Severely injured patients: modern management strategies

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TL;DR

This instructional review synthesizes modern management strategies for severely injured trauma patients, covering the full care continuum from prehospital to rehabilitation. It traces the evolution from early total care (ETC) through damage control orthopaedics (DCO) to contemporary individualized approaches like PR.I.S.M. and MuST surgery, emphasizing that no single strategy fits all patients. The clinical significance lies in providing a structured framework for clinicians to tailor surgical timing and intensity based on physiologic stability, injury pattern, and patient-specific risk factors.

Full summary

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**Background** Trauma remains a leading global health burden, responsible for 4.4 million injury-related deaths in 2021 (8% of all deaths) and the primary cause of death for individuals under 45 years. Beyond mortality, trauma accounts for over 20% of all causes of severe disability, with substantial socioeconomic consequences from lost productivity and lifelong healthcare needs. Fracture fixation is the most frequently required surgical intervention in trauma, yet optimal timing and method remain debated. This instructional review aims to clarify contemporary terminology and provide a comprehensive evaluation of modern management principles across all phases of care.

**Methods** This is a narrative review synthesizing established classification systems, historical management strategies, and contemporary evidence. The authors describe the evolution of trauma care through distinct periods: early total care (ETC, 1980–1990), damage control orthopaedics (DCO, 1990–2000), early appropriate care (EAC, 2013), safe definitive surgery (SDS, 2015), prompt individualised safe management (PR.I.S.M., 2016), and musculoskeletal temporary surgery (MuST, 2021). Key evidence cited includes the landmark ETC study by Bone and Johnson (1989) recommending definitive fixation within 24 hours for femoral fractures, the CRASH-2 and CRASH-3 trials demonstrating tranexamic acid (TXA) reduces all-cause mortality and bleeding-related deaths, and the 2014 Berlin Consensus defining polytrauma by specific anatomic and physiologic criteria.

**Key Results** The review presents several critical data points: (1) Polytrauma is defined by AIS severity ≥3 in more than one body region plus at least one of: hypotension (SBP ≤90 mmHg), acidosis (lactate <–6 mmol/L), age ≥70 years, GCS ≤8, or coagulopathy (INR ≥1.4 or aPTT ≥40 sec). (2) Major trauma in the UK refers to injuries likely fatal or causing long-term disability, warranting transfer to specialized centres. (3) Prehospital interventions now include RSI, TXA (1 g bolus + 1 g infusion over 6–8 hours), permissive hypotension (SBP 70–90 mmHg), pelvic binders (successful placement only 40–70%), and REBOA (59% return of spontaneous circulation in traumatic cardiac arrest). (4) DCR principles emphasize restrictive fluid resuscitation and balanced blood product ratios (1:1:1 red cells:plasma:platelets within 6 hours). (5) Over 10% of severely injured patients require more than five major surgical procedures, with about 60% occurring within the first 24 hours. (6) A 2022 US study reported each severely injured patient requires input from approximately 80 healthcare clinicians upon hospital arrival. (7) By 2050, approximately 40% of trauma admissions are projected to be patients over 65 years. (8) 20–40% of trauma CT scans are negative, raising concerns about unnecessary radiation exposure, particularly in children where the risk of radiation-associated cancer is significantly higher.

**Clinical Implications** The review emphasizes that no single management strategy applies to all trauma patients. The evolution from ETC to DCO to contemporary individualized approaches reflects growing recognition that patient physiology, injury pattern, age, frailty, and available resources must guide decision-making. The PR.I.S.M. strategy ('do no further harm') advocates dynamic assessment and individualized timing of definitive fixation. The MuST concept differentiates staged management for complex monotrauma from DCO for physiologically unstable polytrauma. Key practice recommendations include: (1) early TXA administration, ideally prehospital; (2) DCR with permissive hypotension (except in TBI and elderly with atherosclerosis); (3) VEM-guided resuscitation (TEG/ROTEM) though evidence remains limited; (4) 24/7 access to interventional radiology and dedicated trauma operating theatres; (5) 'Code Red' theatre protocols for exsanguinating patients; (6) cohorting patients in specialized major trauma wards with multidisciplinary input including geriatricians for elderly patients; (7) early rehabilitation involvement and PROMs/PREMs capture, though current follow-up in the UK's Trauma Audit and Research Network is limited to 3–6 months post-discharge. The review underscores that sustained improvements in survival and disability reduction depend on coordinated teamwork and efficient resource utilization across all phases of care.