1. Management of
polytrauma
Dr. Mohammad Taqi Ehsani
PGY1 of Orthopedics, FMIC

2. Definition
• Polytrauma is a syndrome of multiple injuries exceeding a defined
severity (ISS>17)
Or
• Two injuries that are greater or equal to ≥ 3 on the AIS in ≥ 2 body
regions
• And one or more additional physiological risk factor
 Hypotension (Systolic Blood Pressure ≤ 90 mmHg)
 Unconsciousness (GCS Score ≤ 8)
 Acidosis (Base deficit ≤ 6.0)
 Coagulopathy (PTT ≥ 40sec or INR ≥1.4)
 Age (≥70 years)
(“BPD” Berlin Polytrauma Definition)

3. Introduction
• Over 1.2 million people die each year worldwide because of road
traffic injuries
• Only 10% in high-income countries
• Several thousand individuals survive with permanently disabling
injuries
• In the united state, trauma-related costs exceed 400$ billion
annually
• The real cost is that trauma affects the youngest and most
productive members of society

4. • Fractures frequently occur in polytrauma patients
• Can be contaminated if open wounds are present
• May cause compartment syndrome
• Major trauma induces an intense immuno-inflammatory response

6. Scoring Systems
• Appropriate triage and
classification of trauma patients
• Predict outcomes of patients and
family counselling
• Quality assurance, Research:
Extremely useful for the study of
outcomes

7. Injury Severity Score (ISS)
The injury severity score
(ISS) is an anatomical
scoring system that
provides an overall score
for patients with multiple
injuries. Each injury is
assigned an abbreviated
injury scale (AIS) score
and is allocated to one of
these body regions. The
highest AIS score in each
body region is used.

8. Management
• Trauma management should be multidisciplinary team
• Each one in the team plays role where he is perfect in
• “ Captain of the Ship”, typically an ATLS-trained general surgeon

9. Evaluating the trauma patient from
orthopedic perspective
• Trauma care is organized in three
stages:
 Primary survey
 Secondary survey
 Definitive management

10. A. Primary Survey:
• concerned with the preservation of life
• Airway: remove airway obstruction, secured by jaw thrust maneuver
or tracheal intubation
• Breathing: ventilation should be assessed. Major life threatening
problems: tension pneumothorax, massive hemothorax, flail chest
• Circulation: cardiovascular status must be evaluated and supported;
control of external bleeding, critically injured: Blood sample; type
and cross match

11. B. Trauma x-ray series
• Taken in the trauma room while the primary survey
is being conducted
• Even before thorough history and physical exam, to
ruling in or out the next most critical clues to saving
the life and limb
• The trauma series should consist of three x-rays:
• Lateral cervical spine, AP chest, and an AP Pelvis
view
• Our protocol (FMIC): Brain & cervical spine CT
Scan, Chest x-ray, pelvic x-ray, dorsal and
lumbosacral spine x-ray (by trauma team)
• Other investigations may be needed depending on
the finding of secondary survey

12. C. History and Physical Examination
A useful mnemonic to guide the initial history is the
word AMPLE:
• Allergies
• Medications
• Past illness
• Last meal
• Events of accident

13. D. Secondary survey
• A complete physical examination from
head to toe
1. neurologic mental status: note level of
consciousness
• Awake patient: “disability exam” rapid,
organized neurologic exam which
documents mental orientation, verbal
response to questioning, and a response
to stimuli, extremity examination of
motor and sensory function
• Unconscious patient: Glasgow coma score,
used as the measure of neurologic
progress or deterioration
• Use of maximal monitoring and minimal
medication is a useful trauma room
principle

14. D. Secondary survey
• 2. Head and Neck:
• Carefully palpate skull and facial bones
and look for lacerations hidden in the hair
• Cranial trauma: raise an immediate
suspicion for cervical spine injury
• Conscious Patient: any neck pain or spasm
is a cervical spine injury until proven
otherwise
• Unconscious patient: protect the neck with
C-Collar until bony injury is ruled out by
cervical imaging or physical exam

15. D. Secondary survey
• 3. Thorax and abdomen:
• The thorax and abdomen are largely the domain of the general
surgeon, should inspect, palpate and auscultate to determine
possible underlaying injury
• Hemothorax and pneumothorax and abdominal injury are often
cause preventable death
• The imprint of clothes or contusion of the abdominal wall from the
seat belt suggest intraabdominal injury
• In many centers the Spiral “Whole Body” CT Scan of the chest,
abdomen and pelvis has supplanted selective CT scants, ultrasounds
and peritoneal lavage

16. D. Secondary survey
• 4. Pelvis: Low back pain, pubic tenderness, or pain with
compression of the iliac crest can indicate pelvic ring
injury
• Pelvic fractures may cause severe internal bleeding
• A Rectal Examination must be done in all patients with
a spine or pelvic injury, both to check for bleeding as well
as loss of sphincter tone indicative of neurologic injury
• A high-riding prostate also indicates major urologic
disruption common to high-energy pelvic fractures in men
• Inspection of penile meatus for hemorrhage should also
be performed, and urine or inability to void raise the
suspicion of a urethral injury, retrograde urethrogram
should be considered before bladder catheterization
• Bimanual pelvic examination is appropriate for female
patients to rule out open fractures which can penetrate
the vaginal vault
• Perineal inspection for integument laceration should be
conducted and in the setting of displaced pelvic fractures
should be assumed to represent open pelvic fractures

17. D. Secondary survey
• 5. Back and Spine: Carefully log roll the
patient and Palpate the entire spine to detect
tenderness or defects of the interspinous
ligament
• Important: a log roll be conducted properly
with three assistants controlling simultaneous
rotation of the entire body, a fourth assistant
should be controlling the cervical spine (while
in a hard collar) with gentle traction
• An increase in the interspinous distance
accompanied by local swelling may signify
injury
• Occasionally, ecchymosis or kyphosis can be
recognized, and the presence and absence
should be documented

18. D. Secondary survey
• 6. Upper and Lower Extremity:
• All four limbs should be palpated thoroughly and each joint placed through a
passive range of motions
• Look specifically for point tenderness
• Any obvious fractures or deformities are splinted and any open wounds are
covered with sterile dressing
• Dressings over open wounds, particularly over open fractures, should not be
taken down multiple time by multiple examiners, it only increase the rate of
infection
• Should take x-ray of the joint above and below, evaluate circulation of the limb
distal to any fracture and record the presence of any wound after applying a
sterile dressing

19. Orthopedic Emergencies

20. Thank you for your
attention