Problems and Challenges of Polytrauma Management: The Hierarchy of Treatment

Trauma constitutes a significant burden of mortality and disability globally, with the greatest impact felt in low to middle-income countries. Worldwide, there are 2.5 million trauma-related deaths annually, and in developing nations, preventable trauma fatalities can reach as high as 70%. However, advancements over the past decade have led to a decline in mortality associated with polytrauma cases. Defined algorithms, such as the ATLS approach, have played a pivotal role in improving pre-hospital and in-hospital trauma care, directly influencing patient outcomes. For polytrauma patients, defined as those with two or more significant injuries, prompt and efficient delivery to a care center is crucial.

The severity of injuries is assessed using the Injury Severity Score (ISS), with three or more points in two or more anatomical AIS regions, alongside physiological parameters, indicating significant injury. The priorities in trauma care encompass airway management, cervical spine immobilization, hemorrhage control, fluid resuscitation, and timely transport to an appropriate healthcare facility. Challenges persist due to resource constraints, predominantly in personnel and equipment availability, compounded by layman-administered pre-hospital care and civilian-provided transportation.

Grouping patients based on treatment needs and resource availability correlates with improved outcomes for critically injured individuals. Common mechanisms of injury include traffic accidents, falls from height, gunshot and knife wounds, blunt trauma, and burns. The ATLS protocol guides primary assessment, emphasizing airway management, breathing, circulation, disability assessment, and environmental exposure.

In-hospital treatment priorities focus on mitigating immediate life-threatening injuries, employing strategies such as permissive hypotension, haemostatic resuscitation, and damage control surgery. The use of tranexamic acid, as demonstrated in the CRASH 2 and CRASH 3 trials, further underscores advancements in trauma management.