According to Pape et al. (2005) 4 classes of polytrauma patients: stable, borderline, unstable, and in extremis.

Stable Conditions(Grade I): -No life threatening injury, well response to initial therapy;
-haemdynamically stable,
-no caogulopathy/occult hypoperfusion/hypothermia,

-normal acid-base status.

Borderline(Grade II):When the patient has:
-ISS>40
-Multiple Injuries(ISS>20) + Thoracic trauma(AIS>2)
-Multiple injuries + severe abdominal/pelvic injury & presents with haemorrhagic shock (SBP <90)
-Pt. with B/L femur fractures
-Radilogical sign of Pulmonary contusion
-Hypothermia(<35⁰C)
-Additional moderate/severe head injuries (AIS≥3)
-Initial “Mean Pulmonary Artery Pressure >24mm Hg.

The term “borderline” used to describe a patient who is apparently stable before surgery, but is at significant risk of unexpected deterioration and organ dysfunction postoperatively.

-A borderline patient can be managed initially according to ATLS criteria: A-airway; B-breathing; C-circulation etc.

-haemorrhage control & decompression of thorax (if needed)

-Re-evaluation in ER with: ABG, SBP,Coagulation profile, FAST, Urine output.

-If the ‘borderline patient‘ is stable after re-evaluation: the patient should be taken to the operating room(OR) & early definitive treatment/Early Total Care(ETC) can be done as needed.

– A ‘borderline patient‘, with uncertainty about stability, should be managed with ‘DCO‘ i.e. Damage Control Orthopaedics:
–a staged approach for the management of polytrauma patients.
-most ideal for trauma patients of Grade III & IV(clinically unstable or in extremis).
– In these patients,
 Immediate surgery→ “second hit” phenomenon → ARDS/Multi-organ failure/death.