Primary Management of Polytrauma

Abstract

The management of polytrauma patients is a challenging and dynamic process for the whole multidisciplinary team in the emergency department. Decisions made and measures taken during primary management have the ultimate effect on the prognosis of multiple injured patients. Trauma team leaders and team members benefit from a structured approach to such a complex situation. Hospital-specific interdisciplinary consensus on the workflow can help to optimize the management of trauma patients. All medical specialties involved should therefore have a basic understanding of each other’s approaches and the treatment options of the most important injury patterns. Primary Management of Polytrauma aims to provide a systematic and comprehensive guide on how to identify treatment options of potentially life-threatening injuries. The editors, all 3 themselves experienced surgeons from the Republic of South Korea, gathered authors from several surgical disciplines to cover sections on injuries of all major body regions. These specific sections are preceded by 2 sections on “Initial Assessment and Management” and the “Management of Shock,” which are authored by an emergency physician and 2 acute care surgeons. The book ends with 2 chapters on the role of radiology and a section on when and how to transfer trauma patients from your hospital. Within its 183 pages, the book provides a lot of detailed surgical information on how to diagnose and to classify individual injuries and gives insights into the regional approach of the management of trauma patients. Unfortunately, these sections do not intersect with each other, and there exists no overriding framework. Therefore, the book falls short to be a structured step-to-step guide to the management of polytrauma patients. Especially during the primary management of multiple injured patients, anticipation of injury mechanisms, pathophysiology of injury-related diseases (ie, trauma-associated coagulopathy), and critical injury constellations are crucial points. Unfortunately, none of these problems are substantially discussed in the book. The authors do not mention internationally accepted course concepts like the European Trauma Course (ETC) or Advanced Trauma Life Support (ATLS), both of which offer possibilities to learn trauma management in a structured manner. The views of international guidelines are rarely reflected in the book. In the chapter “Management of Shock,” recommendations on hemostatic resuscitation include the immediate transfusion of packed red blood cells; fresh-frozen plasma; platelets; and the correction of the lethal triad of coagulopathy, hypothermia, and acidosis. Lots of such improvident advice can be found throughout the first 2 chapters. For massive transfusion situations, for example, it is stated that (Chapter 2, page 14) “Current data support a target ratio of plasma:red blood cell:platelet transfusions of 1:1:1.” No advice on how to adjust transfusion on laboratory measures or the potential problems that come with transfusing large amounts of plasma is mentioned. The “current data” cited in the reference list, however, were published between 1982 and 2010, although more recent and high-quality evidence would have been available in most cases.1 Cited references in the short section discussing coagulopathy even go back to 1982–1989 (Chapter 2, page 14). More importantly, the book is lacking high-evidence recommendations from international consensus guidelines, like the early application of tranexamic acid to the bleeding trauma patient to treat or prevent hyperfibrinolysis.2 Specific chapters provide more detailed information on the classification and the surgical approach to the respective injuries. Radiological images and the discussion of relevant clinical scoring systems (as can be found in Chapter 4, “Spinal Injuries”) can support the physician’s individual decision-making. However, in most cases, these decisions would not be made by the leader or a member of the trauma team during the initial management of the patient. This is rather a surgical specialist’s task. In summary, this book allows for detailed insight into parts of the surgical decision-making and the approach to specific injuries and injury patterns of the polytraumatized patient. This can be interesting additional information for the advanced trauma leader or interested members of the trauma team. Due to lack of evidence-based information and missing recommendations from current guidelines, we cannot recommend the book as a guide or a reference for studying the primary management of polytrauma patients. Nils Kunze-Szikszay, MDKonrad Meissner, MDKlinik für AnästhesiologieUniversitätsmedizin GöttingenGöttingen, Germany[email protected]