One Page Summary
ATLS | Damage Control Orthopaedics | Second Hit
Patient Categories
Critical Must-Knows
- ISS greater than 15 defines polytrauma (major trauma)
- ATLS primary survey (ABCDE) first
- Damage control orthopaedics (DCO) for unstable/borderline patients
- Early total care (ETC) for stable patients
- Avoid second hit (inflammatory surge from long surgery)
Clinical Pearls
- "Lethal triad: Hypothermia, acidosis, coagulopathy
- "Borderline patient decision is most challenging
- "Femoral shaft: DCO with external fixator, convert to nail when stable
- "Pelvic binder at greater trochanters
Clinical Imaging
Imaging Gallery
![A]Compound Intraarticular fracture of the distal femur. B] Stabilized by a transarticular external fixator. C] Final conversion to the Ilizarov fixator.](/_next/image?url=%2Fimages%2Ftopics%2Fpolytrauma-management%2Fweb-sourced%2F1-polytrauma-management.png&w=1920&q=85)
Systematic approach to the multiply injured patient prioritizing life-saving interventions.
At a Glance
| Status | Definition | Management Goal | Orthopaedic Fixation |
|---|---|---|---|
| Stable | Normal physiology | Complete care | Early Total Care (ETC) - Definitive |
| Borderline | Responding but fragile | Protect physiology | DCO vs ETC (case specific) |
| Unstable | Ongoing shock | Life over limb | Damage Control Orthopaedics (DCO) |
| In Extremis | Dying | Save life only | Life-saving surgery only |
Quick reference table for physiological categorization and management decisions.
Essential Mnemonics
ABCDEATLS Primary Survey
| A | Airway With C-spine protection |
| B | Breathing Ventilation and oxygenation |
| C | Circulation Haemorrhage control, resuscitation |
| D | Disability Neurological status (GCS) |
| E | Exposure Expose and examine, prevent hypothermia |
| A | Airway With C-spine protection | D | Disability Neurological status (GCS) |
| B | Breathing Ventilation and oxygenation | E | Exposure Expose and examine, prevent hypothermia |
| C | Circulation Haemorrhage control, resuscitation |
Hook:ABCDE = systematic trauma assessment!
HACLethal Triad
| H | Hypothermia Core temp less than 35°C - impairs clotting, cardiac function |
| A | Acidosis Base deficit greater than 6, lactate greater than 2.5 - tissue hypoperfusion |
| C | Coagulopathy Consumption, dilution, hypothermia-induced - causes ongoing bleeding |
| H | Hypothermia Core temp less than 35°C - impairs clotting, cardiac function |
| A | Acidosis Base deficit greater than 6, lactate greater than 2.5 - tissue hypoperfusion |
| C | Coagulopathy Consumption, dilution, hypothermia-induced - causes ongoing bleeding |
Hook:HAC the triad - break the cycle or patient dies!
CRASHDCO Indications
| C | Coagulopathy INR greater than 1.5, ongoing transfusion requirements |
| R | Respiratory injury Pulmonary contusion, chest AIS greater than 2 |
| A | Acidosis Base deficit greater than 8, pH less than 7.25 |
| S | Shock Persistent hypotension, lactate greater than 2.5 |
| H | Hypothermia Core temp less than 32°C |
| C | Coagulopathy INR greater than 1.5, ongoing transfusion requirements | S | Shock Persistent hypotension, lactate greater than 2.5 |
| R | Respiratory injury Pulmonary contusion, chest AIS greater than 2 | H | Hypothermia Core temp less than 32°C |
| A | Acidosis Base deficit greater than 8, pH less than 7.25 |
Hook:CRASH patients need DCO, not ETC!
Overview
Polytrauma is defined as an ISS (Injury Severity Score) greater than 15, indicating multiple injuries with life-threatening potential. ATLS principles prioritize life-saving interventions via a systematic primary survey.
Epidemiology
- Incidence: Polytrauma accounts for approximately 25-27% of major trauma admissions (all those with ISS greater than 15). [1,2]
- Age Distribution:
- Bimodal peaks: Younger adults (21-30 years) involved in high-energy trauma (RTAs/Falls). [3]
- Geriatric rise: Increasing prevalence in patients older than 65 years due to low-energy falls in fragile patients with comorbid conditions. [4]
- Mechanism of Injury:
- Road Traffic Accidents (RTA): Predominant cause (~65%) in the working-age population. [1,5]
- Falls from height: Significant contributor to high-energy orthopedic trauma. [5]
- Mortality: Correlates strongly with ISS; patients with ISS 50-75 face mortality rates exceeding 50%. Geriatric patients have significantly higher mortality for equivalent injury scores. [2,4]
Biomechanics and Physiological Decline
Lethal Triad
Hypothermia, acidosis, coagulopathy. These are inter-related and self-perpetuating. The goal of resuscitation is to break this cycle.
Second Hit Phenomenon
The initial injury causes a systemic inflammatory response (SIRS). A "second hit" from major surgery can overwhelm the patient, leading to ARDS, MODS, and death.
DCO aims to stabilize fractures with minimal physiological insult, avoiding the second hit.
Patient Categories
Based on physiological status, not injury severity alone:
Stable: Normal vital signs, responding to resuscitation, no evidence of ongoing shock. → Early Total Care (ETC).
Borderline: Initially responding but has risk factors (ISS greater than 40, hypothermia, pulmonary injury, bilateral femur fractures, shock with massive transfusion). → Judgment call - DCO or ETC.
Unstable: Persistent shock despite resuscitation, ongoing haemorrhage. → DCO.
In extremis: Dying patient, near arrest, maximal therapy. → Damage control surgery (life-saving).
Orthopaedic Management
Damage Control Orthopaedics
Goal: Rapidly stabilize fractures with minimal physiological insult. Buy time for resuscitation.
Techniques:
- External fixator for long bone fractures (femur, tibia)
- Pelvic binder or external fixator for pelvic fractures
- Splinting for other fractures
Benefits: Short surgery, minimal blood loss, avoids second hit.
Conversion: When patient stable (usually 5-10 days), convert external fixator to definitive fixation (IM nail, ORIF).
Resuscitation First
Do not rush to fracture fixation in an unstable patient. Resuscitation and addressing life-threatening injuries takes priority. Orthopaedic DCO is designed to allow life-saving resuscitation to continue.
Anatomy and Pathophysiology
Polytrauma does not have a specific anatomical focus - it involves multiple body regions simultaneously. Key anatomical considerations:
- Thorax: Rib fractures, flail chest, pulmonary contusion affect respiratory function
- Abdomen: Solid organ injury (liver, spleen) causes haemorrhage
- Pelvis: Ring disruption causes major haemorrhage (arterial and venous)
- Femur: Shaft fractures associated with significant blood loss (1-2 litres per femur)
- Spine: Associated in up to 10% of major trauma - assume unstable until cleared
Pathophysiology
The Inflammatory Response in Trauma
First Hit (Initial Trauma)
The initial injury triggers a systemic inflammatory response syndrome (SIRS):
- Tissue damage releases damage-associated molecular patterns (DAMPs)
- Inflammatory cytokine cascade: IL-1, IL-6, TNF-α released
- Complement activation and neutrophil priming
- Endothelial dysfunction and capillary leak
- The response is proportional to injury severity (ISS)
Second Hit Phenomenon
Additional surgical insult during the inflammatory phase amplifies SIRS:
- Prolonged surgery (greater than 2 hours) acts as a "second hit"
- Reaming of long bones releases fat, marrow, cytokines
- Can precipitate multi-organ dysfunction syndrome (MODS)
- ARDS, acute kidney injury, coagulopathy may develop
DCO Rationale
Damage control orthopaedics minimises the second hit by:
- Temporary external fixation (minimal additional trauma)
- Delayed definitive surgery when inflammation has resolved (5-10 days)
- Monitoring inflammatory markers (CRP, IL-6) to guide timing
- The "window of opportunity" for conversion is days 5-10 post-injury
Differential Diagnosis: The Shocked Trauma Patient
The exam question is rarely "what is the fracture" — it is "why is this patient still shocked despite resuscitation?" Haemorrhage is the assumed cause until excluded, but other shock states coexist and change management.
Causes of Persistent Shock in Polytrauma
| Cause | Key clue | Confirm | Immediate action |
|---|---|---|---|
| Haemorrhagic (commonest) | Tachycardia, narrow pulse pressure, responds then relapses; rising lactate/base deficit | FAST, pelvic XR, CT, fall in Hb | Control source, MTP 1:1:1, TXA, DCO/binder |
| Tension pneumothorax | Distended neck veins, tracheal shift, absent breath sounds, hypoxia | Clinical (do NOT wait for CXR) | Immediate needle/finger decompression then chest drain |
| Cardiac tamponade | Distended neck veins, muffled heart sounds, PEA, penetrating chest | FAST/echo (pericardial fluid) | Pericardiocentesis or thoracotomy |
| Neurogenic shock | Hypotension WITH bradycardia, warm peripheries, cord-level deficit | Spinal injury on exam/CT | Exclude haemorrhage first; vasopressors, maintain MAP |
| Cardiogenic (blunt cardiac injury) | Arrhythmia, raised troponin, sternal fracture | ECG, echo, troponin | Telemetry, inotropes, treat arrhythmia |
| Non-bleeding hypovolaemia / overlooked | Multiple long-bone fractures each losing 1-2 L; under-resuscitation | Sum blood loss, log roll, tertiary survey | Splint/stabilise fractures, continue resuscitation |
Controversies & Areas of Uncertainty
- Borderline thresholds are not absolute. No single lactate, base-deficit or ISS value cleanly separates DCO from ETC; the decision is a dynamic physiological judgement (response to resuscitation), not a number.
- DCO vs "Early Appropriate Care" (EAC). Modern data (Vallier and others) suggest many patients previously labelled borderline can undergo definitive fixation early once lactate, pH and base deficit are corrected — pushing practice from blanket DCO back toward earlier definitive surgery in the adequately resuscitated patient.
- Reamed vs unreamed nailing in chest trauma. The historical fear that reaming worsens pulmonary outcome in patients with thoracic injury is not strongly supported by later evidence; reaming improves union, and the chest injury itself, not the reaming, drives ARDS.
- PROPPR did not prove 1:1:1 saves lives. The primary mortality endpoint was negative; the rationale for balanced ratios rests on improved haemostasis and reduced exsanguination, with growing interest in whole blood.
- Whole-body CT ("pan-scan") radiation and overtriage. Survival benefit is debated in stable, lower-acuity patients (REACT-2 was neutral overall); selective imaging is reasonable when injury burden is clearly limited.
- Conversion timing window. The classic "5-10 day" window to convert ex-fix to nail balances inflammatory quiescence against pin-tract colonisation; some advocate conversion within 2 weeks before biofilm forms, but the ideal day is individualised.
Classification
Injury Severity Scoring Systems
Injury Severity Score (ISS):
- Most widely used trauma scoring system
- Sum of squares of AIS (Abbreviated Injury Scale) for 3 most injured body regions
- Range 1-75 (AIS 6 in any region = ISS 75 automatically)
- ISS greater than 15 = major trauma (polytrauma)
- ISS greater than 25 = severe trauma
- ISS greater than 40 = critical, high mortality
New Injury Severity Score (NISS):
- Sum of squares of 3 highest AIS scores regardless of body region
- May better predict mortality in certain injury patterns
- Particularly useful when multiple injuries in same body region
Patient Physiological Categories:
| Category | Definition | Management |
|---|---|---|
| Stable | Normal vitals, responding to resuscitation | ETC appropriate |
| Borderline | Responding but has risk factors | DCO vs ETC - judgment call |
| Unstable | Persistent shock despite resuscitation | DCO |
| In Extremis | Dying, near arrest | Life-saving surgery only |
Clinical Assessment
ATLS Primary Survey (ABCDE)
A - Airway with C-spine Protection:
- Chin lift/jaw thrust (avoid head tilt in trauma)
- Clear debris, suction, insert airway adjunct
- Definitive airway if GCS less than 8 or cannot protect airway
- Maintain in-line immobilization during intubation
B - Breathing and Ventilation:
- Expose chest, assess respiratory rate and effort
- Life-threatening chest injuries: tension pneumothorax, open pneumothorax, massive haemothorax, flail chest with pulmonary contusion
- Needle decompression or chest tube as indicated
C - Circulation with Haemorrhage Control:
- Assess pulse, BP, capillary refill, skin color
- IV access (2 large bore), initiate fluid resuscitation
- Apply direct pressure to external bleeding
- Pelvic binder if suspected pelvic ring injury
- Initiate massive transfusion protocol if indicated
D - Disability (Neurological):
- GCS assessment
- Pupillary response
- Gross motor function
E - Exposure with Environmental Control:
- Fully undress patient for complete examination
- Log roll for back and spine examination
- Actively prevent hypothermia (warm blankets, fluid warmers)
The primary survey must be completed and life-threatening injuries addressed before fracture care.
Investigations
Initial Trauma Investigations
Laboratory Studies:
- Blood gas: pH, base excess, lactate - assess tissue perfusion
- FBC: Haemoglobin (often normal initially despite blood loss)
- Coagulation: PT/INR, APTT, fibrinogen - guide transfusion
- Cross-match: Urgent type and screen, O-negative if exsanguinating
- TEG/ROTEM: Point-of-care coagulation assessment if available
Imaging - Primary Survey:
- CXR portable: Pneumothorax, haemothorax, widened mediastinum
- Pelvic XR: Pelvic ring disruption
- FAST scan: Free fluid in abdomen/pericardium
CT Imaging (once stable):
- CT Head: Intracranial haemorrhage, midline shift
- CT Chest/Abdomen/Pelvis: Solid organ injury, aortic injury, spine fractures
- Whole-body CT (pan-scan): Standard in major trauma centers for ISS greater than 15
Pan-scan is the gold standard for rapid injury assessment once hemodynamically stabilized.
Management Algorithm
Surgical Technique
DCO Techniques by Fracture Location
Femoral Shaft:
- Spanning external fixator (hip to knee or knee-sparing)
- Pins: 2 proximal (subtrochanteric), 2 distal (supracondylar)
- Restore length and alignment
- Convert to antegrade IM nail when stable
Tibial Shaft:
- Spanning external fixator or immediate IM nailing (less physiological insult than femur nailing)
- Pins: 2 proximal (metaphyseal), 2 distal (metaphyseal)
- Tibial nailing can often proceed even in borderline patients
Pelvis:
- Pelvic binder first (at greater trochanters, NOT iliac crests)
- C-clamp for posterior ring if hemodynamically unstable
- Anterior external fixator (supra-acetabular pins or iliac crest pins)
- Angiography and embolization if ongoing arterial bleeding
Open Fractures:
- Debridement and washout
- Temporary external fixation
- Delayed soft tissue coverage and conversion to internal fixation
Temporary stabilization is critical in the early phase of open fracture management.
Complications
Polytrauma Complications
Early Complications (0-72 hours):
- Haemorrhagic shock: Ongoing blood loss, coagulopathy
- ARDS: Pulmonary contusion, fat embolism, transfusion-related
- Compartment syndrome: High index of suspicion in unconscious patients
- Missed injuries: Up to 10% detected on tertiary survey
- Fat embolism syndrome: Triad of hypoxia, confusion, petechiae
Late Complications (Days to weeks):
- Multi-organ dysfunction syndrome (MODS): Inflammatory cascade
- Sepsis: Nosocomial infection, open fractures
- VTE: High risk in immobile polytrauma patients
- Nonunion/malunion: Inadequate initial stabilization
- Heterotopic ossification: Common in head injury + extremity fracture
Orthopaedic-Specific Complications:
- Pin site infection (5-10% with ex-fix)
- Deep infection after conversion (2-15% depending on pin status)
- Nonunion (higher in delayed treatment)
- Stiffness (prolonged immobilization)
Vigilant monitoring for metabolic and pulmonary complications is essential.
Postoperative Care
ICU Phase Management
Ongoing Resuscitation:
- Goal-directed therapy: lactate clearance, urine output
- Blood product replacement per MTP
- Temperature management (active warming to greater than 36°C)
- Nutrition: early enteral feeding when possible
Monitoring:
- Serial lactate and base excess
- Daily bloods: FBC, coagulation, renal function
- CRP and inflammatory markers for conversion timing
- Compartment checks in sedated patients
DVT Prophylaxis:
-
Mechanical (SCDs/IPC) from admission
-
Pharmacological once bleeding risk acceptable
-
Enoxaparin 40mg daily or equivalent
-
Plan for conversion to definitive fixation
Conversion criteria should be strictly followed to avoid complications.
Outcomes
Polytrauma Survival Outcomes
Mortality Rates by ISS:
- ISS 16-24: 5-10% mortality
- ISS 25-40: 15-25% mortality
- ISS greater than 40: 30-50% mortality
- ISS 75: Near 100% mortality
Factors Affecting Mortality:
-
Age (mortality increases significantly over 65)
-
Injury pattern (head + chest worst prognosis)
-
Time to definitive care
-
Trauma center volume and resources
-
Comorbidities
-
Inappropriate ETC in unstable patient increases MODS risk
Proper patient selection is the most critical factor in survival outcomes.
Evidence Base
Key Evidence for Polytrauma Management
Early Total Care (ETC) Evidence:
- Bone et al. (1989): Landmark study showing early femoral stabilization (less than 24h) reduces ARDS, fat embolism, and hospital stay in stable patients
- Multiple subsequent studies confirmed benefit of early long bone fixation in stable patients
Damage Control Orthopaedics (DCO) Evidence:
-
Pape et al. (2002): Defined DCO concept - external fixation for unstable patients avoids second hit
-
Scalea et al. (2000): Showed DCO reduces pulmonary complications in borderline patients
-
Conversion timing: Days 5-10 optimal (Pape et al.)
-
CRASH-2 Trial (2010): Tranexamic acid within 3 hours reduces mortality
Evidence-based protocols focus on physiological optimization and balanced resuscitation.
Clinical Decision Scenarios
Use these scenarios to practise clinical reasoning and management decisions
Scenario 1: Polytrauma
"A motorcyclist arrives with bilateral femoral shaft fractures, pulmonary contusion, and initial BP 80/50. He has received 6 units of blood and now has BP 100/60. How do you manage his femoral fractures?"
Scenario 2: Unstable Pelvic Fracture
"A 45-year-old male is brought in after a high-speed RTA. He is hemodynamically unstable (BP 70/40) with obvious pelvic deformity after an APC-III type injury. How do you proceed?"
Scenario 3: Stable Polytrauma
"A 19-year-old female presents with a closed femoral shaft fracture and a minor chest injury (RIB AIS 1). She is hemodynamically stable, lactate 1.2, and pH 7.4. What is your management plan?"
MCQ Practice Points
DCO vs ETC
Q: When should damage control orthopaedics (DCO) be used instead of early total care (ETC)?
A: DCO indicated: ISS greater than 40, ISS greater than 20 with additional thoracic injury (AIS greater than 2), bilateral femur fractures with shock, hypothermia less than 32°C, base deficit greater than 8, coagulopathy, ongoing transfusion requirements. ETC appropriate: Borderline patients stabilised by resuscitation, no chest trauma, ISS less than 20.
Second Hit Phenomenon
Q: What is the second hit phenomenon and how does DCO prevent it?
A: The first hit is the initial traumatic insult causing SIRS. The second hit is additional surgical trauma (e.g., prolonged orthopaedic surgery) that amplifies inflammation and can precipitate multi-organ dysfunction syndrome (MODS). DCO prevents this by using temporary stabilisation (external fixation) to minimise surgical stress during the inflammatory phase, with definitive fixation delayed 5-10 days when the patient is optimised.
Femur Fracture Timing
Q: What is the optimal timing for femur fracture fixation in polytrauma?
A: In stable patients, early intramedullary nailing (within 24 hours) reduces pulmonary complications, ICU stay, and hospital stay. In unstable patients (shock, coagulopathy, base deficit greater than 6), use external fixation initially with conversion to IM nail at 5-10 days when inflammatory markers normalise and patient is optimised.
Fat Embolism Prevention
Q: How do you minimise fat embolism risk during IM nailing in polytrauma?
A: Techniques include: reaming cautiously or use unreamed nails in chest trauma, venting the femur during nailing, avoiding over-pressurisation of the canal, surgical stabilisation early (prevents ongoing marrow extravasation from mobile fracture). Monitor for fat embolism syndrome: petechial rash, hypoxia, confusion (classic triad).
Guidelines, Registries & Global Practice
Global Epidemiology
Trauma is a leading cause of death in those under 45 worldwide; road traffic injury alone causes roughly 1.2 million deaths per year (WHO), disproportionately in low- and middle-income countries (LMICs) where over 90% of road deaths occur despite those regions owning a minority of vehicles. The injury burden is bimodal: high-energy mechanisms in young adults and an expanding cohort of older patients sustaining major injury from low-energy falls.
Side-by-Side Guidelines
| Body | Position on key issues |
|---|---|
| ATLS (ACS-COT) | ABCDE primary survey; permissive hypotension and haemorrhage control; the universal common language for resuscitation worldwide. |
| EAST / WTA (US) | Practice management guidelines support early appropriate fixation of femoral fractures and selective DCO; whole-body CT in stable major trauma. |
| BOA / BAPRAS (UK, BOAST) | Open fracture and major trauma standards: senior decision-making, antibiotics within 1h, combined ortho-plastic care, definitive fixation only with soft-tissue cover. |
| AO Foundation | Provides the DCO vs ETC framework and the "safe definitive surgery / early appropriate care" concept tying the timing of fixation to the resuscitated physiological state. |
| NICE (UK, NG39) | Major trauma pathway: networked care, damage control resuscitation, TXA early, restrictive crystalloid, whole-body CT in adults with suspected multiple injuries. |
Antibiotics for Associated Open Fractures
A first-generation cephalosporin (e.g. cefazolin) given within 1 hour of injury is the global standard; gram-negative cover (e.g. an aminoglycoside) is added for higher-grade/contaminated wounds and high-dose penicillin where clostridial/soil contamination is a concern. Exact agents follow local microbiology and antimicrobial-stewardship policy.
Registry & System Evidence
National and regional trauma registries (e.g. UK TARN, US National Trauma Data Bank, the German TraumaRegister DGU, Victorian State Trauma Registry) consistently show that inclusive, networked trauma systems with direct transfer to a major trauma centre reduce mortality for ISS greater than 15 patients. Registry data also drive audit of "early appropriate care" timing and missed-injury rates.
High- vs Limited-Resource Practice
- High-resource: rapid whole-body CT, interventional radiology/embolisation, ROTEM/TEG-guided component therapy, ICU-supported staged conversion.
- Limited-resource: clinical and FAST-led triage, external fixation as both damage-control AND sometimes definitive treatment, judicious whole-blood or ratio-based transfusion, and earlier reliance on operative haemorrhage control where angio-embolisation is unavailable. DCO principles remain valid and are often MORE relevant where physiological monitoring is constrained.
POLYTRAUMA MANAGEMENT
Clinical summary
ATLS
- •ABCDE primary survey
- •Life-threatening injuries first
- •Resuscitate before fracture care
Lethal Triad
- •Hypothermia
- •Acidosis
- •Coagulopathy
DCO vs ETC
- •Stable → ETC (within 24h)
- •Borderline/Unstable → DCO (ex-fix)
- •In extremis → Life-saving surgery only
DCO Technique
- •External fixators for long bones
- •Pelvic binder for pelvis
- •Short surgery, minimal blood loss