Multiple trauma

When trauma is referred to several simultaneously traumatic lesions of various regions of the body in medicine, wherein at least one injury or the combination of several life threatening injuries is (definition of Harald Tscherne ). As a rule, an injury with a severity according to the Injury Severity Score (ISS) of at least 16 points is defined as a multiple trauma , with Tscherne's definition also being used. The multiple trauma thus differs from a so-called baryngeal trauma, an injury in only one body region with an ISS≥16.

In medicine, trauma (Greek τραῦμα) is damage, injury or wound that is caused by violence. The multiple injury indicated by the Greek word poly (Gr. Πολύ = much) is distinguished from the isolated injury to a single region of the body, which can also be life-threatening, e.g. B. Isolated traumatic brain injury from headshots.

The most common causes of multiple trauma are traffic accidents and falls from great heights. The care of poly-traumatized patients accounts for around 1% of all emergency medical calls .

In general medical parlance, patients with multiple trauma are counted among the seriously injured or seriously injured. The official traffic accident statistics also know the term “seriously injured”, but defines this as an accident victim who was treated as an in-patient in a hospital for at least 24 hours and survived beyond the 30th day, although these criteria can be given for less serious injuries.

particularities

For several reasons, polytrauma has a special position among the injuries treated by medicine.

• Serious accident injured patients are a special psychological challenge for laypersons as well as for professional helpers, because B. may be covered in blood, disfigured or severely deformed. In traffic accidents several (accompanying) persons are often injured.
• There is a mortal danger for patients with multiple trauma. The treating team is therefore under great responsibility, there is also time pressure for all measures to be carried out.
• By definition, several body regions or organs are affected. The attending physician must therefore simultaneously assess different serious and urgent injuries and possibly treat the most urgent problems immediately.

It is therefore an extremely complex medical problem that has to be solved under time pressure and under great psychological stress.

Scoring systems

Several special trauma scores have been established for assessing the severity of injury :

• Glasgow Coma Scale (GCS) for assessing a traumatic brain injury or the state of consciousness
• Injury Severity Score (ISS) to assess the extent of the anatomical injury severity as the sum of squares of the three most severe injuries from six delimited anatomical regions, the individual severity of which is recorded as the Abbreviated Injury Scale (AIS): the ISS can assume values ​​between 0 and theoretically 75 points, with higher values ​​for higher injury severity. The ISS is used most often, also as a definition of a multiple trauma with an injury severity with an ISS> 15 that is common and frequently used in scientific studies. There is a linear correlation between ISS and mortality , morbidity and hospitalization, but there is a high rate of up to 48% for misclassifications.
• Revised Trauma Score (RTS according to HR Champion) as the degree of physiological impairment is a weighted sum (with coefficients) of the three Glasgow Coma Scale (GCS) parameters for the function of the central nervous system (0 to 4 points, multiplied by 0.938), systolic blood pressure (0 to 4 points, multiplied by 0.736) and respiratory rate (0 to 4 points, multiplied by 0.2908). A value of (rounded) 8 therefore indicates a slight trauma, a value of 6 a moderate, one of 4 a severe and a value below 2 a life-threatening injury. The RTS is between 0 and 7.84, with higher values ​​corresponding to less physiological disturbances. The survival prognosis correlates with the RTS, with RTS = 4 it is 60.5% and with RTS = 3 it is only 36%. The RTS 1989 arose from the Trauma Score (TS), which took more variables into account and was also developed by HR Champion in 1981, with the physiological parameters GCS (1 to 5 points), respiratory rate (0 to 4 points), breathing excursion (1 to 2 points), systolic blood pressure (0 to 4 points) and capillary replenishment to nail bed pressure (0 to 2 points). However, the TS underestimated the severity of traumatic brain injuries and proved to be impractical at the scene of the accident in terms of assessing breathing excursions and capillary filling.
• The severity classification according to Schweiberer is purely descriptive of grade I (moderate injury requiring inpatient treatment without shock) through grade II (severe, but not life-threatening injury with signs of shock) to grade III (life-threatening injury with blood loss of more than 50%).

treatment

The therapy of multiple trauma patients can be divided into four treatment phases:

• Acute phase (approx. 1st to 3rd hour): severity assessment, shock treatment, possibly resuscitation, possibly life-saving operations
• Primary phase (approx. 1st to 3rd day): Stabilization of circulation and breathing in the intensive care unit, X-ray diagnostics, ultrasound diagnostics, exclusion of vascular, bladder and urethral injuries, if necessary emergency interventions
• Secondary phase (approx. 2nd to 8th day): further stabilization of the heart and circulation as well as lung and brain functions, possibly further operations
• Tertiary phase (from about the 8th day): if necessary, weaning from the ventilator, increasing mobilization, if necessary performing surgical interventions that have been postponed up to now.

first aid

Standard measures are securing the accident site under self-protection and making the emergency call - the rescue chain must be observed here.

Immediate life-saving measures may have to be carried out at the scene of the accident , such as stopping heavy bleeding, lying on your side in the event of unconsciousness and, if necessary, performing cardiopulmonary resuscitation .

Rescue service measures at the scene of the accident

Caring for a patient on the highway

The rescue service (emergency paramedic, paramedic, paramedic, emergency doctor) first briefly examines the patient after a possible technical rescue at the accident site with regard to the vital functions and takes measures to stabilize the patient and make them transportable. Standardized processes are used here (for example in accordance with the pre-hospital trauma life support concept).

In the initial assessment, the rescue service gets a rough overview of some important body structures and functions (airways / breathing, circulatory function, injuries to important organ systems). The stabilization of the vital functions is of primary importance; In addition to providing oxygen and securing the airway (often through endotracheal intubation ), a tension pneumothorax is relieved , if present ; squirting bleeding is stopped with a pressure bandage or by tying ; Several large-lumen peripheral venous accesses are indicated for infusion therapy in polytrauma patients. The patient's spine is immobilized with a cervical support and a spine board or vacuum mattress .

Once transportability has been established, the patient is taken to a hospital suitable for the care of multiple trauma patients as quickly as possible. The readiness for transport should be established within 10 to 15 minutes so that the patient can be sent to a trauma center within the first “golden hour”, during which the patient has the best prognosis . It is the task of the emergency doctor, based on the injury pattern, to assess which medical specialties must be available in this hospital in order to adequately care for the patient, e.g. B. Oral and maxillofacial surgery , thoracic surgery, neurosurgery for traumatic brain injuries . The emergency doctor must also decide how urgent the transport is and which means of transport ( ambulance or rescue helicopter ) is used in order to provide the patient with the best possible care as quickly as possible.

Care in the hospital

Shock room of a trauma center

The primary care of the polytrauma patient is typically carried out in the emergency room of the hospital, often according to standardized procedures, such as the ATLS concept. Diagnostics and treatment are interdisciplinary with the addition of various disciplines (general and accident surgery , anesthesia , neurosurgery , radiology and any other required disciplines)

The most important life-threatening injuries are quickly diagnosed and treated in a structured manner. For this purpose, the patient is clinically examined , a sonography of the chest and abdominal cavity is carried out in order to discover internal bleeding or organ injuries ( FAST sonography). Then, within a few minutes, a full-body computed tomography (“trauma scan”, “trauma spiral”) is performed so that all major injuries can be identified. X-rays may be taken if the patient's situation is stable enough for this relatively time-consuming procedure. The necessary acute treatment (such as operative pelvic stabilization, laparotomy for bleeding in the abdominal cavity, trepanation for craniocerebral trauma; subsequent intensive therapy) is then quickly decided.

Epidemiology

Every year 32,000 to 38,000 people in Germany are seriously injured (with ISS> 15) who have to be treated in intensive care for an average of 10.3 days and in hospital for an average of 22.1 days. The survival rate has increased from 63% in the 1990s to 78% (2004). The trauma registry of the German Society of Trauma Surgery has compiled 2002 data from 14,110 polytrauma in the annual report. The mean age of the accident victims was 39.9 years, 72% were men. The mean injury severity was an ISS of 24.3 points. In 95% there was a blunt trauma, in 4% a penetrating trauma (gunshot, stab wound). 62% was a traffic accident, 15% a fall from a height of more than 3 meters and 6% a suicide attempt. In 58% there was a severe head injury , the chest cavity was severely affected in 57.6% of the patients, severe abdominal injuries were found in 25.5%, severe extremity injuries in 40.6%, each with an AIS of at least three points.

59% were intubated at the scene of the accident, 84% in total were ventilated. In 20% there was initially a shock with a drop in blood pressure below 90 mmHg, 32% were unconscious. Already 8% died at the scene of the accident or in the first 24 hours, a total of 16% died before discharge. Multiple organ failure developed in 32% . A blood transfusion was already carried out in 43% of the primary care in the emergency room . 78% of the accident victims were operated on, an average of 4.5 times. In 12%, the first surgical procedure was carried out in the emergency room. In this study, the mean hospital stay was 31 days, including 13 days in an intensive care unit .

In order to determine the incidence of multiple trauma in road accidents and the underlying accident mechanisms, the Accident Research of the Insurers (UDV) carried out a full survey of accident victims with ISS> 15 in six districts and two urban districts with a total of 1.32 million inhabitants. Within one year, 131 patients with this severity of injuries who had accidents in the study region were admitted to clinics, while 66 accident victims died at the scene of the accident. Surviving patients after multiple trauma thus had a share of 10% among seriously injured traffic accident victims according to the official definition.

Supply structures

In its 2006 white paper, the German Society for Trauma Surgery calls for the development of a comprehensive network of trauma centers for the optimized care of severely injured patients in a three-tier system, from local basic care through regional focus care to the care of the seriously injured in supraregional trauma centers with maximum care and specialized treatment centers. For this purpose, precise tasks, structural, spatial and personal equipment features are recommended. In addition, ongoing quality assurance and structured communication between all levels are required. This system is at the participating hospitals in the trauma registry of the DGU (the German Society of Trauma Surgery realized already largely).

Research on the seriously injured

In addition to research in the area of ​​the trauma register , research groups also deal with immunological questions in multiple trauma. The aim is to find early markers of the acute phase reaction that depict the risk of a systemic inflammatory reaction or sepsis after severe accidental injury in the sense of an immunological injury severity , although the research over twenty years to date has not been able to provide any clinically relevant results. On the other hand, the question of the severity and duration of intermittent immunosuppression between the second and fourth day after the accident, during which there is a greatly increased risk of repeated surgical interventions ( second hit ), is investigated .

literature

• Anne-Katrin Döbler, Lisa Ströhlein: DKOU 2016: New S3 guideline for polytrauma published. DGU , press release from October 17, 2016 at Informationsdienst Wissenschaft (idw-online.de), accessed on October 18, 2016.
• S3 guideline for multiple trauma / treatment of seriously injured persons of the DGU . In: AWMF online (as of July 1st, 2016, valid until June 30th, 2021)
• Harald Tscherne , Gerd Regel: Trauma Surgery. Trauma management. Springer-Verlag, Berlin / Heidelberg / New York 1997, ISBN 3-540-61605-5 .
• T. Gross: Long-term outcome after multiple trauma in working age. A prospective data collection at a Swiss trauma center . The trauma surgeon 119 (2016), pp. 921–928.

Web links

Wiktionary: Polytrauma  - explanations of meanings, word origins, synonyms, translations

• Trauma Surgery, Injury & Critical Care (English)
• Seriously injured in traffic

Individual evidence

1. ↑ ^{a b c} http://www.dgu-online.de/ : White book care for the seriously injured. (PDF; 246.51 kB) (No longer available online.) German Society for Trauma Surgery (Ed.), June 2012, archived from the original on September 23, 2015 ; Retrieved February 9, 2015 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.   
2. ↑ M. Bardenheuer et al.: Epidemiology of the seriously injured. In: Emergency & Rescue Medicine. 2000; 3, pp. 309-317.
3. ↑ SP Baker et al .: The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. In: The Journal of Trauma . 1974; 14, pp. 187-196.
4. ↑ HR Champion, among others: A revision of the trauma score. In: The Journal of Trauma. 1989; 29, pp. 623-629.
5. ↑ Walied Abdulla: Interdisciplinary Intensive Care Medicine. Urban & Fischer, Munich et al. 1999, ISBN 3-437-41410-0 , p. 467 f.
6. ↑ Walied Abdulla: Interdisciplinary Intensive Care Medicine. Urban & Fischer, Munich et al. 1999, ISBN 3-437-41410-0 , p. 466.
7. ↑ W. Abdulla (1999), p. 469 f.
8. ^ AG Polytrauma of the DGU: Annual report 2002 of the trauma register of the AG "Polytrauma" of the DGU . German Society for Trauma Surgery (DGU), Berlin 2003.
9. ↑ Serious injuries in traffic accidents. Research report of the UDV 2011: PDF
10. ↑ participating clinics in the trauma register ( memento of the original from June 15, 2009 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved April 7, 2011. 

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