauma centres. The introduction of a"diagnosis-related group" (DRG) system in Germany further revealed the potential negative economic impact of severely injured patients for trauma centres. In recent years several changes of the specific DRG for severely injured patients occurred with the aim of a convenient reimbursement for the trauma patient. MATERIAL AND METHODS: The present study analysed 38 multiply injured patients admitted in the first half of the year 2004. These patients were analysed in terms of the respective DRG that was attributed to the patient on the basis of the definition criteria for 2004 and 2005. In addition for the same patient group the total inpatient treatment costs were calculated according to the algorithm developed by the Working Group on Polytrauma of the German Trauma Society. RESULTS: The analysis revealed three major problems in the reimbursement for severely injured patients according to the German DRG system: (1) In spite of the additional payment for blood compounds on top of the DRG reimbursement in 2005 a mean economic deficit of more than 4000 euro remains for each severely injured patient. (2) In 30% of the analysed trauma patients the combination of the diagnosis and operations did not lead to a specific polytrauma DRG or to an intensive care medicine DRG. (3) In the patients that could not be attributed to a polytrauma DRG, the economic deficit was with an average of more than 9000 euro even higher. This attribution aspect is also currently relevant, since the definition criteria for a polytrauma DRG were not changed in 2006 or 2007. CONCLUSION: We conclude that besides the recent changes in the reimbursement for polytrauma DRGs, which have been at least partly adapted to the real financial burden of these patients, the definition of a severely injured patient in the German DRG system may also need to be revised.     

Quantifying the need for pediatric REBOA: A gap analysis

BackgroundTrauma is the leading cause of death in children. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control, but its potential benefit has not been assessed in children. We hypothesized that there are pediatric patients who may benefit from REBOA.MethodsTrauma patients < 18 years old at a level 1 pediatric trauma center between 2009 and 2019 were queried for deaths, pre-hospital cardiac arrest, massive transfusion protocol activation, transfusion requirement, or hemorrhage control surgery. These patients defined the cohort of severely injured patients. From this cohort, patients with intraabdominal injuries for which REBOA may provide temporary hemorrhage control were identified, including solid organ injury necessitating intervention, vascular injury, or pelvic hemorrhage.ResultsThere were 239 severely injured patients out of 6538 pediatric traumas. Of these, 38 had REBOA-amenable injuries (15.9%) with 34.2% mortality, accounting for 10.2% of all pediatric trauma deaths at one center. Eleven patients with REBOA-amenable injuries had TBI (28.9%). Patients with REBOA-amenable injuries represented 0.6% of all pediatric traumas.ConclusionNearly 20% of severely injured pediatric patients could potentially benefit from REBOA. The overall proportion of pediatric patients with REBOA-amenable injuries is similar to adult studies.Type of StudyRetrospective comparative study.Level of EvidenceLevel III.     

Role of biological modifiers regulating the immune response after trauma

Trauma induces a profound immunological dysfunction. This is characterised by an early state of hyperinflammation, followed by a phase of immunosuppression with increased susceptibility to infection and multiple organ failure. Therapeutic strategies directed at restoring immune homeostasis after traumatic injuries have largely failed in translation from “bench to bedside”. The present review illustrates the role of biological modifiers of the posttraumatic immune response by portraying different modalities of therapeutic immune modulation. The emphasis is placed on anti-inflammatory (steroids) and immune-stimulatory (interferon) pharmacological strategies and modified resuscitative strategies, as well as more unconventional immunomodulatory approaches, such as immunonutrition.     

Schockraummanagement beim Schwer- und Schwerstverletzten

The treatment of most severely injured patients represents a great challenge for the trauma room team. Besides the time factor, which is a crucial cornerstone of the treatment in general and of the appropriate treatment of life-threatening injuries in particular, minor injuries and non-life-threatening injuries must also be taken into account. For this task, multidisciplinary processes play a paramount role. Advanced Trauma Life Support?, Definitive Surgical Trauma Care and the European Trauma Course represent training concepts, which predefine structured diagnostic and treatment procedures. These concepts allocate the highest treatment priority to injuries that may be immediately fatal for the patient. Besides those life-threatening injuries that are commonly summarised under the term ??deathly six??, other minor traumas should also be assessed and treated in a structured manner as they may often considerably affect the quality of life after trauma.     

Connaissance de la maladie par le patient : étude multicentrique française dans la spondylarthrite ankylosante

Objectives. – To assess knowledge of ankylosing spondylitis (AS) by patients and to identify factors associated with knowledge.Methods. – Ninety patients receiving follow-up in France for AS completed a disease knowledge auto-questionnaire yielding a correct answer score [CAS] and a correct item score [CIS]. Correlations between these scores and other factors were examined.Results. – Mean CAS was 16.4/25 (SD =4.8) and mean CIS 7.3 ±3.1/14. Female gender, higher educational level, having read about AS, being aware of AS support groups, and having received longer tertiary-care hospital management were associated with better knowledge. In the multivariate analysis, only three factors were independently associated with the level of knowledge in this population: “reading about AS”, “level of general education”, and “awareness of an AS support group”.Conclusion. – Knowledge of AS by French patients was lower than previously reported in a British population. Although education should be offered to all AS patients, the need may be greater in those with limited formal schooling. Booklets on the disease and contact with patient groups seem to be useful tools for improving knowledge of the disease.