Polytrauma--pathophysiology and management principles.

BACKGROUND: Multiple injury results in a complex pathophysiological and immunological response. Depending on the individual injury pattern, the time elapsed after injury, and the systemic "danger response", the surgical treatment has to be modified.

OBJECTIVES: This overview provides new insights in the pathophysiology of the early danger response after polytrauma and outlines the main resulting consequences for surgical management.

RESULTS: First, synchronically to the clinical assessment, life-saving procedures need to be performed rapidly, such as control of massive intra-thoracic or abdominal bleeding and decompression of the chest and brain, as standardized by advanced trauma life support guidelines. During the second phase of "day-one-surgery" damage-control interventions such as debridement, decompression and temporary fracture stabilization are needed to avoid an excessive molecular and cellular danger response. Trauma-adjusted surgical techniques are crucial to limit the systemic response known to put remote organs at risk. In the "vulnerable phase" when the patient's defense is rather uncontrolled, only "second look" debridement to minimize a "second hit" is recommended. After stabilization of the patient as indicated by improvement of tissue oxygenation, coagulation, and decreased inflammatory mediators, "reconstructive surgery" can be applied.

CONCLUSION: Individually adjusted surgical "damage control" and "immune control" are important interactive concepts in polytrauma management.