Polytrauma. Periods of traumatic illness
The term polytrauma refers to the presence of 2 or more traumatic injuries various tissues and organs. In this case, therapy should be directed both to the treatment of each damage separately, and to the holistic correction of the resulting violations of the body's functions.
Polytrauma is not considered as a certain number of injuries, but rather their cumulative effect on organs and systems.
The presence of complications and the prognosis of polytrauma are determined by the complex medical measures, aimed at general recovery organism and for each local damage separately.
Causes and prevalence of polytrauma
About half of diagnosed cases result from road traffic accidents (about 50 percent). In second place are catatraumas resulting from a fall from a height (35 percent).
Depending on the operating factor and the mechanism of occurrence of damage are distinguished:
- One-stage injury. When exposed to an external force, the victim simultaneously receives damage in several areas.
For example, in a collision vehicle driver can get:
- damage to the knee charter (fracture of the patella, trauma and bruising of the joint itself, ligament rupture, etc.) due to a sharp blow to the front panel;
- multiple fractures ribs and sternum lung contusions and hearts that result from hitting the steering wheel;
- a sharp movement of the head directly at the time of the collision provokes an injury to the upper (cervical) spine.
- Sequential injury. Damage is "stretched" in time (they do not occur simultaneously).
For example, when a pedestrian is hit by a car, he gets:
- hit in the area lower extremities bumper;
- when falling on the hood, spinal injuries, craniocerebral injuries, etc. are possible;
- the third phase with a sequential mechanism is a fall onto the roadway, where, in addition to injuries received from hitting the ground (more often these are skull bones and bruises of brain structures), the victim may suffer from a collision with another car.
- Combined trauma. The nature of the injuries received from various traumatic factors is assessed. For example, as a result of an accident, in addition to mechanical injuries, the driver can also receive thermal burns from a fire in the tank of an overturned car.
Peculiarities
The severity of the victim's condition is determined not only by the total number of injuries received, but also by their "range". Abundant blood loss (in especially severe cases - 3 liters or more), violation of the integrity of the skin and superficial soft tissues, as well as traumatization of vital important organs(heart, liver, lungs, etc.).
There are 4 features of the course, diagnosis and treatment of polytrauma:
- Syndrome of mutual burdening.
We are talking about the fact that the totality of the damage received (almost at the same time) causes more severe consequences For human body. That is, each damage individually may not even be characterized as severe, but their combination is serious threat life, since the body's compensatory capabilities are limited: even multiple injuries of "safe" zones can cause the development of severe shock.
- Progression state of shock.
More than half of the patients admitted to the hospital in a state of shock had its decompensated stage, with a sharp decrease in the body's resistance, up to its death. With absence characteristic features almost all patients with polytrauma had disorders associated with a sharp decrease in the amount of circulating blood (hypovolemic) and a decrease in oxygen content (hypoxic).
- Difficulties in diagnosis.
The appointment of adequate treatment in more than 30 percent is carried out with a delay due to an erroneous or untimely diagnosis. Sometimes this happens due to the incompetence of the doctor, but in most cases the diagnosis is difficult due to serious condition victim: the clinical picture is mild, and loss of consciousness negates attempts to collect anamnesis.
The combination of injuries received can mask or simulate the most severe violations.
For example, irradiation of pain in epigastric region with fractures of the ribs or spine, may erroneously indicate damage internal organs abdominal cavity, and diagnostic tactics will be based on this. As a result, precious time will be lost.
Therefore, to make an accurate diagnosis, it is necessary to use all the necessary additional instrumental research: laparoscopy, beam methods diagnostics - CT, MRI, ultrasound and others.
Of great importance is knowledge of the features of polytrauma in certain form accident. When falling from a great height onto straightened limbs, as a rule, the following set of injuries is diagnosed: fractures or bruises heel bones, spine (lumbar and lower thoracic) with the addition of a craniocerebral injury. At the same time, in the first hours, the patient practically does not complain about pain in the spine. Install accurate diagnosis possible only with the help of purposefully carried out additional examination- X-ray.
- Therapy incompatibility.
Often, with multiple injuries, it is not possible to simultaneously conduct therapy for all affected organs and systems.
For example, with a large burn area, it is impossible to apply plaster cast for immobilization of a limb with a fracture.
Classification (degrees)
Types of polytrauma:
- Multiple damage.
This type includes both fractures of the bones of the trunk and fractures of the extremities. Depending on the nature of the injury and localization, the latter are:
- one bone element; one, two or more limbs;
- unilateral, cross or symmetrical;
- intraarticular, periarticular or in the middle part of the bone (diaphyseal).
Also, multiple mechanical polytrauma is understood as damage to 2 or more organs limited to one cavity (for example, abdominal: liver and intestines).
- Associated injury.
These injuries include combined bone fractures. different localization and tissue damage: skin, muscle fibers, blood vessels, internal organs, etc. The most frequent are injuries of varying severity of the musculoskeletal system in combination with traumatic brain injury.
- Combined lesions.
Violation of the integrity of tissues and organs in this type of polytrauma is caused by external influence various traumatic forces: for example, thermal and mechanical, radiation and thermal, etc.
Diagnostics
It is necessary to find out the mechanism of the injuries received: anamnesis is taken directly from the victim or eyewitnesses of the incident, if the patient is in a state of shock or unconscious.
The final diagnosis for polytrauma is carried out in a hospital and includes a set of measures:
- Evaluation of violations, life threatening patient: state of respiratory and cardiac functions, control blood pressure, work circulatory system(general hemodynamics).
- For the administration of medicinal solutions ( infusion therapy) and venous pressure monitoring catheterized central vein, and to control diuresis - the bladder.
- ECG to determine violations in the work of the heart.
- Visual inspection: the type of position is determined (active, forced or passive). Superficial soft tissues for the presence visible damage: ruptures, edema, bruising, etc.
Inspection and palpation:
- head: for deformation of the skull and damage to the skin, the presence subcutaneous hematomas etc.
- chest: to assess the integrity of the frame chest, detection of crepitus of the ribs, determination of excessive accumulation of air (emphysema).
- abdomen: to determine the degree of muscle tension in the anterior abdominal wall, fluid accumulations.
- pelvis: to determine the degree of bone deformity ( pelvic ring), divergence of the transitional connection (symphysis). When exploring the area ilium(wings) is determined by their convergence and breeding under load.
- limbs: palpation of long tubular bones, with the definition visible signs fractures and preservation and movement disorders in the joints.
- Assessment of general neurological symptoms.
- Conducting percussion and listening (auscultation) of the abdomen and chest.
- Radiography of the skull, pelvis and chest, regardless of clinical picture and no visible signs of damage. According to the indications, an X-ray examination of other areas is performed.
- Endoscopic examination of the abdominal organs.
Volume diagnostic measures may be increased according to the doctor's indications.
Treatment
The main purpose of the diagnostic methods used is to determine the main damage, which is currently the most severe and may pose a threat to the patient's life.
Depending on the therapeutic measures taken, this lesion may “shift”, but the main therapeutic manipulations should always be directed precisely at the dominant damage. The remaining injuries account for the necessary minimum of therapeutic measures.
Treatment in the intensive care period
Depending on the nature of the dominant damage, following groups victims who need emergency surgical intervention and vital manipulations.
- First group. Without holding surgical intervention there is a threat to the life of the victim. Regardless of the severity of the shock state of the victim, a number of manipulations are performed to stop intracavitary bleeding, reduce brain compression due to growing intracranial hematoma, normalization severe disorders breathing. In parallel, anti-shock therapy is carried out. A set of further examinations and symptomatic treatment(For example, debridement wounds) are postponed to a later time.
- The second group includes patients for whom emergency surgery is not associated with a threat to life. In this case, it is possible to preoperative preparation(no more than 4 hours): antishock therapy is aimed at stabilizing blood pressure and homeostasis. Surgical intervention is carried out only after the achieved positive result antishock therapy and conducted (if necessary) additional studies.
- Victims with multiple injuries musculoskeletal system. Priority therapeutic manipulations include stabilization, homeostasis-correcting measures, the use of antiseptic and analgesic manipulations, immobilization (immobilization) of the injured area. Surgical intervention and further treatment of injuries are carried out, if necessary, only after the patient is removed from the state of shock.
An exception may be the fixation of fractures with special instruments, cutting off a non-viable limb (amputation).
- The fourth, rather rare group includes victims without signs of shock and the presence of life-threatening symptoms. Patients undergo complex diagnostics to exclude severe injuries and treatment is prescribed, as with isolated injuries.
The first three groups in acute phase expectant treatment of the musculoskeletal system is carried out, mainly aimed at removing pain syndrome and immobilization of damaged areas. The main therapeutic manipulations are the reduction of dislocations, the reposition (comparison) of bone fragments, etc. - carried out with stabilization of vital signs.
Treatment during the extended clinical picture
In the catabolic period (the first 7 days after injury), the risk of developing fat embolism remains - sharp decline conduction (occlusion) of blood vessels by fat emboli. Therefore, medical manipulations should be as sparing as possible, and transportation, shifting and examinations should be minimal.
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols MH RK - 2013
Multiple injuries unspecified (T07)
Traumatology and Orthopedics, Surgery
general information
Short description
Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated 12/12/2013
polytrauma- it's complex pathological process caused by damage to several anatomical regions or limb segments with pronounced manifestation syndrome of mutual burdening, which includes the simultaneous onset and development of several pathological conditions and is characterized by profound disorders of all types of metabolism, changes in the central nervous system (CNS), cardiovascular, respiratory and pituitary-adrenal systems.
Multiple trauma- damage to two or more organs of one cavity, two or more anatomical formations musculoskeletal system, injury main vessels and nerves in various anatomical segments.
Associated injury- damage to the internal organs of various cavities, joint injuries of the internal organs and the musculoskeletal system, joint trauma of the musculoskeletal system and the main vessels and nerves.
At present, polytrauma must be considered in close connection with the clinical and pathophysiological features of the course of traumatic disease.
The concept of traumatic disease involves the study and evaluation of the whole complex of phenomena that occur during severe mechanical damage to the body in close connection with the reactions of an adaptive, adaptive nature in their complex relationships at all stages of the disease - from the moment of injury to its outcome: recovery (complete or incomplete) or death .
Situations where polytrauma is always suspected(according to 3. Muller, 2005):
In case of death of passengers or the driver of the vehicle;
If the victim was thrown out of the car;
If the deformation of the vehicle exceeds 50 cm;
When squeezed;
In case of an accident on high speed;
When hitting a pedestrian or cyclist;
When falling from a height of more than 3 m;
In an explosion;
When blocking loose materials.
I. INTRODUCTION
Protocol name- Polytrauma
Protocol code:
ICD-10 codes:
T 02 - Fractures involving several areas of the body
T02.1 - Fractures of chest, lower back and pelvis
T 02.2 - Fractures involving several areas of one upper limb
T 02.3 - Fractures involving several areas of one lower limb
T 02.4 - Fractures involving several areas of both upper limbs
T 02.5 - Fractures involving several areas of both lower limbs
T 02.6 - Fractures involving several areas of the upper (their) and lower (their) limbs
T02.7 - Fractures involving chest lower part back, pelvis and limb(s)
T02.8 - Other combinations of fractures involving more than one area of the body
T02.9 Multiple fractures, unspecified
T 03 - Dislocations, sprains and overstrain of the capsular-ligamentous apparatus of the joints, involving several areas of the body
T 03.2 - Dislocations, sprains and overstrain of the capsular-ligamentous apparatus of the joints of several areas of the upper limb(s)
T 03.3 - Dislocations, sprains and overstrain of the capsular-ligamentous apparatus of the joints of several areas of the lower limb(s)
T 03.4 - Dislocations, sprains and overstrain of the capsular-ligamentous apparatus of the joints of several areas of the upper (their) and lower (their) limb(s)
T 03.8 - Other combinations of dislocations, sprains of the capsular-ligamentous apparatus of the joints and overstressing of several areas of the body
T 03.9 - Multiple dislocations, sprains and overstrain of the capsular-ligamentous apparatus of the joints, unspecified
T06 - Other injuries involving multiple areas of the body, not elsewhere classified
T06.4 - Injuries of muscles and tendons involving multiple body regions
T06.5 - Injuries of chest associated with injuries of abdomen and pelvis
T06.8 - Other specified injuries involving multiple body regions
T07 - Multiple injuries, unspecified
T06 Other injuries involving multiple areas of the body, not elsewhere classified.
T06.3 - Injuries of blood vessels involving multiple areas of the body
T06.4 - Injuries of muscles and tendons involving multiple areas of the body
T06.5 Injuries of chest organs in combination with injuries of abdominal cavity and pelvis
T06.8 Other specified injuries involving multiple body regions
T07 - Multiple injuries, unspecified
S31 - Open wound of abdomen, lower back and pelvis
S36 - Injury of abdominal organs
S37 - Injury pelvic organs
S37.7 - Injury of multiple pelvic organs
S37.0 - Injury of kidney
S36.8 - Injury of other intra-abdominal organs
S36.3 - Injury of stomach
S36.2 - Injury of pancreas
S37.6 - Injury of uterus
S36.7 - Injury of multiple intra-abdominal organs
S36.5 - Injury colon
S36.4 - Injury small intestine
S36.1 - Injury of liver or gallbladder
S36.0 - Injury of spleen
S31.8 - Open wound of other and unspecified part of abdomen
S 39.6 - Combined injury of intra-abdominal and pelvic organs
S 39.9 - Injury of abdomen, lower back and pelvis, unspecified
S26 - Injury of the heart
S26.0 - Injury of the heart with haemorrhage into the cardiac sac
S26.8 Other injuries of the heart S26.9 Injury of the heart, unspecified
S27 - Injury to others and unspecified organs chest
S22.2 - Fracture of sternum
S22.3 - Fracture of ribs
S22.4 - Multiple fractures of ribs
S22.5 - Retracted chest
S22.8 - Fracture of other parts of sternum bone
S30.7 - Multiple superficial injuries of abdomen, lower back and pelvis
S31.7 - Multiple open wounds abdomen, lower back and pelvis
Abbreviations used in the protocol:
ANF - external fixation device
AFO - anatomical and physiological area
URT - upper respiratory tract
IVL - artificial ventilation lungs
IT - intensive therapy
KOS - acid-base state
CT - computed tomography
LM - laryngeal mask
MIA - local infiltration anesthesia
SMP - combined mechanical damage
ESR - erythrocyte sedimentation rate
MODS - multiple organ failure syndrome
TAP - difficult airway
ultrasound - ultrasonography
CVP - central venous pressure
CNAB - central neuraxial blocks
CNS - central nervous system
RR - respiratory rate
HR - heart rate
SHI - shock index
ZBIOS - closed blocking intramedullary osteosynthesis
CO2 - carbon dioxide
SpO2 - saturation
Protocol development date: year 2013
Protocol Users: traumatologists, anesthesiologists-resuscitators, emergency doctors, surgeons, neurosurgeons, maxillofacial surgeons, otorhinolaryngologists, urologists, angiosurgeons.
Classification
CLINICAL CLASSIFICATION
Pathogenetic classification the course of a traumatic disease:
1. Period acute reaction for trauma: corresponds to the period of traumatic shock and the early post-shock period; it should be considered as the period of the induction phase of the MODS.
2. Period early manifestations traumatic disease: the initial phase of MODS - characterized by a violation or instability of functions individual bodies and systems.
3. Period late manifestations traumatic disease: an extended phase of MODS - if the patient survived in the first period of the course of a traumatic disease, then the course of this period determines the prognosis and outcome of the disease.
4. Rehabilitation period: at favorable outcome characterized by complete or incomplete recovery.
The above concept calls for considering traumatic shock, blood loss, post-traumatic toxicosis, thrombohemorrhagic disorders, post-traumatic fat embolism, MODS, sepsis, not as complications of polytrauma, but as pathogenetic associated links of a single process - traumatic disease.
Scheme 1. Classification of injuries
Scheme 2. Classification of combined mechanical damage.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
Basic Research
1. Anamnesis
2. Physical examination
3. General analysis blood: the level of erythrocytes, leukocytes, hemoglobin, hematocrit, ESR, erythrocyte aggregation
4. Biochemical analysis blood: total protein, its fractions, urea, creatinine, bilirubin and its fractions, blood enzymatic activity, blood lipid composition, electrolytes
5. Hemostasiogram
6. Electrocardiography
7. Ultrasound of the abdominal cavity, retroperitoneal space, small pelvis
8. Ultrasound pleural cavities
9. Echoencephaloscopy
10. X-ray of the skull
11. Chest X-ray
12. Radiography cervical spine
13. Radiography thoracic spine
14. Radiography of the pelvis
15. Radiography of various segments of the musculoskeletal system depending on the localization of damage
16. CT scan skull, thoracic, abdominal segments of the spine, pelvis - according to indications, depending on the location of damage, the mechanism of injury
Transportation of the patient to the radiology department for CT is possible only after exclusion intra-abdominal bleeding and pathology of the chest organs requiring surgical intervention.
1. KOS and blood gases
2. Serum osmolarity
3. Determination of lactate level
4. Magnetic resonance imaging
5. Angiography of the pelvic vessels
6. Ultrasound of the joints (in the area of damage)
7. Troponins, BNP, D-dimer, homocysteine (if indicated)
8. immunogram (according to indications)
9. cytokine profile (interleukin-6.8, TNF-α) (according to indications)
10. markers of bone metabolism (osteocalcin, deoxypyridinoline) (according to indications)
Assessment of the patient's condition should be carried out on the basis of the results of examinations carried out on integral prognostic scales
To assess the severity of injury, the TRISS scale, based on the age-adjusted RTS scale, is used.
Table 3 Revised Trauma Score (RTS)
The probability of survival of the patient is determined by the formula:
Where b= b0+b1*(TS)+b2*(ISS)+b3*(A)
Ps - probability of survival;
E - Constant equal to 2.718282
A - age score of the victim:
Age up to 55 years - 0 points
55 years and over - 1 point
B0 , b1 , b2 ,b3 - coefficients obtained by the method regression analysis(different for closed and open injury).
To assess the patient's condition, the APACHE II scale is used.
Table 4. Acute and chronic condition Health II - The Acute Physiology and Chronic Health Evaluation II (APACHE II)
A. Physiological health status 
C. Correction chronic diseases
For each case:
Liver cirrhosis confirmed by biopsy
Heart failure: NYHA functional class IV
Severe chronic obstructive pulmonary disease (hypercapnia, need for oxygen therapy at home)
Chronic dialysis
Immunodeficiency
2 points are added for elective surgery and neurosurgery, 5 points for emergency surgery
APACHE II calculation
A. Acute Rating Scale physiological state health
B. Age correction
C. Chronic disease management
Table 5 APACHE II total scores
Diagnostic criteria
Anamnesis: useful primary information that can be provided by the relatives of the victim, eyewitnesses of the incident or the team members who delivered the victim from the scene of injury.
timely and brief information about the mechanism of injury, time from the moment of injury, the amount of approximate blood loss at the site of injury can greatly facilitate the work of doctors and improve its results.
Physical examination:
It is carried out in parallel or after the solution of priority tasks for the provision of emergency care.
First of all, an assessment of impairment of consciousness is carried out. For this purpose, it is more convenient to use the Glasgow Come Scale (GCS) (see tab. 1)
Table 1. Glasgow coma scale
Gradations of disorders of consciousness
It is necessary to carefully examine the eyeballs, assess the width of the pupils and identify the presence of oculomotor disorders as a sign of an intracranial volumetric process. Should be inspected hairy part head, oropharynx and all skin to detect penetrating damage and foreign bodies(including dentures eyeballs and false teeth).
Special attention should be given to the cervical spine.
It is reasonable to assume that all patients with polytrauma "conditionally" have damage to the cervical spine. This concept requires the mandatory use of coaxial stabilization with a rigid, removable collar from the prehospital stage of care. medical care. Suspicion of damage to the cervical spine is removed only after X-ray control, even despite high level consciousness of the victim and the absence of severe focal symptoms!
When examining the chest, attention should be paid to the visible deformation and asymmetric participation of the chest in the act of breathing. It is necessary to carefully examine the condition of the clavicles, ribs and carefully after turning the victim on his side - chest and lumbar spine. Deformation of the chest indicates a chest injury with a violation of its frame function and the development of hemo- or pneumothorax. The presence of swelling of the jugular veins against the background low scores systemic blood pressure in combination with deformity of the chest or the presence of a penetrating wound in the "dangerous" zone allows us to suspect a heart injury with the development of its tamponade.
"Dangerous" zones of heart injury:
Above - II rib;
Below - the edge of the costal arch;
Right - midclavicular line;
Left - mid-axillary line
The deformity of the spine revealed in the victim, pain on palpation may indicate damage to it. The victim's absence active movements in the lower extremities, pronounced abdominal type breathing with weak chest excursion may be a sign of spinal cord injury.
Initial inspection of the anterior abdominal wall in polytrauma is not informative enough. However, it is necessary to examine the skin in order to detect hemorrhages in the projection parenchymal organs. If the victim is conscious, then palpation of the abdomen may reveal symptoms of peritoneal irritation. IN without fail the perineum should be visually examined with rectal and vaginal examinations. catheterization Bladder carried out carefully, taking into account possible damage to the urethra. Gross hematuria is an indication for X-ray studies using contrast to avoid damage to the bladder and kidneys.
In the absence of consciousness or with its significant oppression clinical methods(percussion determination of the fluid level, auscultation, determination of an increase in the circumference of the abdomen in dynamics) cannot exclude the pathology of the abdominal organs. Then the exclusion of the pathology of the abdominal organs (primarily parenchymal) becomes a priority for the next diagnostic stage- "instrumental".
Examination of the upper and lower extremities is aimed at identifying deformities, fractures of tubular bones and damage to the joints. Particular attention should be paid to identifying possible fractures pelvic bones. Fracture immobilization should be prehospital stage otherwise, it should be done immediately upon admission to the hospital.
Identification of fracture sites can help in a preliminary assessment of the volume of blood loss (see Table 2).
Table 2. Assessment of blood loss in injuries of the musculoskeletal system and surgical trauma
Indications for expert advice:
All patients with polytrauma must be jointly examined by a traumatologist, resuscitator, surgeon, and neurosurgeon.
Consultations of other specialists - depending on the localization of damage (otorhinolaryngologist, maxillofacial surgeon, urologist) and the presence of a combined injury (combustiologist).
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Treatment
Purpose of treatment: stabilization of the patient's condition and prevention septic complications, acute syndrome lung injury, multiple organ failure.
Treatment tactics
Mode depending on the severity of the condition - 1, 2, 3. Diet - 15; other types of diets are prescribed depending on concomitant pathology
The main directions of therapy
1. Ensuring airway patency and adequate ventilation.
2. Ensuring adequate tissue perfusion, which is achieved by correction acute blood loss, hypovolemic and metabolic disorders.
4. Treatment of organ dysfunctions.
5. Surgical treatment damage.
Ensuring airway patency
Absolute readings for endotracheal intubation (tracheal intubation and transfer to mechanical ventilation is carried out in the presence of at least one sign):
1. Lack of breath
2. Lack of cardiac activity
3. Oppression of consciousness according to the Glasgow coma scale less than 8 points; violation of the mechanics of breathing (multiple fractures of the ribs with flotation of the chest).
Additional Features for endotracheal intubation(tracheal intubation and transfer to mechanical ventilation is performed if there are at least two signs):
1. Respiratory rate more than 29 or less than 10 per minute
2. Non-rhythmic breathing pattern
3. PO2/FiO2 ratio<300
4. PCO2>45 or<25 мм рт.ст. (при FiO2=0,21)
5.PO2<70 мм рт.ст. (при FiO2=0,21)
6.SpO2<90% (при FiO2=0,21)
7. Aspiration of blood, gastric contents
8. The presence of damage to the facial skeleton
9. Presence of head and neck burns
10. Presence of signs of damage to the cervical spine
11. Mean arterial pressure< 80 мм рт.ст.
12. Existence of a pre-existing chronic lung disease
13. Oppression of consciousness according to the Glasgow coma scale 9-13 points
14. Convulsive syndrome
15. The need for the introduction of narcotic analgesics and sedatives
16. Significant collateral damage
17. If there is any doubt about the state of the respiratory tract
Algorithm for endotracheal intubation in patients with polytrauma:
1. Assessment of the state of the respiratory tract with the removal of foreign bodies from the oropharynx
2. Preoxygenation and mask assisted ventilation at FiO2 1.0
3. Manual coaxial stabilization
4. Removing the front part of the stabilizing cervical collar
5. Cricoid pressure (Selick maneuver) during mask assisted ventilation and intubation
6. Local anesthesia (lidocaine) or general anesthesia (diazepam, ketamine, thiopental in standard induction or reduced doses). At the first attempt of intubation, the use of muscle relaxants is not recommended.
8. Confirmation of the position of the endotracheal tube by auscultation and capnogram
9. Return of the front part of the stabilizing collar
Basic principles of intensive care
According to modern concepts, during the intensive care of any critical condition, it is necessary to maintain a correspondence between the body's needs for oxygen and nutrients and the possibilities of their delivery: VO2 = DO2.
To create this correspondence, there are two areas of intensive care:
1. Decrease in oxygen (VO2) and nutrient consumption - hypothermia induced by physical or pharmacological methods.
2. Increasing the delivery of oxygen and nutrients (DO).
Delivery of oxygen and nutrients depends on the following parameters:
DO2= MOC x Hb x (SaO2 - SvO,),
Where MOC is the minute volume of the heart,
Hb - hemoglobin level,
SaOn, SvO2—oxygen saturation of arterial and venous blood.
Increasing DO can be achieved by:
Increased MOC (infusion therapy with colloids and crystalloids, vasopressor and inotropic support);
Improving the rheological properties of blood (pentoxifylline, reopoliglyukin, hemodilution);
anemia correction.
Life Support First Aid Program(Recommendations of the World Association of Emergency and Disaster Medicine (WAEDM)).
1. Release of the victim without causing him additional injuries.
2. Releasing and maintaining the patency of the upper respiratory tract (triple reception P. Safar)
3. Carrying out expiratory methods of mechanical ventilation.
4. Stop external bleeding with a tourniquet or pressure bandage.
5. Giving a safe position to the victim in an unconscious state (physiological position on the side).
6. Giving a safe position to the victim with signs of shock (with the head end lowered).
Medical assistance to the victim at the scene
1. Identify vital disorders and eliminate them immediately.
2. Conduct an examination of the victim, establish the causes of life-threatening disorders and make a pre-hospital diagnosis.
3. Decide on the need to hospitalize the patient or refuse it.
4. Determine the place of hospitalization of the patient according to the nature of the injuries *.
5. Determine the order of hospitalization of the victims (in case of mass trauma).
6. Ensure the maximum possible non-traumaticity and speed of transportation to the hospital.
The division of the victims on the basis of an assessment of their general condition, the nature of the injuries and the complications that have arisen, taking into account the prognosis, into 4 groups:
1 sorting group (black marking): victims with extremely severe, incompatible with life injuries, as well as those in a terminal state (agonizing), who need only symptomatic therapy. The prognosis is unfavorable for life.
2 sorting group (red marking)- severe injuries that pose a threat to life, i.e. victims with rapidly growing life-threatening disorders of the main vital functions of the body (shock), for the elimination of which urgent therapeutic and preventive measures are required. The prognosis can be favorable with timely medical care.
3 sorting group (yellow marking)- injuries of moderate severity, i.е. not posing an immediate threat to life. Life-threatening complications may develop. The prognosis for life is relatively favorable.
4 sorting group (green marking)- lightly affected, i.e. casualties with minor injuries requiring outpatient treatment.
Priority tasks of the prehospital stage:
1. The problem of normalization of breathing.
2. Elimination of hypovolemia (crystalloids)
3. The problem of pain relief (tramadol, moradol, nabuphine, small doses of ketamine 1-2 mg/kg in combination with benzodiazepines).
4. The imposition of aseptic dressings and transport tires.
Protocol for resuscitation for patients with polytrauma at the prehospital stage:
1. Temporary stop of bleeding.
2. Point assessment of the severity of the patient's condition: heart rate, blood pressure, Algover index (SHI), pulse oximetry (SaO2).
3. With systolic blood pressure<80 мм рт.ст., пульсе >110 min., SaO2< 90%, ШИ >1.4 requires a complex of emergency intensive care.
4. Resuscitation allowance should include:
At SaO2< 94% - ингаляция кислорода через лицевую маску либо носовой катетер.
At SaO2< 90% на фоне оксигенотерапии - интубация трахеи и перевод на ИВЛ или ИВЛ.
Catheterization of a peripheral / central vein.
Infusion of HES preparations at a rate of 12-15 ml / kg / hour (or an adequate volume of crystalloids, excluding the introduction of a 5% glucose solution).
Anesthesia: promedol 10-20 mg, or fentanyl 2 mg/kg, droperidol 2.5 mg, diazepam 10 mg, local anesthesia at fracture sites with a solution of 1% lidocaine.
Prednisolone 1-2 mg/kg
transport immobilization.
5. Transportation to a medical institution, against the backdrop of ongoing IT.
Intensive care program at the hospital stage
1. Stop bleeding
2. Pain relief
3. Assessment of the patient's condition according to the integral prognostic scales adopted in the hospital!
4. Recovery of oxygen transport:
Replenishment of the BCC
Improving the rheological properties of blood
Stabilization of macro- and microdynamics
Recovery of oxygen carriers
Respiratory support
5. Nutritional Support
6. Antibacterial therapy
7. Prevention of multiple organ failure
Events of the first stage
1. Catheterization of the main or peripheral vein
2. Oxygen inhalation or mechanical ventilation
3. Bladder catheterization
The rate of infusion therapy does not depend on the caliber of the vein into which the infusion is carried out, but is directly proportional to the diameter and inversely proportional to the length of the catheter.
Damage control is a tactic for the treatment of life-threatening and critical polytraumas, according to which, depending on the severity of the victim’s condition, assessed by objective indicators, only those methods are used in the early period that do not cause a serious deterioration in the patient’s condition.
Table 6. Classification of shock (according to Marino P., 1999).
Table 7. Principles of blood loss replacement depending on the degree of shock.
Criteria for the adequacy of the therapy:
1. Stabilization of blood pressure with a decrease in tachycardia
2. Increased CVP up to 15 mm Hg.
3. Increasing the rate of diuresis more than 1 ml / (kg * h)
4. Increase in blood hemoglobin up to 80-100 g/l
5. Increase in total protein and blood albumin
6. Increase and stabilize VO2
Surgery:
79.69 - surgical treatment of an open fracture of another specified bone
79.39 - open reposition of bone fragments of another specified bone with internal fixation.
79.19 - closed reposition of bone fragments of another specified bone with internal fixation.
78.19 - Application of an external fixation device to other bones.
77.60 - local excision of the affected area or bone tissue of unspecified localization
77.69 - local excision of the affected area or tissue of other bones
77.65 - local excision of the affected area or tissue of the femur.
78.15 - application of an external fixation device to the femur.
78.45 - other reconstructive and plastic manipulations on the femur.
78.55 - internal fixation of the femur without reduction of the fracture.
79.15 - closed reposition of bone fragments of the femur with internal fixation.
79.25 - open reposition of bone fragments of the femur without internal fixation.
79.35 - open reposition of fragments of the femur with internal fixation.
79.45 - closed reposition of fragments of the epiphysis of the femur
79.55 - open reposition of fragments of the epiphysis of the femur
79.85 - open reposition of hip dislocation.
79.95 Unspecified manipulation for hip bone injury
79.151 - Closed reposition of bone fragments of the femur with internal fixation by intramedullary osteosynthesis;
79.152 - Closed reposition of bone fragments of the femur with internal fixation with a blocking extramedullary implant;
79.351 - Open reposition of bone fragments of the femur with internal fixation by intramedullary osteosynthesis;
79.65 - Surgical treatment of an open fracture of the femur.
81.51 - Total hip replacement;
81.52 - Partial hip replacement.
81.40 - Hip reconstruction, not elsewhere classified
79.34 - open reposition of bone fragments of the phalanges of the hand with internal fixation.
79.37 - open reposition of bone fragments of the tarsal and metatarsal bones with internal fixation.
78.19 Application of an external fixation device to other bones.
45.62 - Resection of the small intestine
45.91 Small bowel anastomosis
45.71-79 Colon resection
45.94 Colonic anastomosis
46.71 - Suturing of duodenal rupture
44.61 - Suturing of gastric rupture
46.10 - Colostomy
46.20 - Ileostomy
46.99 - Other manipulations of the intestines
41.20 - Splenectomy
50.61- Closure of liver rupture
51.22 - Cholecystectomy
55.02 - Nephrostomy
55.40 - Partial nephrectomy
54.11 - Diagnostic laparotomy
54.21 - Laparoscopy
55.51 - Nephrectomy
55.81 - Suturing of a ruptured kidney
57.18 - Other suprapubic cystostomy
57.81 - Suturing of bladder rupture
52.95 - Other reconstructive procedures on the pancreas
31.21 - Mediastinal tracheostomy
33.43 - Thoracotomy. Suturing a ruptured lung
34.02 - diagnostic thoracotomy
34.04 - Drainage of the pleural cavity
34.82 - suturing of diaphragmatic rupture
33.99 - Other manipulations on the lung
34.99 - Other chest manipulations
Preventive measures:
The main event is injury prevention.
Rehabilitation:
exercise therapy. The classes include elementary exercises for all muscle groups of the limbs and trunk, all joints of healthy limbs and joints of damaged limbs free from immobilization.
Breathing exercises of a static and dynamic nature are performed in a ratio of 1:2.
Under relieved conditions, the patient performs active movements with his limbs, sliding along the surface of the bed, with a sliding plane or a roller trolley leading up),
To restore the support ability, in particular the spring function of the limbs, the exercises include active movements with the toes, dorsiflexion and plantar flexion of the feet, circular movements of the feet, axial pressure on the footrest, grabbing small objects with the toes and holding them;
Isometric tension of the muscles of the back and limbs to prevent muscle atrophy and improve regional hemodynamics, the intensity of tension is increased gradually, the duration is 5-7 seconds. The number of repetitions is 8-10 per session;
The formation of temporary compensations during exercise therapy concerns, first of all, unusual motor acts, such as lifting the pelvis in the position of the patient lying on his back, turning in bed and getting up.
The number of classes is gradually increased from 3-5 to 10-12 per day.
The question of the duration of bed rest after surgical treatment is decided in each case individually. Patients are trained to move with the help of crutches - first within the ward, then the department. It must be remembered that body weight when relying on crutches should fall on the hands, and not on the armpit. Otherwise, compression of the neurovascular formations may occur, which leads to the development of the so-called crutch paresis.
Massage. Massage is an effective means of influencing the state of local blood flow and liquorodynamics, as well as the functional state of muscles. In the absence of contraindications, to improve peripheral blood circulation, from the 3-4th day after the operation, massage of intact limbs is prescribed. The course of treatment is 7-10 procedures.
Physical methods of treatment. When indicated, physical factors are prescribed that reduce pain and reduce swelling and inflammation in the area of surgical intervention, improving sputum discharge:
ultraviolet irradiation,
drug inhalations,
Cryotherapy,
low frequency magnetic field,
The course of treatment is 5-10 procedures.
Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol:
- this is the simultaneous or almost simultaneous occurrence of two or more traumatic injuries, each of which requires specialized treatment. Polytrauma is characterized by the presence of a syndrome of mutual burdening and the development of a traumatic disease, accompanied by violations of homeostasis, general and local adaptation processes. With such injuries, as a rule, intensive care, emergency operations and resuscitation are required. The diagnosis is made on the basis of clinical data, the results of radiography, CT, MRI, ultrasound and other studies. The list of medical procedures is determined by the type of injury.
ICD-10
T00-T07
General information
Polytrauma is a generalizing concept, meaning that the patient has several traumatic injuries at the same time. In this case, it is possible both to damage one system (for example, the bones of the skeleton), and several systems (for example, bones and internal organs). The presence of polysystemic and multiple organ lesions negatively affects the patient's condition, requires intensive therapeutic measures, increases the likelihood of traumatic shock and death.
Classification
The distinguishing features of polytrauma are:
- Mutual burden syndrome and traumatic disease.
- Atypical symptoms that make diagnosis difficult.
- High probability of developing traumatic shock and massive blood loss.
- Instability of compensation mechanisms, a large number of complications and deaths.
There are 4 degrees of severity of polytrauma:
- Polytrauma 1 degree of severity- there are slight injuries, there is no shock, the outcome is a complete restoration of the function of organs and systems.
- Polytrauma 2 severity- there are injuries of moderate severity, shock of I-II degree is detected. Long-term rehabilitation is necessary to normalize the activity of organs and systems.
- Polytrauma grade 3- there are severe injuries, shock II-III degree is detected. As a result, partial or complete loss of functions of some organs and systems is possible.
- Polytrauma 4 severity- there are extremely severe injuries, shock III-IV degree is detected. The activity of organs and systems is grossly impaired, there is a high probability of death both in the acute period and in the process of further treatment.
Taking into account the anatomical features, the following types of polytrauma are distinguished:
- Multiple trauma- two or more traumatic injuries in the same anatomical region: fracture of the lower leg and fracture of the femur; multiple rib fractures, etc.
- Associated injury- two or more traumatic injuries of different anatomical regions: TBI and damage to the chest; shoulder fracture and kidney injury; clavicle fracture and blunt abdominal trauma, etc.
- Combined injury- traumatic injuries as a result of simultaneous exposure to various traumatic factors (thermal, mechanical, radiation, chemical, etc.): burn in combination with a hip fracture; radiation injury combined with a vertebral fracture; poisoning with toxic substances in combination with a pelvic fracture, etc.
Combined and multiple injuries may be part of a combined injury. A combined injury can occur with the simultaneous direct action of damaging factors or develop as a result of secondary damage (for example, when a fire occurs after the collapse of an industrial structure that caused a limb fracture).
Taking into account the danger of the consequences of polytrauma for the life of the patient, there are:
- Non-life-threatening polytrauma- injuries that do not cause gross violations of life and do not pose an immediate danger to life.
- Life-threatening polytrauma- damage to vital organs that can be corrected by timely surgical intervention and / or adequate intensive care.
- Fatal polytrauma- damage to vital organs, the activity of which cannot be restored even by providing timely specialized assistance.
Taking into account localization, polytrauma is isolated with damage to the head, neck, chest, spine, pelvis, abdomen, lower and upper extremities.
Diagnostics
Diagnosis and treatment of polytrauma often represent a single process and are carried out simultaneously, due to the severity of the condition of the victims and the high probability of developing traumatic shock. First of all, the general condition of the patient is assessed, injuries that may be life-threatening are excluded or detected. The volume of diagnostic measures for polytrauma depends on the condition of the victim, for example, when a traumatic shock is detected, vital studies are carried out, and the diagnosis of minor injuries is carried out, if possible, in the second place and only if this does not aggravate the patient's condition.
All patients with polytrauma undergo urgent blood and urine tests, and also determine the blood type. In case of shock, bladder catheterization is carried out, the amount of urine excreted is monitored, blood pressure and pulse are regularly measured. During the examination, chest x-ray, x-ray of the bones of the extremities, x-ray of the pelvis, x-ray of the skull, echoencephalography, diagnostic laparoscopy and other studies may be prescribed. Patients with polytrauma are examined by a traumatologist, neurosurgeon, surgeon and resuscitator.
Treatment of polytrauma
At the initial stage of treatment, antishock therapy comes to the fore. In case of bone fractures, complete immobilization is carried out. With crush injuries, avulsions and open fractures with massive bleeding, a temporary stop of bleeding is performed using a tourniquet or hemostatic clamp. With hemothorax and pneumothorax, drainage of the chest cavity is performed. If the abdominal organs are damaged, an emergency laparotomy is performed. With compression of the spinal cord and brain, as well as with intracranial hematomas, appropriate operations are performed.
If there is damage to internal organs and fractures, which are a source of massive bleeding, surgical interventions are carried out simultaneously by two teams (surgeons and traumatologists, traumatologists and neurosurgeons, etc.). If there is no massive bleeding from fractures, open reposition and osteosynthesis of fractures, if necessary, are performed after the patient is taken out of shock. All activities are carried out against the background of infusion therapy.
Then, patients with polytrauma are hospitalized in the intensive care unit or intensive care unit, continue infusion of blood and blood substitutes, prescribe drugs to restore the functions of organs and systems, and carry out various therapeutic measures (dressings, change of drains, etc.). After the condition of patients with polytrauma improves, they are transferred to the traumatological (less often, neurosurgical or surgical department), treatment procedures are continued, and rehabilitation measures are carried out.
Forecast and prevention
According to WHO, polytrauma ranks third in the list of causes of death in men aged 18-40, second only to oncological and cardiovascular diseases. The number of deaths reaches 40%. In the early period, death usually occurs due to shock and massive acute blood loss, in the late period - due to severe brain disorders and related complications, primarily thromboembolism, pneumonia and infectious processes. In 25-45% of cases, the outcome of polytrauma is disability. Prevention consists in carrying out activities aimed at preventing road, industrial and domestic injuries.
For the first time this concept was formulated at the II All-Union Congress of traumatologists and orthopedists A.V. Kaplan et al. (1975). Multiple injuries included 2 or more injuries within the same anatomical region (for example, fractures of the femur and lower leg or damage to the liver and spleen), combined injuries included damage to any internal organ and fractures or other injuries of the musculoskeletal system, as well as a combination of fracture limbs with damage to blood vessels and nerves. This definition has supporters to date.
In addition to this definition, the following formulations should be noted: “The group of combined injuries should include simultaneous mechanical damage to two or more anatomical regions, including limbs” (Tsibulyak G.N., 1995); “The concept of traumatic disease and the practical recommendations arising from it are of particular importance for the treatment of victims with combined trauma, i.e. simultaneous damage to two or more anatomical areas of the body. We are talking about a conditional, but generally accepted allocation of 7 anatomical regions of the body: head, neck, chest, abdomen, pelvis, spine, limbs "(Eryukhin I.A., 1994):" Combined injuries are understood as damage to internal organs in various cavities, simultaneous damage to internal organs and the musculoskeletal system, as well as simultaneous damage to the musculoskeletal system, blood vessels and nerves ”(Shapot Yu.B., 1993).
However, the lack of assessment of the severity of individual injuries and their significance can mislead the practitioner. For example, should the combination of a fracture of one rib and a fracture of a finger on the arm be considered a multiple injury, and a mild concussion of the brain and a fracture of the beam in a typical place - a combined injury? Formally, this is so, but it is clear that these injuries do not require any special medical recommendations and can be treated like a normal isolated injury.
Abroad, a combined injury is referred to as "polytrauma”, referring to multiple injuries in one person, one or more of which is life-threatening. A scoring of the severity of injuries on the AIS scale is also mandatory, with the score of life-threatening (4) or critical (5) squared, and the remaining points are added. In accordance with this, the minimum polytrauma score is 17. This figure is obtained as follows: a life-threatening injury score of 4 - squared, get 16 and add a minor injury score (1). For example, this corresponds to a patient with a severe brain contusion (4) and a closed fracture of one of the bones of the forearm. In our opinion, the lower limit of the injury severity score on the ISS scale should be shifted to 10 points, since such victims are admitted to intensive care units and undergo examination and treatment there. They make up to half of the victims who have 2 or more severe injuries (3 points according to AIS), but at the same time they are the most promising in terms of treatment and rehabilitation. The disadvantage of the AIS and ISS scales is also the absence of the patient's age score and the score of severe diseases that the patient had before the injury.
According to the decision of the Interdepartmental Scientific Council on the Problems of Combined and Multiple Injuries (1998), the following definition of combined injury was adopted: "Simultaneous damage by a mechanical traumatic agent to two or more of the seven anatomical regions of the body." There cannot be severe and mild concomitant or multiple injuries, since by definition they are severe, and this addition is redundant.
This definition of a combined injury would be more complete if the severity score of the leading and other injuries were simultaneously determined. However, while in our country there is no generally accepted scale for the severity of injuries, and the American AIS and 1SS scales are not mandatory, this is difficult to do. At the same time, these scales are common, rather simple, and, according to many experts, relatively correctly reflect the anatomical severity of injuries. Therefore, when defining combined and multiple injuries, they cannot be ignored.
Thus, the most complete concept of combined injury will be the following. Associated injury is damage by one or more mechanical traumatic agents within 2 or more of 6 anatomical regions of the human body, one of which is necessarily life-threatening and is assessed on the AIS scale of 4 points. Multiple injury should be considered damage within 2 or more anatomical regions, one of which is severe and is assessed on the AIS scale of 3 points. The number of anatomical regions should be limited to 6, combining head and neck injuries, since individual neck injuries are rare: head, face and neck, chest, abdomen, pelvis, spine, limbs.
It is inappropriate to single out an open and a closed concomitant injury, since the victim usually has both injuries, although closed ones predominate. Of the open fractures, the most frequent are open fractures of the extremities, in second place are open fractures of the vault and base of the skull.Combined and multiple injuriescan also be caused by firearms, but they have a number of specific features and are predominantly found in the practice of military medicine. The author's experience in the treatment of these injuries is small, so they are not considered in this book.
Multiple knife woundscan also affect both the chest and abdominal cavities, but with them there is no damage to the bones of the limbs and pelvis, the vault of the skull, so the traumatologist is rarely involved in providing assistance, only for the surgical treatment of wounds of the limbs. These injuries are handled by general surgeons.
V.A. Sokolov
Multiple and combined injuries
Polytrauma is a combination of two or more injuries requiring specialized treatment, the nature of which depends on the characteristics of each of the injuries and on their mutual influence on the body. This is not just the sum of damages, but the totality, i.e., the overall, resulting total of all damages.
The nature and severity of this "outcome" will determine the nature, sequence and intensity of therapeutic and preventive measures, both of a general nature and specifically aimed at each local injury.
The following types of polytrauma are distinguished.
1. Multiple damage.
1.1. Multiple bone fractures.
1.1.1. Multiple fractures of the bones of the body.
1.1.2. Multiple fractures of limb bones:
one segment;
One limb:
Intra- and periarticular;
diaphyseal;
Two limbs:
Unilateral;
symmetrical;
Cross;
Three and four limbs.
2. Other types of multiple injuries.
3. Combined damage. ZL. Combined fractures of the bones of the extremities.
3.1.1. Combined traumatic brain injury.
3.1.2. Combined spinal injuries.
3.1.3. Combined chest injuries.
3.1.4. Combined pelvic injuries.
3.1.5. Combined injuries of the abdominal organs.
3.1.6. Combined damage to the main vessels, nerves, extensive destruction of muscles, fiber, skin.
3.2. Other types of combined injuries.
4. Combined lesions.
4.1. Radiation-mechanical.
4.2. Radiation-thermal.
4.3. Radiation-thermomechanical.
4.4. Thermomechanical.
4.5. Other types of combined lesions.
PRINCIPLES OF TREATMENT OF MULTIPLE FRACTURES
Treatment of patients with polytrauma is one of the urgent problems of modern medicine. To solve this complex problem requires the efforts of many specialists. The main efforts of traumatologists and orthopedists should be aimed at improving the results of treatment of multiple fractures in combination with injuries to the internal organs of the abdomen, chest, traumatic brain injury, spinal cord injury, as well as damage to the main vessels, large nerve trunks, extensive destruction of soft tissues, significantly aggravating the prognosis both for life and for the function of injured limbs.
The basic principles of treatment of victims with severe polytrauma are now quite fully developed practically and justified theoretically: first of all, it is necessary to carry out resuscitation and intensive care measures aimed at saving the life of the victim and restoring the functions of vital organs. The timing and volume of treatment of all other damaged organs and systems, including the musculoskeletal system, are determined by the effectiveness of anti-shock measures and the prognosis for the life of the victim and the viability of the damaged organ.
Although bone fractures do not directly threaten the lives of the victims, one cannot but take into account that the fracture area, and even more so several fractures, is also a source of blood loss, intoxication, and intense pain stimuli. In addition, bone fractures always pose a threat of fat embolism, and destruction of soft tissues - the threat of purulent, putrefactive or anaerobic infection. Therefore, despite the severity of the injury, specialized treatment of fractures cannot be postponed for a long time, since local circulatory disorders, inflammation, pain syndrome aggravate the general condition of the victims, and the loss of function of the damaged limb segments leads to permanent disability.
From a practical point of view, it is advisable to divide the treatment of fractures into preliminary and final.
Preliminary treatment of fractures must be considered as an important part of the complex of resuscitation measures and intensive care and must be carried out without fail for all victims in the first hours of hospitalization.
Indications for preliminary treatment of a fracture are:
Severe shock and terminal states;
Mass flow of patients;
The inability to perform the final specialized treatment of fractures (for example, in the absence of a specialist, when providing care in a non-specialized medical institution, etc.).
Pretreatment of fractures includes pre-reposition and pre-fixation of fractures.
The main tasks of preliminary reposition are:
Elimination of gross angular and rotational deformities that disrupt local blood circulation and injure soft tissues, blood vessels, and nerves;
Orientation of the distal fragment along the axis of the proximal one;
Restoration, if possible, of the length of the damaged segment;
Giving the limb a functionally advantageous position;
Reduction of dislocations.
Preliminary reposition is carried out, as a rule, in a closed manual way; with open fractures, visual control is also possible. Undoubtedly, a valuable means of preliminary reposition is skeletal traction. However, it should be remembered that without additional manipulations (sometimes rather complicated), it is rarely possible to achieve an accurate reposition with a standard skeletal traction system.
The tasks of preliminary fixation of fragments are:
Elimination of the possibility of gross displacement of fragments during forced manipulations in victims (for example, to perform lumbar puncture, to prevent bedsores, for transportation, to change clothes, etc.), as well as during motor excitation;
Ensuring the distraction of the joints in case of intra-articular fractures;
Ensuring the possibility of wound treatment and subsequent care and control;
Preservation of segment length in comminuted fractures.
Known means of preliminary fixation of fragments - plaster casts and skeletal traction systems - cannot fully provide a solution to these problems. The use of various devices for extrafocal fixation of bone fragments has significantly increased the effectiveness of both preliminary and final treatment of fractures of any location.
The objectives of the preliminary treatment of open fractures are:
Temporary stop of bleeding (using clamps, pressure bandage, tourniquet);
Local administration of novocaine solution with antibiotics;
Removal of superficially lying fragments (it is advisable to wash large fragments, treat with antiseptics, "saturate" with antibiotics, store in the refrigerator);
Active drainage (in case of severe contamination - simultaneous washing of the wound with a solution of chlorhexidine, chlorophyllipt, dioxidine).
After removing the victims from shock, the final treatment of open fractures is carried out by full surgical treatment. If there are several wounds, it is advisable to treat the heavier, more contaminated one first, i.e., first it is necessary to eliminate the main focus of infection, and then treat less dangerous foci of potential infection, the treatment of which may have to be postponed due to the deterioration of the victim's condition after the first intervention .
In the presence of open and closed fractures, the final treatment must be performed first in the area of open damage, since it is a real focus of purulent infection, and until this focus is eliminated, it is hardly advisable to perform a clean operation. The risk of developing a purulent infection increases significantly with a forced delay in the surgical treatment of an open fracture, for example, due to the development of shock after internal osteosynthesis of a closed femoral fracture. The thesis "a closed fracture must be treated closed" is of particular importance in polytrauma. For its implementation, intramedullary osteosynthesis with blocking without reaming the medullary canal, minimally invasive osteosynthesis with plates, as well as extrafocal external fixation are used.
The final treatment of fractures, the task of which includes accurate reposition and strong fixation of fragments, is carried out after the elimination of life-threatening conditions and infectious complications. If in the acute period of injury the condition of the victim is not complicated by the development of shock, then it is advisable to carry out the final treatment of fractures in the first 2 days. For the treatment of polyfractures, combined methods are more preferable, which use the positive qualities of several methods in accordance with a specific combination of injuries. When choosing the method of final fixation of fragments, preference should be given to those that allow you to quickly activate the victim, raise him to his feet and restore the function of walking.
Combined damage is described in the relevant sections.
