definicion de polytrauma.pdf

8/11/2019 definicion de polytrauma.pdf

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www.elsevier.com/locate/injury

00201383/$see front matter 2009 Published by Elsevier Ltd.doi:10.1016/j.injury.2009.10.032

Injury, Int. J. Care Injured (2009) 40S4, S12 S22

1 Abstracts in German, French, and Spanish are printedat the end of this supplement.

Basic concepts relevant to the esign anevelopment of the Point Contact Fixator (PC-Fix)

Stephan M. Perren anJo S. Buchanan

AO/ASIF Research Institute, Clavadelerstrasse, 7270 Davos, Switzerland

AO/ASIF Research Institute, Clavadelerstrasse, 7270 Davos, Switzerland

KEywORdS:

One silly fountain;Progressive dwarves;Umpteen mats;Five silly trailers;

Summar1 bla bla bla bla One aardvark marries the pawnbroker, even though fivebourgeois cats tickled umpteen Macintoshes, but two obese elephants drunkenlytowed umpteen almost irascible sheep. Two bureaux easily telephoned Paul, eventhough the wart hogs gossips, but one elephant tastes partly putrid wart hogs,because umpteen purple botulisms kisses Mark, although the subways bought oneextremely angst-ridden lampstand, even though five obese televisions perusedsubways, then five progressive mats auctioned off the bureau, although two trail-ers grew up, but irascible Jabberwockies untangles five speedy fountains, yet onecat ran away, then the trailer very cleverly kisses two irascible bureaux.

The efinition of poltrauma:the nee for international consensus

Neria Butcher, Zsolt J Balogh

Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle,

Newcastle, NSW, Australia

KEywORdS:

Polytrauma, definition

Summar1 INTRODUCTION: Polytrauma patients represent the ultimate challenge

to trauma care and the optimisation of their care is a major focus of clinical andbasic science research. A universally accepted definition for polytrauma is vital forcomparing datasets and conducting multicentre trials. The purpose of this review isto identify and evaluate the published definitions of the term polytrauma.MATERIALS AND METHODS: A literature search was conducted for the time periodJanuary 1950August 2008. The Medline, Embase and Cochrane Library databaseswere searched using the keyword polytrauma. Articles were evaluated withoutlanguage exclusion for the occurrence of the word polytrauma in the text andthe presence of a subsequent definition. Relevant online resources and medicaldictionaries were also reviewed.RESULTS: A total of 1,665 publications used the term polytrauma, 47 of whichincluded a definition of the term. The available definitions can be divided intoeight groups according to the crux of the definition. No uniformly used consensus

definition exists. None of the existing definitions were found to be validated orsupported by evidence higher than Level 4.CONCLUSION: This review identified the lack of a validated or consensus defini-tion of the term polytrauma. The international trauma community should considerestablishing a consensus definition for polytrauma, which could be validated pro-spectively and serve as a basis for future research.

Introuction

The term polytrauma has been in use for manydecades. It is generally used to describe (mainly)

blunt trauma patients whose injuries involve mul-tiple body regions or cavities, compromise the pa-tients physiology and potentially cause dysfunctionof uninjured organs. These patients are at risk ofhigher morbidity and mortality than the summa-tion of expected morbidity and mortality of theirindividual injuries. Polytrauma patients are veryseriously injured but can be potentially saved with

efficient triage and focused trauma specialist carein dedicated institutions. Polytrauma managementis highly resource intensive often involving massiveresuscitation efforts, extensive imaging, multiple

operations, extended intensive care unit (ICU) stayand complex rehabilitation programmes.Given the high risk of unfavourable outcomes

and the extent of invested resources, research intopolytrauma patients is potentially highly rewardingand is the main focus of many clinical and basic sci-ence projects. Most of the current popular traumaresearch topics (postinjury coagulopathy, transfu-sion strategies, immunological aspects of trauma,damage control surgery, complex pelvic fractures,timing of secondary surgery and multiple organfailure) have the same target populationthe poly-

1 Abstracts in German, French, and Spanish are printedat the end of this supplement.


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The definition of polytrauma: the need for international consensus S13

trauma patient. A universally accepted definitionfor polytrauma is vital for comparing datasets andconducting multicentre trials.

The ideal definition of polytrauma is one that is(1) reproducible, (2) sensitive and specific, (3) read-ily available at the early phase of resuscitation and(4) captures both the physiological and anatomicalelements of polytrauma (ie, recognises that multipleregions are involved).

We hypothesised that the international trauma lit-eraturehasaclear,validatedandconsensusdefinitionof the term. The aim of this review was to identifyand evaluate the existing definitions of polytrauma.

Materials an methos

A literature search was conducted for the time peri-od January 1950August 2008. The Medline, Embase

and Cochrane Library databases weresearched usingthe keyword polytrauma. All available articleswere evaluated for the occurrence of the word inthe text and the presence of a subsequent defini-tion. Where full texts were not available online,hard copies were obtained and searched by hand.Where only abstracts were available these weresearched and any definitions present were includedin the review. No language restrictions wereapplied.The abstracts of non-English articles were screenedfor potential relevance and full texts obtained andtranslated as necessary.

The following relevant online resources were alsosearched: the International Statistical Classificationof Diseases (ICD) and Related Health Problems 10thRevision Version for 2007 [67], UK National Libraryfor HealthClearinghouse for Protocols (searchingboth UK and International guidelines) [42], Centresfor Disease Control and Prevention (USA) [13] and aselection of major surgical organisations includingthe German Society for Trauma Surgery (DGU) [13],the American Association for the Surgery of Trauma[1], the American College of Surgeons [2], Royal Col-lege of Physicians and Surgeons of Canada [55], TheRoyal College of Surgeons of England [56] and theRoyal Australasian College of Surgeons [54]. Finally,a search was conducted of selected English languagemedical dictionaries [9, 15, 18, 38, 41, 62].

Results

The search resulted in a total of 1,665 publicationscontaining the word polytrauma. Of these 1,665publications, 47 attempted to define the term poly-trauma [3, 68, 10, 11, 14, 1619, 2137, 39, 43,35, 36, 38, 5053, 5761, 6366, 68]. These were

divided into eight basic groups according to the cruxof the definition: 1) number of injuries, body regionsor organ systems involved, 2) pattern or mechanismof injury, 3) consequent disability, 4) injuries rep-resenting a threat to life, 5) injury severity score(ISS), 6) a combination of both 4 and 5, 7) criterionbased and 8) definitions based on a combination ofISS and systemic, immune-based features. Only twodefinitionswereconsideredtobesupportedbyLevelIV evidence, all other definitions represent Level Vscientific evidence [47].

Number of injuries, bo regions or organsstems involve

Eight articles were found in which the definitionof polytrauma was based on the total number ofinjuries, body regions or organ systems involved

(summarised in Table 1).Three articles defined polytrauma in accord-

ance with the number of injuries sustained [8, 11,16]. In one of the earlier definitions found in theliterature, Border et al [11] defined polytrauma as 2 significant injuries. These authors also arguedthat single injuries later developing multiple organfailure (MOF) should be defined as part of the samepolytrauma category. Blacker et al [8] defined poly-trauma as 2 injuries, with the added requirementof the involvement of at least one vital organ andadmission to trauma ICU. Deby-Dupont et al [16] in-

creased the number to 3 major injuries, and addedthe development of severe shock to their definition.Five publications defined polytrauma in relation

to the number of organ systems or body regionsinvolved [14, 18, 36, 45, 63]. Tool et al [63] and Dor-lands Medical Dictionary [18] defined polytraumaas the occurrence of injuries to more than onebody system. Two of the five defined polytraumapatients based on two or more organ systems orregions involved, but both contained additional cri-teria: McLain et al [36] further defined significantinjury as the need for hospital admission and activemanagement, while the study by Osterwalder [45]defined polytrauma patients as shock room patientswith an AIS of 2 or more in 2 ISS body regions, withthe external system excluded. Cerra et al definedpolytrauma as 3 organ systems involved with alaparotomy [14].

Pattern or mechanism of injur

Of the eight definitions in this group, seven werebased on a defined pattern of injury [17, 23, 31,33, 50, 52, 53], and one was unique in defining


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S14 N Butcher, ZJ Balogh

Table 2. Pattern or mechanism of injury

First author(year) Definition of polytrauma Level ofevidence(IV)

Rohde [53](1980)

Involvement of at least 3 body cavities (head, thorax, abdomen), 2 body cavitiesand 1 extremity fracture, 1 body cavity and 2 extremity fractures or 3 extremityfractures. (An extremity fracture was defined as a fracture of a long bone, ie,humerus, femur.)

V

Reff [52](1984)

Fractures with multisystem injuries and/or head trauma (with associated spastici-ty), or patients with multiple fractures in whom stabilisation of the skeletal injuryenables more satisfactory patient care

V

Marx [33](1986)

Injury to abdomen, chest, or head associated with significant fractures, or, if novisceral injuries present, as 2 major fractures of long bones or 1 major longbone fracture with a pelvic fracture

V

Loder [31]

(1987)

At least one fracture of a long bone, the shoulder, pelvic girdle or the spine PLUS

at least one other injury involving the neural, face and neck, chest or abdominalbody areas

V

Dick [17](1999)

Injury to one body cavityhead/ thorax/ abdomen (multiple trauma) PLUS twolong bone and/or pelvic fractures OR injury to two body cavities

V

Herbert [23](2000)

Injury to at least one area in addition to spine fracture, dislocation, or subluxa-tion

V

Pepe [51](2003)

Severe blunt trauma with injuries to multiple organ systems V

Pape [50](2006)

Injuries to at least 2 long bone fractures, or one life-threatening injury and atleast one additional injury, or severe head trauma and at least one additional in-jury

V

The level of evidence is based on the Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001), andrefers to the level of evidence used by the authors to determine the definition of polytrauma [47].

Table 1. Number of injuries, body regions or organ systems involved

First author(year)

Definition of polytrauma Level ofevidence

(IV) Border [11](1975)

2 significant injuries V

Cerra [14](1983)

3 organ systems involved with a laparotomy V

Deby-Dupont [16](1984)

3 major injuries (head, chest, abdomen or limbs) leading to severe shock V

Tool [63](1991)

Injuries to >1 body system V

McLain [36](1999)

Significant injury (requiring hospital admission and active management) to 2major organ systems

V

Osterwalder [45](2002) AIS-85 of 2 in at least 2 of the six defined ISS body regions, excluding theexternal system (AIS-6). V

Dorlands MedicalDictionary [18](2003)

Injuries to > 1 body system

Blacker [8](2004)

2 injuries that involve at least 1 vital organ (eg, lung or liver) and necessitatepatient admission to a trauma intensive care unit.

V

AIS = Abbreviated injury scale; ISS = Injury severity score. The level of evidence is based on the Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001), andrefers to the level of evidence used by the authors to determine the definition of polytrauma [47].

polytrauma via the mechanism of injury (Table 2).This latter definition came from an editorial dis-cussing the definition and management of shock inpolytrauma [51]. Here, Pepe defined polytrauma

as a situation entailing severe blunt trauma withinjuries to multiple organ systems. This paper dis-tinguished blunt polytrauma with its characteristicpathophysiology from the more focused tissue injury


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and exsanguination resulting from critical penetrat-ing or lacerating injuries.

Six studies identified their definitions as beingspecifically designed for patient selection [23, 31,33, 50, 52, 53]. In 1980, Rhode et al [53] presentedfour combinations of injuries to define a poly-trauma patient for inclusion in their trial of cime-tidine prophylaxis in severe polytrauma. In a studyanalysing the use of external fixation devices inmanagement of childhood pelvic injuries and lower-extremity trauma, Reff [52] defined polytrauma as:Fractures with multisystem injuries and/or headtrauma (with associated spasticity), or patientswith multiple fractures in whom stabilization of theskeletal injury allows for more satisfactory patientcare. For the purpose of their analysis of polytrau-ma in the elderly, Marx et al [33] defined the termas Injury to abdomen, chest, or head associatedwith significant fractures, or, if no visceral injuries

present, as 2 major fractures of long bones or onemajor long bone fracture with a pelvic fracture. Inorder to be included in the paediatric polytraumapopulation group, the study by Loder [31] requiredpatients to have at least one fracture of a longbone, the shoulder, pelvic girdle, or the spine plusat least one other injury involving the neural, faceand neck, chest or abdominal body areas. Herbertet al [23] in their analysis of polytrauma in patientswith traumatic spine injury defined it as injury toat least one area in addition to spine fracture, dis-location, or subluxation. Here, any patient with an

AIS coding for a region other than the spine, or witha neurological deficit, was considered a polytraumapatient. In this study, an ISS greater than nine wasalso argued to be synonymous with polytrauma.Pape et al used a study-specific retrospective defi-nition for evaluating polytrauma patient outcomes:Injury of at least two long bone fractures, or onelife-threatening injury and at least one additionalinjury, or severe head trauma and at least one ad-ditional injury [50].

The International Trauma Anaesthetic and Criti-cal Care Society also attempted a definition basedon injury pattern. From this group, Dick et al [17]published a set of recommendations for the uniformreporting of trauma data and argued the case for es-tablishing distinct trauma-related definitions.In thispaper a unique step was taken to clearly distinguishbetween the terms multiple trauma and poly-trauma. Multiple trauma was first defined as in-jury to one body cavityhead/ thorax /abdomen,with the authors thenfurther defining polytrauma asmultiple traumaplustwo long bone and/or pelvicfractures or injury to two body cavities [17].

Consequent isabilit

This unique group was characterised by an inclu-sion of the consequent disability sustained from thepolytrauma as part of the definition (Table 3). Thecrux of these definitions was that polytrauma shouldbe defined as injuries resulting in physical, cogni-tive, psychological, or psychosocial impairment andfunctional disability [29, 59, 66].

Criteria-base efinition

Two articles defined polytrauma using a gradingsystem based on the pathophysiological response totrauma (Table 4). Appearing first in Schweiberer etal [58] in 1978, the grading system was adopted byHeberer et al [22] in a paper 5 years later. Thesetwo papers could be considered Level IV evidence

in terms of the definitions.

Injuries representing a threat to life

Thirteen articles were found in which the crux ofthe definition was injuries representing a threat tolife (Table 5) [6, 19, 28, 30, 32, 34, 35, 39, 43, 36,57, 65, 68].

In Barbieri et al [6] polytrauma was defined asmultiple lesions with at least one endangering lifeeither immediately or in the short term. Schalamon

et al [57] and Linsenmaier et al [30] both definedpolytrauma as a life-threatening injury of 2 bodyregions. Martins et al [32] defined it as a potentiallythreatening situation where multiple lesions arepresent in a given anatomical region, or throughoutthe entire body.

Two articles defined polytrauma as the simultane-ous occurrence of injuries where their combinationis life threatening [39, 43]. Seven papers [19, 28,34, 35, 46, 65, 68] defined polytrauma as a situa-tion in which at least one injury or the combinationof all injuries was life threatening, however, thesepapers differed in their descriptions of the type ofinjury pattern required to meet the definition (seeTable 5, eg, Faist et al [19]; injury to several bodyregions or organ systems versus Tscherne et al [65]; 2 severe injuries).

Injur severit score

A total of 13 publications contained the ISS as partof their definition. Of these 13, seven defined poly-trauma exclusively by this score (Table 6) [3, 7, 10,24, 37, 48, 60]. Sikand et al [60] defined polytrauma


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as an ISS > 15, Biewener et al [7] as ISS > 16, andHildebrand et al [24] ISS > 18. Bone et al [10] andPape et al [48] defined polytrauma as ISS 18, andfinally, both McLain [37] and Asehnoune et al [3]defined it as an ISS > 25.

Threat to life plus ISS

The Guideline Committee of the Polytrauma Asso-ciation of the German Registered Society of Traumapublished recommended guidelines for diagnosticsand therapy in trauma surgery. Combining elementsof previous definitions, these guidelines explicitlydefined polytrauma as: Injury to several physicalregions ororgan systems, whereat least one injury orthe combination of several injuries is life threaten-ing, with the severity of injury being ISS 16. [21]

This group also recommended the term poly-trauma be differentiated from both multiple inju-ries (which are not life threatening), and severe,

life threatening single injuries (which they termedbarytrauma). In 2006, this definition was adoptedby Koroec Jagodi et al [27] in their study of long-term outcomes in patients treated in the surgicalICU (Table 7).

The ISS plus sstemic inflammator response

This group of definitions found in the literatureoriginated from the definition published in 2000 byTrentz [64] in the AO Principles of Fracture Manage-ment (Table 8) [25, 26, 61, 64]. While the criteriafor the severity of injury (ISS > 17) echoed the valueproposed by the German Trauma Society [21], thisdefinition was unique in both defining polytraumaas a syndrome and also in its explicit inclusion ofthe systemic inflammatory response of polytrauma.This definition was subsequently adopted by Stahelet al [61] in their paper on the current concepts ofpolytrauma management.

Table 3. Consequent disability

First author(year)


(IV) Lew [29](2005)

Injury to the brain in addition to other body parts or systems resulting in physi-cal, cognitive, psychological, or psychosocial impairment and functional disability

V

United StatesDepartment ofVeterans Affairs [66](2008)

2 injuries to physical regions or organ systems, one of which may be life threat-ening, resulting in physical, cognitive, psychological or psychosocial impairmentsand functional disability

V

Sigford [59](2008)

2 injuries to physical regions or organ systems, one of which may be life threat-ening, resulting in physical, cognitive, psychological or psychosocial impairmentsand functional disability

V


Table 4. Criteria based definitions

First author(year)


(IV) Schweiberer [58](1978)

According to severity:Grade I: Moderate injury, hospitalisation necessary, no shock, paO2 normal.Grade II: Heavy injury, signs of shock, loss of approximately 25% of blood volume,paO2 below normal.Grade III: Acute life-threatening injury, severe shock, loss of more than half ofcirculating blood volume, paO2 below 60 mm Hg

IV

Heberer [22](1983)

According to severity:Grade I: Moderate injury, hospitalisation necessary, no shock, paO2 normal.Grade II: Heavy injury, signs of shock, loss of approximately 25% of blood volume,paO2 below normal.Grade III: Acute life-threatening injury, severe shock, loss of more than half ofcirculating blood volume, paO2 below 60 mm Hg

IV



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Table 5. Injuries representing a threat to life

First author(year)


(IV) Faist [19](1983)

Injury to several body regions or organ systems, where at least one or a combinationof several injuries is life threatening

V

Tscherne [65](1984) 2 severe injuries, with at least one injury or the sum of all injuries being lifethreatening V

Kroupa [28](1990)

2 severe injuries in at least two areas of the body, OR 2 severe injuries in one body area.PLUS incidence of traumatic shock and/or haemorrhagic hypotension and1 vital function seriously endangered.1 out of two or more injuries or the sum total of all injuries must endanger life

V

Mittlmeier [39](1999)

Simultaneous violation of several body or organ systems, which in their combinationcause systemic dysfunction and even death

V

Ott [46](2000)

Simultaneous occurrence of injuries to a number of regions of the body or organsystems, with at least one or a combination of several injuries being life threatening

V

Oestern [43](2001)

Simultaneous injuries of several body regions or organ systems, where the combina-tion is life-threatening

V

Barbieri [6]

(2001)

Multiple lesions of which at least one potentially endangers, immediately or in the

short term, their life

V

Linsenmaier [30](2002)

Two injured body regions, of which one is potentially fatal V

Matthes [34](2003)

Injury to various areas of the body that alone or in combination pose an acute,life-threatening risk

V

Schalamon [57](2003)

Life-threatening injury to 2 body regions V

Martins [32](2004)

Potentially threatening situation where multiple lesions are present in a givenanatomical region, or throughout the entire body

V

Zelle [68](2005)

2 severe injuries, with at least one injury or the sum of all injuries being lifethreatening

V

Matthes [35](2006)

Injury to different areas of the body, which alone or in combination pose an acutelylife-threatening risk

V


Table 6. Injury severity score (ISS)

First author(year)

Definition of Polytrauma Level ofevidence

(IV) Bone [10](1995)

ISS 18 V

Pape [48]

(2000)

ISS 18 V

Hildebrand [24](2004)

ISS > 18 V

McLain [37](2004)

ISS 26 V

Biewener [7](2004)

ISS > 16 V

Sikand [60](2005)

ISS > 15 V

Asehnoune [3](2006)

ISS > 25 V



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Table 7. Threat to life plus ISS

First author(year)


(IV) Guideline Committee ofthe German Registered

Society for TraumaSurgery [21](2001)

Injury to several physical regions or organ systems, where at least one injuryor the combination of several injuries is life threatening, with the severity of

injury being ISS 16.To be differentiated from both multiple injuries, which are not life-threaten-ing, and severe, life-threatening single injuries (barytrauma)

V

Koroec [27](2006)

Injury to several physical regions or organ systems, where at least one injuryor a combination of several injuries is life threatening, with the ISS 16

V

ISS = Injury severity score. The level of evidence is based on the Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001), andrefers to the level of evidence used by the authors to determine the definition of polytrauma. 47

Table 8. ISS plus systemic inflammatory response

First author(year) Definition of polytrauma Level ofevidence(IV)

Trentz [64](2000)

Syndrome of multiple injuries exceeding a defined severity (ISS >17) with se-quential systemic traumatic reactions that may lead to dysfunction or failureof remote organs and vital systems, which had not themselves been directlyinjured

V

Stahel [61](2005)

A syndrome of multiple injuries exceeding a defined severity (ISS > 17) withconsecutive systemic trauma reactions that may lead to dysfunction or fail-ure of remoteprimarily not injuredorgans and vital systems

V

Keel [26](2005)

Syndrome of combined injuries with an injury severity score (ISS > 17) andconsequent SIRS for at least one day, leading to dysfunction or failure ofremote organs and vital systems, which had not been directly injured them-selves

V

Keel [25](2006) Syndrome of multiple injuries (ISS > 17) with consequent SIRS for at leastone day leading to dysfunction or failure of remote organs and vital systems,which had not been directly injured themselves

V

ISS = Injury severity score; SIRS = Systemic inflammatory response syndrome. The level of evidence is based on the Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001), andrefers to the level of evidence used by the authors to determine the definition of polytrauma [47].

In 2005, Keel and Trentz further refined the origi-nal Trentz definition with the phrase sequentialsystemic traumatic reactions, replaced by themore objective criteria of systemic inflammatoryresponse syndrome (SIRS) for at least one day [26].In 2006, the phrasing again changed subtly from asyndrome of combined injuries to a syndrome ofmultiple injuries[25].

discussion

Despite previous attempts to define the term,there remains no universally accepted definition ofpolytrauma [17, 21, 28]. Throughout the European

trauma literature the term polytrauma is found fre-quently, and is typically used to define a situation ofsimultaneous injuries involving a threat to life [6,21,39, 43]. By contrast, in the Anglo-American litera-ture the term is rarely used. A polytrauma patient inthe Anglo-American papers is classically defined bya nominated injury severity score and the term usedinterchangeably with others such a major traumaand multiple trauma [60]. Despite its frequentuse in both spheres of trauma literature, no authorin either one has sought to validate their proposeddefinition in accordance with the traditional rulesof evidence.

In the last 5 years, the term polytrauma hasfound new life among US military doctors, addingfurther complexity to the definition. Here, the


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term has been adopted to specifically describe thedevastating blast injuries in soldiers returning fromIraq and Afghanistan and has been paralleled by thedevelopment of so-called polytrauma centres tomanage these patients under the direction of the USDepartment of Veteran Affairs [66].

Polytraumapresentsasignificantthreattolifeandcarries a high risk of complications. To improve out-come,theactualpopulationatriskandtheincidencehas to be determined. A prospective assessmentand comparison of outcomes from current practiceis needed, along with more rigorously designed tri-als to evaluate potential interventions. Without aclear definition of what constitutes a polytraumapatient, this process is hampered from the outset.With different trauma centres each using their ownparticular definition based on different anatomicalor physiological scores, any attempt to compareoutcomes, interventions and even polytrauma

patient loads between centres is challenging.This review illustrates the lack of consensus

definition of the term polytrauma. While over 1500publications used the term, only 47 were found toactually contain a definition, and of the eight majorapproaches to the definition of polytrauma, limita-tions and advantages exist within each.

Defining polytrauma simply by the number of sig-nificant injuries, body regions or organ systems in-volved makes this approach appear straightforward.However, the definition of significant injury relieson a great degree of clinician judgement. Mclain et

al [36] attempted to clarify significant injury asinjuriesrequiringhospitaladmissionandactiveman-agement. Evenwith thisspecification, thedefinitionremains subjective because of the indistinct termactive management. It is unclear where nonop-erative management would fit into this description.A second limitation of defining polytrauma by thenumber of injuries, body regions or organ systemsinvolved is the difficulty in distinguishing it from theconcept of multiple trauma. Three studies did addqualifying criteria to their definition which couldpotentially aid in this distinction (Cerra et al [14];involvement with a laparotomy, Deby-Dupont et al[16]; leading to severe shock and Blacker et al [8];involvingatleastonevitalorgannecessitatingpatientadmission to a trauma intensive care unit). However,none of these qualifying statements were validatedin their use in defining polytrauma.

Defining polytrauma with a specific injury pat-tern [17] has been adopted in an attempt to givethe definition more practical relevance. Most ofthese definitions are based on a prescribed patternof injury, intentionally designed as study-specificdefinitions. The lack of their prospective validationhas limited their wider application.

Defining polytrauma by an ISS cut-off representsan attractive objective method based on anatomicalregions. Although ISS is the most widely acceptedanatomical score, there are major limitations withthis approach. Firstly, the final ISS figure does notdifferentiate between one serious single region in-jury (not polytrauma) and multiple regions involvedwith low severity injuries (not polytrauma). Forexample, an ISS of 25 can be equally achieved bya single region injury with AIS of 5 (52 = 25), or byinjury to two regions, eg, AIS of 3 plus AIS of 4 (3 2 +42 = 25). This idiosyncrasy of ISS makes it difficult todifferentiate between multitrauma and polytraumaif lower cut-offs are used (> 15 or > 17). Using highercut-offs (> 20 or > 25) would increase the specificity,but would exclude patients with two AIS = 3 inju-ries. We believe that any definition should clearlyseparate multiple traumafrompolytrauma.A secondlimitation to the use of ISS to define polytrauma is

the great range of scores used to define it. Thirdly,the exclusiveuseof ISS (ananatomical score) ignoresthe important physiological aspects of polytrauma.Finally, ISS is hardly ever calculated on admission,which makes it difficult to use as a prospective toolespecially for clinical trials.

The definition by Osterwalder [45] could prove aneffectivealternativeapproachtoanoverallISSscoreas it specifically requires a score of AIS 2 in at leasttwooftheISSregions.Breakingdownthescoringsys-tem in this way avoids obscuring the actual severityof injury in each body region. However, like others,

this definition has not been validated. The cut-off ofAIS 2 would enable defining a patient with a fairlylow ISS such as 8, 12 and 13 as polytrauma, whichwould not make the score specific enough.

The anatomical score (ISS) could be improved byadding a physiological, criterion-based definition,as found in Schweiberer et al [58] and Heberer et al[22].Whilethisgradingsystemofpolytraumahasnotbeen adopted into general use, and is based only onLevel IV evidence, it does contain some potentiallyuseful objective elements that may be included ina general definition of polytrauma; in particular theinclusion of shock and blood volume lost (or alterna-tively number of transfusions needed).

A more recent approach emerging from Zurichcombines physiologicalelementswith an anatomicalscore [25, 26, 61, 64]. While retaining the ISS, thestrength of this approach is in its emphasis on thepathophysiological response to polytrauma. The dif-ferentiation between polytrauma and multitraumais based on the injured persons pathophysiologicalresponse to the injury load. Numerous studies haveshown that it is the deregulation of the immune sys-tem posttrauma that represents one of the greatestthreats to life [40]. By consciously recognising this


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element, the definition has much greater power todetect true polytrauma. However, formally definingthepathophysiological response to trauma remains achallenge. In 2005, Keel et al changed the wordingof the Trentz definition from sequential systemictraumatic reactions, to SIRS for at least one day[26]. While this achieved a more succinct definitionof the pathophysiological response to trauma, thereare some inherent limitations to the use of the SIRScriteria. SIRS can be objectively defined based onthe consensus definition established in 1992, but thetiming and duration necessaryforpolytrauma defini-tion needs further clarification. The other potentialflaw of this definition is that an ISS > 17 cut-off couldinclude single-system severe injuries with additionalminor injuries in other regions (4 2 + 1 2 + 1 2 = 18 or42 + 2 2 + 1 2 = 21 or 4 2 + 2 2 + 2 2 = 24). In this case,the minor injuries (AIS 1 or 2) would not be likelyto represent a significant additional effect on the

single major injury (AIS 4) in the other body region.To overcome the potential limitations of the ISS

(adherence to body regions and neglecting secondhighest AIS in the same body region), the New InjurySeverity Score (NISS) was described and validated.The NISS is calculated similarly to ISS, the sum ofsquares of thethree highest AIS scores, butunlike ISS,it is calculated irrespective of body region [44]. TheNISS has been extensively validated and found to be abetter predictor of mortality, especially in penetrat-ing trauma [12, 44] and multiple organ failure [4] andis a better predictor of ICU and hospital lengths of

stayin multipleorthopaedic injuries [5].AlthoughtheNISS was used for inclusion criteria of some recentrandomised trials on major orthopaedic trauma [49],the fact that it abandons the body regions makes itan impractical descriptor for polytrauma.

Although the low level of evidence and the lackof prospective validation is common to all availabledefinitions, the main message of the current defini-tions suggests the need for an objective anatomicalscore (enabling inclusion of those patients who havesevere injuries in at least two body regions) and a

physiological component (to include host responseto the trauma).

A potential limitation of this review is the riskof excluding possibly relevant papers, due both tothe difficulty in accessing older literature, and tothe necessity of relying on abstracts to judge thepotential relevance of non-English language articlesprior to translation. Despite these limitations, thisreview has identified eight alternative approachesto defining polytrauma and the lack of evidence tosupport a uniformly accepted definition.

Conclusion

This review has shown that there is no consensus onthe definition of the term polytrauma. Furthermore,of all the approaches identified in the literature, no

validated definition has been found, and no defini-tion was found to be supported by evidence higherthan Level IV.

We recommend forming an international expertgroup to work toward establishing a consensusdefinition of the term polytrauma. We believe theestablishment of such a definition would serve tomore clearly identify patients needing the high-est resource utilisation and benefits of specialisttrauma care. This reproducible universal definitionof polytrauma would facilitate a better descriptionand comparison between patient populations of dif-

ferent centres (benchmarking), and assist in estab-lishing a uniform inclusion criteria for multicentrestudies of severely injured patients.

Provisionally, we recommend a clear distinctionto be made between the terms of monotrauma,multitrauma and polytrauma (Table 9).

Until the establishment of a consensus defini-tion, we propose the best definition of polytraumato validate is an anatomical injury of AIS 3 in atleast two body regions with the presence of SIRS onat least one day during the first 72 hours.

Table 9. Recommended definitions for mono-, multi- and polytrauma

Term DefinitionMonotrauma Injury to one body region.

Severe monotrauma could be considered if ISS > 15, or ISS < 15 with significant acutephysiological deterioration (cardiovascular or respiratory or neurological)

Multitrauma Injury to more than one body region (not exceeding AIS 3 in two regions) without SIRS.Severe multitrauma could be considered if ISS > 15, or ISS < 15 with significant acutephysiological deterioration (cardiovascular or respiratory or neurological)

Polytrauma Injury to at least two body regions with AIS 3 and with the presence of SIRS on at leastone day during the first 72 hours. Until further characterisation, polytrauma is recom-mended as an all or nothing diagnosis without further grading

AIS = Abbreviated injury scale; ISS = Injury severity score; SIRS = Systemic inflammatory response syndrome.


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Corresponding Author:Zsolt J. Balogh, MD, PhD, FRACSDepartment of Traumatology, Division of SurgeryJohn Hunter Hospital and University of NewcastleLocked bag 1, Hunter Region Mail CentreNEWCASTLE NSW 2300,AUSTRALIATel.: +61 2 49214259Fax: +61 2 49214274email: [email protected]

This paper has been written entirely by the authors, andhas received no external funding. The authors have nosignificant financial interest or other relationship relat-ing to this paper.

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