Polytrauma

Polytrauma or multiple trauma is a medical term describing the condition of a person who has been subjected to multiple traumatic injuries, such as a serious head injury in addition to a serious burn. It is defined via an Injury Severity Score ISS >=17.^[1] The term has become common among US military doctors in describing the seriously injured soldiers returning from Operation Iraqi Freedom (Iraq) and Operation Enduring Freedom (Afghanistan). The term however is generic, and has been in use for a long time for any case involving multiple traumata.

Civilian medicine

In civilian life, polytraumas are often associated with motor vehicle accidents. This is because car accidents often occur at a high velocities causing multiple injuries. On admission to hospital any trauma patient should immediately undergo x-ray diagnosis of their cervical spine, chest and their pelvis, commonly known as a 'trauma series', to ascertain possible life threatening injuries. Examples would be a fractured cervical vertebra, a severely fractured pelvis, or a haemothorax. Once the initial survey is complete, x-rays can be taken of the limbs to assess for other possible fractures. It is also quite common in severe trauma for patients to go straight to CT or a surgery theatre if they require emergency treatment.

ECMO can be effective in treating some polytrauma patients with pulmonary or cardiopulmonary failure. ^[2]

A retrospective study of 93 children (average age of 8.0 +/- 4.1 years) with polytrauma and at least one major musculoskeletal injury showed that 80% of the incidents had been caused in this way (motor vehicle accident).^[3]

Military medicine

Blast injuries account for most battlefield polytrauma.

Overview

Polytrauma often results from blast injuries sustained by improvised explosive devices, or by a hit with a rocket-propelled grenade, with "Improvised explosive devices, blasts, landmines, and fragments account[ing] for 65 percent of combat injuries...".^[4] The combination of high-pressure waves, explosive fragments, and falling debris may produce multiple injuries including brain injury, loss of limbs, burns, fractures, blindness and hearing loss,^[5] with 60 percent of those injured in this way having some degree of traumatic brain injury.^[4]

In some ways, the high incidence of polytrauma is in fact a sign of medical advancement, for in previous wars, soldiers with such multiple damage types simply did not survive in most cases, even if quickly transferred into hospital care. The downside is however that many of the victims, though surviving, will never fully regain their physical or mental form. They are also prone to psychological complications such as post traumatic stress disorder.^[4]

U.S. treatment

One of the four US clinics specialising in polytrauma, this one in Palo Alto.

There are currently four rehabilitation centers in the US specialising in polytrauma (as of 2010). They are managed by the United States Department of Veterans Affairs and are located in Minneapolis, MN; Palo Alto, CA; Richmond, VA; and Tampa, FL.^[5] In addition to the actual intensive care insofar as still required, these hospitals mainly specialize in rehabilitative treatment. In addition the Department of Veterans Affairs has 18 polytrauma network sites, located throughout the country. As of April 2007, the Department of Veterans Affairs has treated over 350 service members in their inpatient centers.

The treatment and rehabilitative care for polytrauma patients is a very extensive and time-consuming activity. The recommended staffing numbers (FTE = Full Time Equivalent) for six rehabilitation treatment beds are:^[4]

0.5 FTE - Physician Discipline FTE Rehabilitation 5.5 FTE - Registered Nurse (1.0 must be CRRN) 4.0 FTE - Licensed Practical Nurse and/or Certified Nursing Assistant 0.5 FTE - Nurse Manager 0.5 FTE - Clinical Case Manager, Admission and Follow-up 1.0 FTE - Social Worker Case Manager 0.5 FTE - Social Worker

1.0 FTE - Speech-Language Pathologist 1.0 FTE - Physical Therapist 1.0 FTE - Occupational Therapist 0.5 FTE - Recreation Therapist 0.5 FTE - Counseling Psychologist 0.5 FTE - Neuropsychologist

In other words - 2.8 people are required full time (24h), for every patient, often for months, while some care may be required for life.

References

1. ^ Pathophysiology of polytrauma - Keel, M. & Trentz O. - Injury, Volume 36, Issue 6, Pages 691-709
2. ^ http://www.resuscitationjournal.com/article/S0300-9572%2810%2900124-3/abstract Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock
3. ^ Factors predictive of immobilization Complications in pediatric polytrauma - Loder, Randall T. et al., Journal of Orthopaedic Trauma 2001, vol. 15, no5, pp. 338-341
4. ^ ^{a b c d} Polytrauma Rehabilitation Procedures - Veterans Health Administration (VHA) Handbook, Thursday September 22 2005
5. ^ ^{a b} President's Project: Support for VAMC Polytrauma Centers (from the American Legion Auxiliary website)