Though there is lack of a validated consensus in definition, polytrauma is defined as two or more injuries to physical regions or organ systems, one of which may be life-threatening, resulting in physical, cognitive, psychological, psychosocial impairments and functional disability. In another study, polytrauma is defined as a syndrome of multiple injuries of defined severity [injury severity score (ISS) ≥16] with consecutive systemic reactions, which may lead to dysfunction of remote organ, also comprises the complex host response to the injury.9)

Among various types of polytrauma, severe traumatic brain injury (TBI) is classified as Glasgow Coma Scale (GCS) score<9, carries a poor prognosis and the mortality in severe brain injury is approximately 25% with only 20% recovering with a good outcome.11)

The successful management of polytraumatised patients remains challenging despite of expanding scientific knowledge and modern diagnostic and therapeutic approaches. Initial management of the polytrauma patient is of vital importance to minimizing both patient morbidity and mortality. Specific attention is paid to innovations in care and specific controversies in early management as well as local solutions to challenging problems.7)

Our points in this study are focused on the relationship between prognosis and radiographic findings of brain CT and/or MRI from long-term bed-ridden patients due to polytrauma with head injury who had been followed-up for more than 6 months.

Between January 2000 and December 2007, a retrospective study was carried out in 47 patients with polytrauma including head injury who admitted more than 6 months. We performed neurologic examination and brain CT and/or MRI scan was taken within 6 hours after admission. The patients were classified into two groups by initial GCS score (GCS score≥9 as good and GCS score≤8 as bad) and outcome at 6 months post-injury was assessed by using the Glasgow Outcome Scale (GOS)(patient with good recovery and moderate disability as good outcome and patient with severe disability, persistent vegetative state and death as bad outcome). We retrospectively studied using various parameters such as age, gender, duration of admission, mode of injury, previous medical disease, associated injuries, diffuse axonal injury, space occupying lesion, GCS score, GOS and operative procedures done. Statistical analysis was performed using SPSS for windows version 12 (SPSS Inc, Chicago, IL, USA). A p value <0.05 was considered statistically significant.

For the classification of polytrauma patients, more than 50 scoring systems have been published. Among these systems, the Revised Trauma Score is a physiological scoring system, with high inter-rate reliability, demonstrated accuracy in predicting death and consists of GCS score, systolic blood pressure and respiratory rate to provide a general assessment of physiologic derangement.2) The other definition of polytrauma implies the use of ISS. The ISS is established medical score to assess trauma severity,1,5) by which Keel and Trentz14) defines polytrauma as ISS≥16.

Metabolic changes after trauma were described more than seven decades ago by Cuthbertson et al.6) and characterize as occurring in two different phases, termed the "ebb" phase and the "flow" phase (Table 8). The "ebb" phase is initiated within minutes after trauma and persists for several hours after the initial insult. It is characterized by a decline in body temperature and oxygen consumption, aimed at reducing post-traumatic energy depletion. However, the brief duration of this phase limits its clinical relevance. The "flow" phase, which occurs after compensation of the state of traumatic-hemorrhagic shock, is associated with an increased metabolic turnover, activation of the innate immune system and induction of the hepatic acute-phase response. This results in an increase of the catabolic state with a significantly increased consumption of energy and oxygen. The authors in this study said appropriate immunonutrition should be started in the intensive care unit, preferably by enteral route, in order to counteract the potentially devastating effects of the massive hypermetabolic state after major trauma.12)

The prognosis of patients with TBI is well documented and is highly correlated to the neurobehavioral sequelae after central nervous system (CNS) damage. Estimates of TBI incidence, severity and cost reflect the enormous losses to individuals, their families and society from these injuries. In one study, cerebral damage was a more common cause of death than multiple organ failure following multiple non-penetrating trauma.8) And in other study, older age, low GCS, absent pupil reactivity and the presence of major extracranial injury predicted poor prognosis.16) However, studies about polytrauma patients' prognosis are indecisive. Our study found no definite prognostic factor, either (Table 6, 7). But, severe trauma is still the most frequent cause of death in people below the age of 40 and in one study, among various types of polytrauma, 69 percent of patients with polytrauma had cerebral injuries, 62% thoracic trauma and 86% fractures (40% open fractures).19)

A study of the injury fatality rate in an adult population was done in the Moscow region.20) Investigators determined that side by side with the severity of injury, the direct causes of death were erroneous diagnosis, ungrounded delay of surgical interventions and insufficient use of necessary medical care. They also showed that the attention of administrative and public health agencies to the material/technical equipment of prehospital and hospital medical service and to the training of medical personnel, was insufficient and that activity on accident prevention was inadequate. Determination of causes will help to create concrete measures to decrease injury fatality.

According to a study on the periodic classification of polytrauma, immediate and early trauma deaths are determined by primary brain injuries or significant blood loss (hemorrhagic shock), while late mortality is caused by secondary brain injuries and failure of host defence.14) Individually adjusted surgical "damage control" and "immune control" are important interactive concepts in polytrauma management and 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.9) In a study about late death after severe polytrauma, causes of in-hospital deaths are head injury (37%), adult respiratory distress syndrome (14%), sepsis (11%), hemorrhagic shock (10%), pneumonia (9%), multiple organ failure (9%) and others (10%). Causes of death after discharge include cardiovascular diseases (23%), second major trauma (19%), neurologic diseases (16%), suicide (10%), malignancies (6%) and others (26%). The analysis of survival shows a higher mortality for polytrauma compared with the general population group during the first year after the event (p<0.05). Between 2 years and 10 years after the event, the annual mortality of the polytrauma group approximates the general population group.18) But, elderly patients with minor injuries and pre-existing medical conditions have an increased risk of death relative to their younger counterparts and are more likely to die of medical complications late in their hospital admission.4)

About outcome after polytrauma, despite differences in injury pattern and severity of injury, there is strong evidence from the literature that the quality of life is significantly impaired after major trauma. This is true for functional outcome as well as for psycho-social outcome in up to 70% of patients.3)

In a recent retrospective study by Jiang et al.13) eight hundred forty-six cases of severe TBI (GCS≤8) were analyzed to clarify the effects of multiple factors on the prognosis of patients. At 1 year after injury, the outcomes in these cases were as follows: good recovery (31.56%), moderate disability (14.07%), severe disability (24.35%), vegetative status (0.59%) and death (29.43%). The outcomes were strongly correlated (p<0.05) with GCS score, age, pupillary response and size, hypoxia, hyperthermia and high intracranial pressure (ICP). The authors in this study reported these findings indicated that prevention of hypoxia, control of high ICP and prevention of hyperthermia might be useful means for improving the outcome of patients with severe head trauma (SHT). In our study, GCS score and GOS were divided into two groups and statistical analysis showed significant correlation with each other (p<0.001)(Table 4).

According Neugebauer et al.17) isolated SHT or SHT in combination with polytrauma are important factors for the prognosis of morbidity and mortality in patients suffering from the consequences of accidents. The prognosis mainly depends on the presence of primary mechanical brain injury and the development of secondary brain damage. Causes for the development of secondary brain damage are the intracranial space demand after traumatic injury and edema formation which may result in ischemia, as well as inflammatory processes. Both isolated SHT and polytrauma with or without brain damage may result in a systemic inflammatory response syndrome (SIRS) due to the synthesis of cytokines and other inflammatory mediators which may cause a single or multiple organ failure. Often the organism is able to survive isolated traumatic injuries and functional disturbances, but in combination or accumulation they may be lethal. The hypermetabolism after SHT is often regarded as an interaction between the CNS and the whole organism by the activation of the neuroendocrine axis. In contrast to the consequences of SHT for the whole organism, multiple injuries after polytrauma may affect brain functions, such as the shock dependent disturbance of the brain perfusion accompanied by brain hypoxia which may lead to an aggravated prognosis. Moreover, coagulation, metabolism and fracture healing are influenced by the onset of SIRS as well. Their knowledge about the bidirectional inflammatory interaction between brain and whole organism is still limited. In their study, the effects of secondary surgical interventions which may additionally, stress a traumatized body have to be considered and are the subject for actual clinical discussions and experimental studies.

SHT in combination with polytrauma patients show a different functional, neuropsychological and social outcome depending on several clinical parameters. In a stepwise regression analysis age, injury severity, GCS score, length of coma and weaning time are proved to be suitable predictors. During the intensive care stay an early prognosis on SHT patients is possible.15)

The rehabilitation outcome of patients with severe TBI is well documented and is highly correlated to the neurobehavioral sequelae of CNS damage. However, many of these patients suffer from polytrauma involving systems other than the CNS and to systems involved in acquisition of external information. In the present series of 328 patients with severe TBI, 58% had associated trauma, mostly in the skeletal system. The presence of one single associated trauma had no additional effect on rehabilitation as evaluated by actual work placement. In contrast, multiple lesions were liked with a less favorable outcome, probably due to a greater severity of the initial CNS damage. Disturbances in the various information-acquiring systems (e.g., disturbances in eye movements, visual field defects and severe bilateral auditory deficits) were associated with poor outcome. Presence of peri-articular new bone formation and communicating hydrocephalus, usually associated with prolonged periods of unconsciousness, indicated a poor rehabilitation outcome as well.10)

Though there is obvious lack of information about prognosis of patients with polytrauma including brain injury, we found some statistical significance in our study. Firstly, GOS correlates well with GCS score in these polytrauma patients. Secondly, the operative procedures (decompressive craniectomy and/or shunt) have strong impact on the formation of ventriculomegaly. Lastly, the mode of injury also has statistical significance on post-traumatic infarction. However, there is still lack of randomized trials showing the prognosis of polytrauma patients and therefore more randomized future studies seems justified.