POLITRAUMATISM

A DEFINITION OF POLITRAUMATISM: severe

pathological condition as a result of aggressive agents
producing two or more major traumatic actions with immediate
or secondary vital risk. Associated and interfering lesions may
create vicious pathogenic circles.
Such interference may cause:
- Sum-up effect – with lesions not instantly deadly, but
becoming deadly when summing up (e.g. hypo-volemic
shock due to blood loss generated by bigger bones
fractures);
- Subtraction effect – when diagnosis and monitoring are
being obstructed by other vividly manifesting lesion (e.g.
abdominal lesions may be covered by coma or spine
damage);
- Amplifying effect there is a tendency towards mutual
aggravation (e.g. shock may have traumatic, metabolic,
septic, hypo-volemic dimensions that enhance one-another);

Etiology

Politraumatism can happen on many occasions:

- transport accidents – road, railway, air;

- work accidents – high level falls, mining accidents,
building-site trauma;
- natural catastrophes – earthquake, flood, etc.;
- war trauma;

Such circumstances may act differently:

- by mechanical aggression – like falling down against or

casting a tough object towards the victim, crushing action,
etc.;

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- by other physical aggression – compression effect (crush
syndrome), vibrating effect (blast syndrome);
decompression effect (inside fluid or air);
- Other lesion factors can be added: chemical, thermal,
nuclear, etc.;
- There are favoring factors such as: alcohol, drugs,
medication side-effects;

Pathogeny

The mechanical factor seems by far the most frequently

involved. It is of little importance if a hard object hits a person
or the person itself is projected against the ground or an
obstacle of some kind. The kinetic energy sustaining the
collision between the two parties will be promptly dissipated,
but only by producing damage to both in the process.
Speaking about collision, the perfect example seems to be the
car crash. In this type of accident, the kinetic energy of the
impact depends on the speed of the vehicle. In the case of a
person getting hit by the vehicle, we are talking about sudden
acceleration; if the person is inside colliding vehicle, then we
are confronted with similar values of deceleration.
Calculation of mechanical impulse (H = m x v) can give us a
hint about the reversed relationship between speed (v) and
mass (m) during severe
variations of energy.

86. One major cause for

politraumatism - car crash

If we take for an
example the person seated in a colliding vehicle, we will
observe that during an abrupt stop due to some obstacle,
preservation of the impulse by rapidly decreasing the speed
will generate a significant increase of dynamic mass of all
objects, including the passenger’s body. For example, if a car
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cruising at 60 km/hour is suddenly stopped within 1/10 of a
second, the dynamic mass of a 70 kg passenger will raise to
almost 1200 kg, his blood only will account for 34, 5 kg and
the brain for 35 kg.
During traffic accidents, lesions will happen by direct or
indirect impact, involving hyper-flexion, hyperextension or
rotation. We can describe different types of syndromes
according to the mechanism involved:

- front panel syndrome – as the passenger on board of a

colliding car in the front seat continues cruising at the initial
speed, his knee will hit the front panel and destructive
kinetic energy will be transmitted along his lower limb.
Thus, patellar fractures may occur, but also fractures of the
lower extremity of the femur, femoral shaft or upper
extremity of the femur, sometimes involving acetabular
area. Such syndrome may be combined with other lesions.

- Steering wheel syndrome – during collision, driver can be

projected against the steering wheel, thus suffering
contusion of the chest or abdomen;

- Forward projection syndrome – with severe face and skull

trauma, as the passengers are crushing their upper
extremities against the wind shield;

- Ejection syndrome – skull and spine trauma for the

passengers that get ejected outside of their seats;

Physiopathology

Vital function failure may endanger politraumatized patient’s

life.

Respiratory failure has various clinical aspects. Certain

features characterize the acute development:
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- Clinical facts: breathing rate up to 30 / min.; cyanosis (less
visible if the patient is also affected by anemia);
- Lab facts: oxygen saturation in peripheral blood (PaO2)
decreased down to 70%, or even lower.
There are several events that can cause this:

- nervous system lesions – from coma to local function

disability, according to the level of the damage;
- damage of the air ways – pharynx ( tongue retraction,
foreign body (either fluid or solid) obstruction; larynx
(foreign body obstruction, local edema, compressing
fractures); trachea & bronchi problem (fluid inhaling,
haemoptizia, foreign bodies obstruction, tracheal or bronchi
disruption);
- damage of the thorax – laceration, multiple rib fractures,
flap;
- pleural damage – hemo-thorax; pneumo-thorax;
- lung damage – edema, diffuse contusion, atelectasis,
pulmonary embolism;
- diaphragm lesions – disruption & ascent with inner thorax
compression;
Circulatory failure is triggered especially by impaired venous
return. Poor venous function can be caused by severe
hemorrhage (internal or external), heart compression by
pneumo-thorax or increased abdominal pressure. In some other
cases, circulatory failure can happen second to direct heard
wound, spine-chord injury with sympathetic impairment or
metabolic conditions such as: hypoxia, acidosis, hypothermia.

Other functions may be damaged following politraumatism.

Kidney function – may be altered in 10% of these patients,

reaching the level of kidney failure. There can be a pre-renal
development (which is reversible), renal development
(reversible second to acute tubular destruction but irreversible
if acute cortical destruction is involved) and post-renal

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development, that can be functional or organic when
obstruction of the urine way is the cause.

Liver function – the shock of the liver has a severe clinical

appearance, with early hemolytic jaundice. Later development
of jaundice may reveal an infectious complication.

Digestive function – there can be early alteration, especially at

stomach and duodenum level, where stress ulceration may
occur and has to be prevented;

Haemostasis function – may be altered because of extremely

diluted coagulation factors during acute post-hemorrhage
anemia or because of enhanced consumption of the same.
Increased fibrinolysis may also impair coagulation and
consequences can be devastating.

Endocrine and hydro-electrolytic disorders may either deplete

ions or restrict the elimination of sodium.

Classification

There are several criteria enabling us to classify

politraumatism:

A) Classification according to location

- cranial (C)
- thorax (T)
- abdominal (A)
- locomotion system (L)
There are various lesion associations:
- 2 areas prevailing (70%) – CT, CA, CL, TA, TL, AL;
- 3 areas prevailing (20%) – CTA, CTL, CAL, TAL;
- 4 areas prevailing - CTAL;

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B) Clinical classification
Clinical classification depends upon the actual status of basic
vital functions. According to this there can be various
situations:
1. Politraumatism with vital function alteration:
a) apparent death – demanding immediate resuscitation;
b) asphyxia – demanding immediate fight against the
cause (obstruction of air-ways; compression pneumo-
thorax; flap syndrome;);
c) collapse state – demanding correction of severe blood
loss or heart tamponade (pericardium fluid jamming);
d) comatose – requiring correct ventilation; when
cranial and abdominal trauma are simultaneously
involved, oro-tracheal intubation (OTI) is
compulsory;

2. Politraumatism with obvious lesions, but still stable vital

functions;
These patients require close monitoring as their condition may
be subject to sudden aggravation (two - stage organ tearing or
hematoma development);
87. Mechanical
trauma can be
accompanied by
severe burns;
number of
victims can be
great;

3. Politraumatiz
ed patients
with
apparently
stable vital functions and lesions; these may allow a more
“relaxed” approach and repeated / meticulous investigation
with close monitoring regarding complications.

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C) Clinical and therapeutical classification

- Exigent – larynx tearing with air- way obstruction and

compression pneumo-thorax. These require immediate and
aggressive action in order to save life;
- Emergency – continuous bleeding, severe skull trauma.
They need to be attended within the first 60 minutes.
- Urgent – open fractures, acute ischemia, visceral damage.
They all demand attendance within the first 4 hours.
- Deferrable – like facial fractures, urethra tearing; they may
be registered as apparently immediate; they will surely
require attendance at a certain moment later.

D) Anatomy-clinical classification

1. Cranial and spine dominance

It will be revealed by severe clinical phenomena such as:
a) syncope – momentary loss of consciousness; inadequate
ventilation; good prognosis;
b) coma – abnormal breathing; acidosis + hypoxia; it has a
poor prognosis and it commonly accompanies skull
trauma with cerebral damage.

2. Thorax injury dominance

a) Associated cranial and pericardium lesions – possible
coma and cardiac shock;
b) Air-way, thorax wall or diaphragm injury that will be
revealed by:
- polypnoea (rapid breathing)
- normal BP and pulse rate;
- cyanosis
- anxiousness;
- paleness and weak pulse may be added when
hemorrhage is associated;
- in comatose patients it is hard to differentiate the
cause between cranial damage or thorax injury itself;

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3. Abdominal injury dominance
The events that may justify such development are:
- hemorrhage shock
- septic shock (that will be manifest within 12 hours);

4. Limb injury dominance

There can be:

- traumatic shock, with hemorrhage component;
- toxic / septic shock
- crush syndrome;
Immediate attendance (blood substitution, oxygen and
adequate surgery) may quite quickly reverse evolution. Resting
hemo-dynamic instability may reveal undiagnosed / unattended
visceral injury.

5. Hemorrhage dominance

- hypo-volemic shock – paleness, superficial breathing,

tachycardia, cold extremities;
- lesion severity depends on their location, number and the
likelihood of two stage evolution for some of them.

88. Victims of
politraumatism require
intensive care in
special units;

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Severity scores

There are 2 different systems allowing a significant assessment

of politraumatism, presented as severity score:

a) Scores based on prompt assessment of available parameters

(BP, capillary refill, breathing expansion and rate) such as:
- TS (Trauma Score)
- GCS (Glasgow Coma Scale)
- PS (Probability for Survival)
- RTS (Revised Trauma Score)

b) Scores based on recognition and codification of every type

of specific injury:
- AIS (Abbreviated Injury Scale)
- ISS (Injury Severity Score)
- TRISS (TS + ISS)

Some of the most important are described here:

a-1) TS
It is used for patient selection and assessment of attendance
before hospital.

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 TRAUMA
SCORE
Breaths / > 36 2
minute
25 – 35 3
10-24 4
1–9 1
Absent 0
Breath Normal 1
expansion
Superficial 0
Absent 0
Systolic BP > 90 4
70-89 3
50-69 2
0 – 49 1
Absent pulse 0
Capillary Normal 2
refill Delayed 1
Absent 0

Small TS values are consistent with increased severity of the

lesions.

a-2) GCS (Glasgow coma scale)

This scale is used for assessing the neurological condition,
using the following parameters:

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GLASGOW COMA SCALE
Eye opening
4 Spontaneous
3 On voice command
2 With pain
1 Absent
Spoken answer
5 Coherent
4 Confuse
3 Inadequate
2 Unintelligible
1 Absent
Motor answer
6 On command
5 Localizing pain
4 Pain reaction
3 Flexion with pain
2 Extension with pain
1 Absent

a-3) P S (Possibility of survival)

This allows the assessment of survival possibilities in

percentage, according to a comparative table (TS or GCS). Any
GCS under 13 may render as much as 10% fatalities, so we
have a landmark here for severe emergencies.

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a-4) RTS (Revised Trauma Score)

This type of score is the codified assessment of 3 different

parameters.

REVISED TRAUMA SCORE

GCS SYSTOLIC BREATH RATE CODIFIED
BP VALUE
13-15  89 10 – 29 4
9 – 12 76 – 89 > 29 3
6-8 50-75 6–9 2
4-5 1 – 49 1–5 1
3 0 0 0

Indications are that any patient scoring below 4 in any of the

above presented parameters should be evacuated to a trauma
center.

b-1) AIS (Abbreviated injury scale)

This system consists of a scale from 1 – 6 for codified

anatomical lesions:
- 1 – head and neck
- 2 – face
- 3 – thorax
- 4 – abdomen and pelvis and their viscera
- 5 – extremities and bony pelvis
- 6 – external (skin)

The severity code 1 – 6 means:

- 1 – minor
- 2 – moderate
- 3 – serious (no vital risk)
- 4 – severe (vital risk with probable survival);

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- 5 – critical (uncertain survival)
- 6 – deadly (no survival expectancy under standard therapy);

b-2) ISS (injury severity score)

This represents the sum of maximal AIS score for three of the
most affected body parts. For each region the maximal score is
25, thus maximal ISS is 75.

Diagnosis

This activity has a number of well- established objectives:

- assessment of severity
- injury list
- injury hierarchy and assessment of priorities;

Specific diagnosis activities can be carried out:

- at accident site;
- during transport;
- at the hospital;

Diagnosis is a dynamic process, as new lesions may be found

while important ones are already being taken care off. Clinical
and lab findings will allow positive and differential diagnosis.
Clinical examination must be:
- swift, complete and detailed;
- non harmful (one must avoid unnecessary or harmful
maneuvering);
- performed together with simultaneous intensive care
approach, whenever necessary;
- repeated during the first (48) hours. This may allow
adequate monitoring of the patients and registering of
possible alterations, but it can also enable us to complete the
lesion list with the less important or overlooked ones;

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Clinical examination

Anamnesis

Information concerning the patient and the circumstances of

the accident can be taken from the victim herself – if conscious
– or from witnesses, paramedics that saw accident site or
family members.
The information we need about the patient concerns past or
chronic diseases such as diabetes, heart or kidney conditions,
pregnancy, etc. We are also interested about habits like
drinking, smoking or certain specific medication uptake before
the accident.
The accident circumstances can reveal its mechanism and
enable us to figure out all possible lesion combinations and
locations, even when less visible in the beginning.
We want to know details concerning the aggressive agent,
location, and victim’s position during trauma.
Patient or witnesses will be questioned about possible
phenomena such as cough, exceeding pain, difficulty in
breathing, vomiting, digestive hemorrhage revealed by
hematemesis or rectal blood spill and loss of consciousness.

Objective examination

There is a certain pattern for accomplishing such task. It is

obvious that we will have to follow a specific proceeding, by
examining all body systems in a certain order, given by the
vital risk involved for each one.

a) Examination of the cranial extremity

- Assessment of cranial lesions: wound, bruising, skull

fracture, cerebral fluid fistula, consciousness, all quantity
and quality alterations, vegetative functionality, etc.
- Examination for cranial nerves;
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- Eye assessment: consistency of eye balls, obvious cornea
damage, pupil dimension and response to light;
- Assessment of facial injury: teeth missing, wounds,
fractures in the face area (most important and urgent are
those obstructing air ways);

b) Examination of the spine

Inspection and palpation are necessary here and there is need

for a very gentle approach, as secondary damage can happen.
There will be a serious assessment of:

- local deformity (kyphosis, hump, scoliosis);

- local pain and its areas of resonance;
- assessment of motor function and the bone-tendon reflexes;
- assessment of sensitivity: local, partial or total loss;

c) Thorax examination

Using inspection, palpation, percussion and auscultation can

help us depict immediate vital risk lesions, such as:
- obstruction of superior air ways;
- compression syndromes – open pneumothorax with
traumatopnoea (abnormal breathing oh damaged thorax),
compression pneumothorax, massive haemothorax, cardiac
tamponade;
- the mobile wall syndrome - the so called “soft” thorax;

d) Abdomen examination

The important thing here is revealing the possible intra-

peritoneal hemorrhage or infection.
Internal hemorrhage can display lack of proper response under
adequate substitution therapy or even relapse after brief
improvement, flank dullness of the abdomen and positive
puncture (blood or abnormal fluid).

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Muscle contraction can be present because of reasons outside
abdomen (skull, spine or pelvic injury) or can lack in
abdominal trauma older than 4 hours, especially when
associated with other lesions.

e) Examination of the locomotion system

This is supposed to assess the situation of the limbs and pelvis.

- Pelvic fractures cause severe hemorrhage (sometimes more
than 2000 ml), gathered in the shape of a retroperitoneal
hematoma. This can render false acute abdomen symptoms:
defending muscle contraction, meteorism (distension) and
digestive functional arrest. Anatomical deformity and local
modification, positive compression signs and rectal touch
should be considered.
- Limb fractures can easily be revealed according to the
specific clinical signs: localized pain, functional disability,
abnormal mobility, lack of transmission of movement
towards the distal parts. Distal vascular and neurological
functionality should always be assessed.

Para-clinical assessment

The existing proceedings establish the content and the number

of lab tests considered necessary for each and every stage of
diagnosis and attendance.
There are several types of exploration:
- lab tests – blood group and RH factor, hemoglobin rate and
blood cell count, urea, glycemia, ion rate, urine test, alkaline
reserve, blood gas rate (O2 and CO2), liver enzymes and
other.
- X-ray and other imagery: radiography, ultrasonography, CT
scan or MRI, angiography, etc.
- Exploring puncture – rachis, pleural, abdominal,
pericardium, etc.

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Treatment principles

There is a specific strategy involved in politraumatism

treatment. It involves medication, surgery and other means of
therapy available (including HBO – hyperbaric oxygen
therapy). The coordination of the strategy implies swift action
and flexibility, as there has to be a strict correspondence
between the diagnosis – which gets more and more detailed
within the first hours – and the treatment applied to the patient.
The strategy of the treatment depends on the stage and the
location of the attendance activity:
The main stages are:
1. acute or resuscitation stage ( 1 – 3 hours);
2. stabilization stage (3 – 72 hours);
3. regeneration stage (3 – 15 days);
4. rehabilitation stage (beyond 15 days);
The activity takes place at certain echelons:
a) pre-hospital ;
b) ECD (Emergency Care Department);
c) Hospital;
d) Post-hospital attendance;

I Pre-hospital attendance

There are 3 objectives involved in this approach:

- survival;
- stabilization of lesions and preparation of the patient for
evacuation;
- patient evacuation towards adequate attendance facility;

The first three measures to be considered in case of accident

are:
- protection ( P ) – accident site is marked and assistance
units are brought to the site;

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- announcement ( A ) – sending adequate info able to alert
next attending posts (transport ambulance, police, other
authority);
- security ( S ) – enhanced emergency attendance able to
ensure patient survival;

Survival

Three main conditions have to be fulfilled:

- make the patient breathe;

- make his heart beat:
- avoid blood loss;
First attendance measures can be taken by non-specialized
(but instructed) persons or by specialized personnel (medic /
other). They will make sure that the patient will continue
breathing and having heart beat, preserve circulatory function
and stop hemorrhage by compression or tourniquet and prevent
chilling by adequate covering.
Apparent clinical death characterized by bi-lateral
mydriasis, pulse absence on the carotid and femoral arteries
and abolished conscience, will benefit from mouth to mouth
breathing (preceded by air ways dis-obstruction) and cardiac
resuscitation. As the survival chance depends on any such
measure taken within the first 4-6 minutes, it is important that
we either ensure an emergency system that can bring a CPR
unit within this time to the accident site (highly unlikely) or
extend the basic CPR knowledge for citizen use. The idea is
that some person with this kind of basic training might be
around in the necessary time interval and is committed to act in
a responsible way. For this reason, present law demands that all
cars are equipped with a first aid kit that involves mouthpieces
for CPR, wound dressing and provisional immobilization
material and this kit being available for use by anybody close
to the site.
One important rule to respect is the head – neck – trunk
axis. This means that even under the pressure to provisionally
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relocate the patient (because of fire or dangerous location), we
have to preserve with adequate immobilization means the
normal position of this essential part of the body. Any forceful
movement can inflict additional damage to the patient –
especially the cervical spine – and the spine chord injury is the
worst possibility.
Medical security is achieved when the specialized personnel
get to the site. Specialized advice will get information on last
attendance actions and is supposed to allow extrication by
avoiding lesion aggravation. Medical specialized assessment is
concentrated upon:
- lesion type and severity;
- prevention of lesion aggravation;
- initiation of attendance starting with saving gestures;

The pre-hospital attendance comprises the first evaluation.

The first evaluation (ABCDE)

A) A is for Airway permeability and cervical spine assessment.

This may consist of several separate operations:
- overall removal of the victim by adequate extrication within
15 min;
- checking and taking care of all causes for obstruction:
tongue position, face , larynx or trachea lesions, other
means of obstruction by foreign bodies such as vomit,
blood, dirt, etc.
- maneuvers for upper air ways release and functionality:
mandible protrusion, mouth opening, sticking out the
tongue (and even its fixation if needed). Digit checking and
control for obstructive bodies should be continued by
aspiration of fluids.
- Guedel pipe application;
- If dis-obstructive measures fail, 2-3 thick needles should be
inserted inside the crico-tyroid larynx area (enabling air
take);
- OTI (oro-tracheal intubation);
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B) Breathing – ensuring normal thorax expansion

Ventilation can be compromised by:

- compression pneumothorax;
- traumatopnoea on open pneumothorax;
- complex rib flap;
Adequate breathing can be achieved by:
- mouth to mouth artificial breathing;
- provisional immobilization of rib flap (including arm-to-
thorax immobilization by Dessault bandage);
- compressive bandage for open pneumothorax;
- puncture by thick needle for suffocating pneumothorax,
followed by assisted breathing;
- decompression of pneumo-mediastinum;

C) Circulation and hemorrhage control

Cardiac arrest is treated by immediate measures:

- external cardiac massage;
- adrenaline injection (intra-cardiac)- 0,5 – 1 mg.
- Sodium bicarbonate 0,5 ml / kg of body weight (counter
measure for acidosis);
- Electric de-fibrillation;

Hemorrhage control

- if external, hemorrhage can be stopped by direct external

compression, compressive bandage or even tourniquet (seen
as an ultimate approach). When tourniquet is used, marking
the time it was installed becomes a necessary gesture, as
there is a limited time for such acceptable ischemia.
- if internal, a rapid rate fluid infusion, preferably by multiple
way and rapid evacuation towards a specialized anti-shock
center;

D) Neurological disturbances
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This one is assessed by the AVPU system:

- A – slow response;
- V - answering to verbal stimuli;
- P – answering to pain stimulation;
- U – lack of response;

E) Exposure of patient for complete examination

This approach will be carefully indicated, as sometimes, a

complete exposure may aggravate hypothermia. Swift
segment / limb to limb examination, even if more complicated,
can be considered when climate is a menace.

The first assessment can reveal:

- a conscious patient with functional breathing and
circulation;
- unconscious patient with functional breathing and
circulation:
- comatose patient with nonfunctional breathing and
circulation;
As brain damage can readily occur, immediate salvation
gestures are required.
CPR is performed during the first evaluation and will be
carried on, by fighting hypoxia and fluid unbalancing.
A second assessment is needed in order to observe the impact
of the CPR maneuvers and to complete the list of the alleged
lesions before evacuation.

Stabilization of lesions preparation for evacuation

Stable parameters for circulation and breathing are required.

Immobilization of fractures is necessary, especially if these are
to be regarded as delayed emergencies.

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 89. CPR and field attendance
for patient prior to transport

Heating of the patient if

necessary and sedation may
prove appropriate, while
establishing the severity score.
The Glasgow score remains the most useful. A score under 8
points demands evacuation towards a brain surgery facility.
Some important rules should be considered:
- patients not requiring extrication should undergo
stabilization and evacuation within 15 minutes.
- For patients requiring extrication, the “golden hour” rule
seems crucial.

Evacuation

Stabilized patient must be evacuated towards a specialized

center, preferably by medical transport (mortality is 10 times
smaller than in non-medical transport).

90. Paramedics perform CPR

during ambulance transport

There are rules and special attendance measures during

transport:
- removal of the patient and depositing him on the stretcher
according to the axis rule;
- preservation of provisional immobilization;
- quick therapy for anxiety, if necessary;
- caution on analgesics;
- fighting hypothermia;
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- carrying on CPR and monitoring circulation / breathing;
- tetanus prophylaxis;
- prevention of cerebral edema;
- maintaining oxygen intake and prevention of acidosis;

There are specific positions for adequate transport:

- Fowler position for skull trauma (head up);
- comatose patients are placed into lateral decubitus;
- facial trauma with possible air way obstruction needs
ventral decubitus with head leaning to one side upon
forearms;
- possible cervical spine damage requires stiff collar and
dorsal decubitus, preserving the “axis” rule;
- well balanced conscious patients with thorax trauma have a
better position when half seated; the unconscious ones are
transported in lateral decubitus with lowered position of the
head;
- dorsal decubitus and slight flexion of the lower limbs is
needed when abdominal trauma prevails; dorsal decubitus
also goes for pelvic injury and additional immobilization is
required by injuries at this level;
- hemorrhage shock may require the Trendelenburg position
(head lower than feet);

II. E. R. Attendance (Emergency room)

Patient reception / handing takes place in the ER, a specially

designed area for investigation, diagnosis and treatment of
shock / emergencies, available in larger hospitals. Smaller ones
may be provided with emergency compartments, smaller and
less provided, where specialized personnel can provisionally
stabilize and prepare for further transfer severe cases. In the
ER, the “well-coming” team should consist of anesthesiologist,
ICU (intensive care unit) specialist and surgeon. All necessary
information will be registered, along with continued medical
attendance, as previously described.
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Main objectives at this stage are:
a) Evaluation of performed and still necessary survival
measures;
b) Lesion diagnosis list;
c) Prognosis assessment;
d) Adequate therapy;

91. Continued attendance within

ER

a) Evaluation of already done and

still necessary survival gestures

This stage is divided in two surveys:

primary and secondary.
Primary survey - is performed by
the ICU specialist and surgeon(s).
The ICU specialist plays the main
part in assessing the following:
- neurological condition;
- breathing function;
- hemo-dynamic balance;
- trauma score (TS);
The following maneuvers are simultaneously performed:
- assessment of pulse rate and blood pressure;
- intubation check-out and oxy-meter check;
- assessment of already installed infusion and establishing
new infusion site (a larger vain, preferably the jugular, but
not in the case of severe cerebral damage);
- hemo-dynamic balance survey;
- blood samples for transfusion match;
- gastric probe ;
- thermal monitoring;
- urine catheter (following x-ray assessment of the pelvis);
- surgical assessment is performed during these maneuvers;

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Second survey
This benefits from the necessary time for a more detailed
inventory of the primary lesions, assessment of the secondary
or complicated damage and it is accompanied by corresponding
attendance. CPR maneuvers are to be continued until patient
proves stable; if so, they will cease and personnel will focus
upon monitoring vital functions, under readiness status.
Clinical examination will be repeated until detailed diagnosis is
undoubtedly stated. Apart from clinical evaluation, biological
tests (hemoglobin rate, urea, creatinine, ion rate, glucose rate,
bilirubin, enzymes, etc.) and imagery investigation is continued
beyond diagnosis needs, that is for monitoring therapy early
results and possible occurrence of complications.
Secondary or delayed emergency gestures are to be considered
at this stage:
- rib flap fixation;
- evacuation of pleural fluid;
- evacuation of extra-dural hematoma;
- dislocation reduction (by external maneuvering or surgery);
- fracture attendance (primary approach on opened ones or
straight osteosynthesis);
- exploration of urinary tract (catheter, fiberscopy);

b) The surgeon will perform a first lesion list. A complete

system checkout will be followed by diagnosis punctures in
allegedly affected cavities (pleura, peritoneal, etc.).
The dominant lesion(s) are now revealed and the team has to
answer to 2 direct questions:

- Is there an indication for immediate surgery?

- Should / Can the politraumatized patient be transferred on
to a trauma center?

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 92. Team surgery may
be needed for
emergency treatment
of various severe
lesions

However, there are

immediate surgical
indications requiring
non-delayed action:
- thorax drainage;
- haemostasis: cranial
in acute arterial hemorrhage compression; abdominal in
organ tearing; vascular in peripheral blood vessel damage;

Patient transfer

Transfer is necessary when the facility that holds the

patient proves unable to cope with the complexity of at least
some of the injuries. Adequate transfer circumstances require a
biologically stabilized patient, with functional vital systems,
with suitable transfer means (vehicles) and swift information
towards receiving facility.

c) Prognosis

Various types of scoring are used in order to establish adequate

prognosis.
Glasgow (GCS) is adequate for neurological dominating
lesions; less than 9 means poor prognosis.
For extra-neurological maneuvers the ISS score is used and
MISS merges the two, basing upon the 4 areas (I- skull; II –
face and neck; III – thorax, abdomen, pelvis; IV – limbs;) and a
severity score from 1 to 5. The scale runs from 2 to 59. MISS
score above 25 means 50% death toll and almost 17%
handicapped remaining persons.
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 93. Staged surgical
treatment may be
needed for permanent
results

Therapy and action

principles

Any surgery is due only

when patient is well balanced and with the ICU specialist
approval. The typically indicated surgery is meant to keep the
patient alive and consists of:
- stopping hemorrhage (abdominal, thorax, pelvis or
external);
- compression hemo-pericardium;
- extra-dural hematoma;
Further surgery is necessary in order to maintain functionality
of organs and systems:
- treatment for intra-abdominal lesions;
- treatment for fractures with vascular involvement;
- treatment for opened fractures;
- treatment for compartment syndrome;
- treatment for opened skull trauma;
- treatment for opened eye damage;
- early stabilization of fractures in the limbs, pelvis and spine;
There is a priority list with all these surgical approaches and it
should be respected.
Generally, there are two types of interventions:
- early approach, with permanent results; commonly done by
multi-specialized or several surgical teams. There will be a
specific approach on as many as possible lesions and a
sustained intensive and anti-shock care.
- staged approach, according to the emergency hierarchy of
the areas;

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There is a secondary stage – regeneration stage – lasting
commonly from day 3 to 15. It has two sub-stages of its own:
- 3-5 days – a critical period for the capillary vascular system
stability. Effort is made during this stage in order to control
blood pressure and cardiac function, effective diuresis and
an adequate pH rate. Surgery should be avoided at this time,
if possible, but not if such approach is vital.
- Beyond 5 days – a stable hemo-dynamic and respiratory
stage. During this we can perform;
- Resting necessary surgery;
- Some invasive investigation (urology);
- treatment of septic complications (hematomas, necrosis);
- permanent closure of wounds;
- osteosynthesis and joint involving fractures
reconstruction;
- approach on face and maxillary fractures;

There is also a third stage, beyond the 15th day

- this activity is meant for rehabilitation and social and
professional reinsertion of the patient;
- re-constructive surgery and rehabilitation

94. Friends forever

181