Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Clinical Orthopaedics and Trauma

journal homepage: www.elsevier.com/locate/jcot

Evolving concepts and strategies in the management of polytrauma

patients
Gaurav K. Upadhyaya a, Karthikeyan P. Iyengar b, Vijay Kumar Jain c, *, Rakesh Garg d
a
Department of Orthopaedics, All India Institute of Medical Sciences, Raebareli, UP, 229405, India
b
Southport and Ormskirk NHS Trust Southport, UK
c
Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
d
Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India

a r t i c l e i n f o a b s t r a c t

Article history: Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of
Received 28 September 2020 disability on the quality of life and functionality in this younger population is worrisome. This remains a
Received in revised form major public health concern across the globe. Immediate and early deaths account for nearly 80% of
4 October 2020
trauma deaths occurring within the first few hours of injury to the first few days, usually because of
Accepted 12 October 2020
Available online xxx
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
Keywords:
Polytrauma
and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-
Trauma models related coagulopathy can be an emerging complication during resuscitation of such patients which
Hemorrhage should be recognized early so appropriate corrective measures can be undertaken. We describe the
Shock evolving models of care in the management of polytrauma and trauma associated coagulopathy.
Coagulopathy © 2020
Resuscitation

1. Introduction decreased owing to improvement in factors related to the safety of

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 poly-
traumatized 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, sur-
gery, resuscitative measures, surgical methods, and perioperative
management strategies have occurred. Complication rates have
* Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee
Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001,
India.
E-mail addresses: drgkupadhyaya@yahoo.co.in (G.K. Upadhyaya), kartikp31@
hotmail.com (K.P. Iyengar), drvijayortho@gmail.com (V.K. Jain), drrgarg@hotmail.
com (R. Garg).
passengers in motor vehicle accidents and clinical management of
polytrauma patients.3e7
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 complica-
tions 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 sur-
geons. 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.

https://doi.org/10.1016/j.jcot.2020.10.021
0976-5662/© 2020

Please cite this article as: G.K. Upadhyaya, K.P. Iyengar, V.K. Jain et al., Evolving concepts and strategies in the management of polytrauma
patients, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.10.021
G.K. Upadhyaya, K.P. Iyengar, V.K. Jain et al.
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 poly-
trauma patient was defined as having two or more significant in-
juries.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, pre-
dominantly based on Injury Severity Score (ISS) with modifica-
tions.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 in-
ternational 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 Defini-
tion’.1 (Table 1).
2.2. Berlin definition
As per new ‘Berlin definition’, Polytrauma is defined as “a sig-
nificant 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
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
2
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
sepsis-related mortality with the integration of ETC.22 However,
subsequently, it was observed that ETC was associated with “sec-
ond-hit” in patients with hemodynamic instability, head, and/or
chest injuries. It was noticed that the rate of intraoperative com-
plications 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 manage-
ment. They postulated that external fixation of bony injuries initially
would require less operative time, prevent blood loss and hypo-
thermia, 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 frac-
tures, 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 parame-
ters 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 2e5 days after inflicting trauma and remained at increased risk
of ARDS, multi-organ failure. In view of these concerns, it is sug-
gested to provide definitive management only to patients who have
potentially life-threatening injuries like an unstable pelvic fracture,
compartment syndrome, fractures with vascular injuries, unre-
duced dislocations, traumatic amputations, unstable spine frac-
tures, 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 over-
zealous untimely definitive surgeries and thus avoiding adverse
outcomes (Fig. 1).26,27
3. Early appropriate care (EAC)
EAC has emerged as a safer concept with identifying and tri-
aging the need of the patients with regards to the need for defin-
itive 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. Val-
lier 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.
G.K. Upadhyaya, K.P. Iyengar, V.K. Jain et al. Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx

Table 1
Evolution of Definition and classification of Polytrauma.

Authors Year/ Definition of polytrauma

Decade

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 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
Definition” parameters namely age, consciousness, hypotension, coagulopathy and acidosis".

Abbreviations: ISS¼ Injury Severity score; AIS ¼ Abbreviated Injury Score.

Table 2
Evolution and characteristics of models of Polytrauma care.

Concepts Early Total Care (ETC) Damage Control Orthopaedics (DCO) Early Appropriate Safe Definitive Prompt individualized safe management
Care (EAC) Surgery (SDS) (PRISM)

1 Year 1989 2000 2013 2015 2017

2 Philosophy Early fixation of long bones
as soon as possible prior to
48e72 h ‘at risk’ period.
Early Stabilization
Aggressive resuscitation
3 Advantages Decrease in pulmonary
complications.
Reduce Fat Embolism
Syndrome
Facilitates nursing care
4 Disadvantages Led to exacerbation of
‘Second Hit’ in a subset of
patients with
haemodynamic instability
e.g. Extremely high ISS
Involves staged management - - Fracture definitive Definitive Doing no further harm.
‘Definitive’ management after fixation guided by surgery in stableNo need to assign a protocol to patient.
physiology improves to avoid laboratory patients and Individualized treatment to each patient.
‘Second Hit’ to the patient during parameters such as DCO in unstable Use of different physiological parameters
vulnerable period. lactate and pH. patients. to assess patient’s condition and then
Hemostatic Resuscitation proceed accordingly.
Prevents blood loss and Physiological and Same as DCO Considers the local healthcare resources
hypothermia, less operative time. Biochemical and prevents available in each hospital/country.
rationale two surgeries in Assessment of the patient in great details
some patients 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
Two surgeries are required, e e -
increased cost of treatment and
hospital stay.

Abbreviations: ISS¼ Injury severity score.

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 sys-
tem (CGS). CGS was based on shock (blood pressure, transfusion
requirement, lactate levels, base deficit and urine output), tem-
perature, coagulation (platelet count, factor II and V, fibrinogen and
D-Dimer level) and soft tissue injury (chest trauma score, abdom-
inal 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), un-
stable (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 coun-
tries. So, to categorize the patients into specific protocols, the
3
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 e
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 poly-
trauma patients. The priority remains the identification and stabi-
lization 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
G.K. Upadhyaya, K.P. Iyengar, V.K. Jain et al.
Fig. 1. Flow chart depicting concepts of Early Total Care and Damage Control Orthopaedics.
subsequent hemothorax and or pneumothorax should be
identified.32
The identification of hemorrhage, rapid, and accurate assess-
ment 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
4
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
that “evaluated trauma patients receiving fluid in the emergency
found that crystalloid resuscitation of more than 1.5 L indepen-
dently 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:
G.K. Upadhyaya, K.P. Iyengar, V.K. Jain et al.
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 coag-
ulation, 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 coagulop-
athy, hypothermia, and acidosis.
7. Trauma associated coagulopathy
7.1. Types
Coagulopathy associated with trauma together with hypother-
mia and academia form constituents of the “triad of death”. Coag-
ulation 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 devel-
oping 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 ap-
pears to be due to activation of the protein C pathway.37 Other
proposed mechanisms for this acute coagulopathy include “acti-
vation 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 contrib-
utor 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 initi-
ation 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 identi-
fication of coagulopathy in trauma victims in ED itself helps in
5
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
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. How-
ever, 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 pro-
cessing 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 coagula-
tion 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 di-
agnose coagulopathy in polytrauma patients.48
7.4. Resuscitation associated coagulopathy (RAC)
Resuscitation coagulopathy complicates acute traumatic coa-
gulopathy 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 (Ca2þ) 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 hemor-
rhage, permissive hypotension, hemostatic resuscitation, preven-
tion/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 fa-
cilities, the use of various agents like fibrinogen concentrate or
prothrombin complex concentrate as part of hemostatic manage-
ment has been advocated.49
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 establish-
ment of a minimum of 2 large-bore intravenous access points
and infusion of 1e2 L (or if a child 10e20 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, angi-
ography, pelvic packing, and Resuscitative Endovascular Balloon
G.K. Upadhyaya, K.P. Iyengar, V.K. Jain et al.
Fig. 2. Pathophysiology of Trauma associated coagulopathy.
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, in-
terventions, and outcomes in polytrauma from some recent studies.
6
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
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 proto-
col for initial resuscitation of major trauma patients.52
G.K. Upadhyaya, K.P. Iyengar, V.K. Jain et al.
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 ser-
vices, 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 psy-
chosocial 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 hos-
pitalization is increasingly important. Development of a multidis-
ciplinary 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
7
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
need for early identification and appropriate timely management of
key parameters like hypothermia, coagulopathy, and intervention
of potentially life-threatening injuries before the definitive man-
agement 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, re-
view, 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.
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