the official magazine of the brain injury association of california




Treatment of patients with multiple
complex injuries as a result of trauma
is challenging — even more so when
traumatic brain injury is present.

Polytrauma is a specific medical term that describes the condition of someone who has sustained injuries to multiple body parts and organ systems. For instance, in a car crash, an individual may suffer serious burns over large portions of his or her body in addition to broken bones or a traumatic brain injury (TBI). The critical nature of an injury is evaluated in the U.S. medical community through a scale referred to as the Injury Severity Score (ISS). Polytraumas have scores of 16 or greater on this scale. CAUSES OF POLYTRAUMA Motor vehicle accidents are a major cause of polytrauma among civilians. The high speeds and sudden impacts that occur in many types of car crashes often lead to disastrous outcomes. The U.S. military has used the medical designation of polytrauma to categorize injuries sustained by military personnel during conflicts. Military personnel are subject to some of the most serious threats of polytrauma injuries, including blasts from explosive devices.

Patients who were taken off of life-sustaining therapy whil neuromonitoring continued as the patient died revealed something striking. “Previously, it was thought that the end occurs when the brain stops its electrical activity and goes silent,” said Hartings. “But it doesn’t. We can show that the brain remains in a viable state for several minutes after this flatline, at which point a wave of depolarization sweep through the cortex. This is referred to as a brain tsunami.” “The spreading depolarization shows that brain cells are dying, and gives a tremendously useful clinical marker for brain damage,” said Dreier. This is not just a curiosity, but something actionable in intensive care.” By studying the brain at the end of life, these researchers have made the connection between death and spreading depolarization in a very controlled clinical setting with strong data. This may be the first step in discovering othe ways in which spreading depolarizations impact the brain and could inform breakthroughs in brain injury research and treatment.


rehabilitative perspective when it comes to the treatment of these patients. Treatment management is complex and should be systematic, beginning at the scene with timely transport. Early operative interventions are also key. According to the World Journal of Emergency Surgery, critical trauma care is ever-improving, yet TBI-related mortality rates are rising compared to other causes of death. Managing the acute phase after a severe TBI with polytrauma represents a challenging situation for every trauma team member and often involves the ‘damage control’ approach to sustain life. The challenge with polytrauma and concomitant traumatic brain injury patients is making sure equal emphasis is placed on stabilizing life-sustaining systems and doing everything possible to minimize brain damage. POLYTRAUMA COULD WORSEN BRAIN INJURY Primary brain injury results from mechanical injury at the time of the trauma whereas secondary brain injury is caused by the physiologic responses to the initial injury. Post-trauma care, as it relates to traumatic brain injury, is focused on halting or minimizing bleeding or clotting in the brain, among other biochemical processes, all of which result in secondary brain injury. Because polytrauma patients may require multiple damage control procedures, there is a risk of not providing

ample emphasis on brain care. In addition, the presence of hypotension (low blood pressure), hypoxia (low oxygen levels), and fever — all commonly found in polytrauma patients — have been shown to initiate secondary brain damage. TRAUMA NEUROSURGERY The trauma neurosurgeon plays a key role in being able to ensure optimal treatment of polytrauma and concomitant TBI patients while minimizing secondary brain damage. Although brain surgery is highly complex and specialized, how it helps TBI patients comes down to decompression. Known as a craniotomy, this surgery relieves pressure on the brain, in turn slowing secondary brain damage. Dating back to Hippocrates, who is documented to have suggested their use in treating TBI, craniotomy revolutionized neurosurgery. CHOOSING THE BEST TRAUMA CENTER The best facilities for polytrauma patients to receive care are level one trauma centers. According to the American Trauma Society, A level one trauma center is capable of providing total care for every aspect of injury from prevention through rehabilitation, including surgical intervention. Although a level one trauma center can provide comprehensive treatment to trauma victims, they are not always capable of providing what is known as Simultaneous Multisystem Surgery (SMS) — which allows for different surgical teams to work on a patient simultaneously — the key to optimally treating polytrauma patients with TBI. For a level one trauma center to provide SMS they must be equipped with a hybrid-emergency room system

(HERS) where diagnostic procedures, such as CT scans, and damage control interventions, such as neurosurgery, can be performed simultaneously without patient transfer. Studies have shown that the HERS approach has been associated with a shorter time to initiate CT scanning, emergency surgery, and fewer unfavorable outcomes in polytrauma patients with and without TBI — ultimately resulting in higher – and more functional — survival rates. While the ability to perform SMS seems to be straightforward and beneficial, very few centers in the United States are equipped with HERS and have trained staff to perform SMS in the context of TBI complicated by polytrauma. Other countries appear to be ahead of the curve in this area of trauma response. For example, not only are many of Japan’s trauma centers equipped with HERS, but they have also developed the Japanese Association for Hybrid Emergency Room Systems to specifically address the needs of specialized HERS trauma teams. FACTORS TO CONSIDER FOR THE BEST OUTCOME According to an article published in the National Library of Medicine, the occurrence of TBI in polytrauma patients increases mortality and reduces their quality of life. Studies have shown that the crucial factors for ensuring the best outcomes in these cases involve getting the most appropriate care as quickly as possible. Factors such as the speed in which ambulatory care is on scene and the patient being transported to a level one trauma center — when possible one equipped to administer SMS — can make substantial differences in a patient’s recovery