Polytrauma. Periods of traumatic illness

Along with the increase in injuries, the number of victims with polytrauma has increased significantly, and over the last decade their share in the structure of peacetime injuries has doubled. This type of damage is especially often observed during disasters (accidents, natural disasters). In trauma departments of hospitals in large cities, polytrauma occurs in 15-30% of patients; in disasters, this figure reaches 40% or more.

1. Terminology, classification, clinical manifestations

   In the recent past, the terms “polytrauma” and “combined, multiple trauma” included different concepts, there was no single generally accepted terminology until a unified classification was adopted at the III All-Union Congress of Orthopedic Traumatologists.

   First of all, mechanical injuries were divided into two groups: single trauma and polytrauma.

   Monotrauma (isolated injury) is an injury to one organ in any area of ​​the body or (in relation to the musculoskeletal system) an injury within one anatomical and functional segment (bone, joint).

   In each of the considered groups, damage can be mono-or polyfocal, for example, injury small intestine in several places or breaking one bone in several places (double fractures).

   Damage to the musculoskeletal system accompanied by trauma great vessels and nerve trunks, must be considered as complicated injury.

   Term "polytrauma" is a collective concept that includes the following types injuries: multiple, combined, combined.

   TO multiplemechanical injuries include damage to two or more internal organs in one cavity (for example, the liver and intestines), two or more anatomical and functional formations of the musculoskeletal system (for example, a fracture of the hip and forearm).

   Combined damage is considered to be simultaneous damage internal organs in two or more cavities (for example, lung damage and spleen) or damage to internal organs and segment musculoskeletal system(for example, traumatic brain injury and broken limbs).

   Combined are injuries received as a result of exposure to various traumatic factors: mechanical, thermal, radiation (for example, a hip fracture and burn of any area of ​​the body or traumatic brain injury and radiation exposure). Possibly larger number options for simultaneous exposure to damaging factors.

   Multiple, combined and combined injuries are characterized by a particular severity of clinical manifestations, accompanied by a significant disorder in vital life. important functions organism, difficulty of diagnosis, complexity of treatment, high percentage of disability, high mortality. This kind of damage is much more often accompanied by traumatic shock, blood loss, and threatening circulatory and respiratory disorders. The severity of polytrauma is indicated by mortality rates. For isolated fractures it is 2%, for multiple fractures - 16%, for combined injuries - 50% or more.

   In the group of victims with combined mechanical damage Trauma to the musculoskeletal system is most often combined with traumatic brain injury. This kind of combination is observed in almost half of the victims. In 20% of cases with combined trauma, damage to the musculoskeletal system is accompanied by chest trauma, in 10% - damage to organs abdominal cavity. It is not uncommon to experience simultaneous injury to 3 or even 4 areas of the body (skull, chest, abdomen and musculoskeletal system).

   There is a certain pattern in the dynamics general changes, occurring in the body of a person exposed to trauma. These changes are called "traumatic disease". Strictly speaking, a traumatic disease develops with any, even minor, damage. However, its clinical manifestations become noticeable and significant only with severe shockogenic (usually multiple, combined or combined) lesions. Based on these positions, currently a traumatic disease is understood as a pathological process caused by severe trauma and manifested in the form of characteristic syndromes and complications.

   During traumatic illness There are 4 periods, each of which has its own clinical symptoms.

   First period (shock) lasts from several hours to (occasionally) 1-2 days. In time it coincides with the development of the victim traumatic shock and is characterized by disruption of vital activity important organs both as a result of direct damage and as a result of hypovolemic, respiratory and cerebral disorders inherent in shock.

   Second period determined by post-resuscitation, post-shock, post-operative changes. The length of this period is 4 -6 days. The clinical picture is quite varied, largely depends on the nature of the dominant lesion and is most often represented by such syndromes as acute cardiovascular failure, respiratory distress syndrome adults (ARDS), disseminated intravascular coagulation syndrome, endotoxicosis. It is these syndromes and the complications associated with them that during this period directly threaten the life of the victim. In the second period of a traumatic illness, with multiple organ pathology, it is especially important to take into account that the patient’s multiple disorders are manifestations of a single pathological process, therefore treatment should be carried out comprehensively.

   Third period is determined mainly by the development of local and general surgical infection. It usually begins on the 4th-5th day and can last several weeks, and in some cases even months.

   The fourth period (recovery) occurs when favorable course traumatic illness. It is characterized by suppression of the immune background, slow reparative regeneration, asthenization, dystrophy, and sometimes persistent dysfunction of internal organs and the musculoskeletal system. During this period, victims require restorative treatment, medical, professional and social rehabilitation.

   For the right decision therapeutic and tactical tasks when providing medical care for victims with polytrauma it is extremely important to identify leading (dominant) lesion, defining on this moment severity of the condition and posing an immediate threat to life. The dominant damage during the course of a traumatic disease may vary depending on the effectiveness of the measures taken. therapeutic measures. At the same time, the severity general condition victims, disturbances of their consciousness (up to lack of contact), difficulty in identifying the dominant damage, acute shortage time with mass receipts often lead to untimely diagnosis of damage. About 3 of victims with combined trauma are diagnosed untimely, and 20% are diagnosed incorrectly. Often one has to deal with the erasure or even distortion of clinical symptoms (for example, with injuries to the skull and abdomen, spine and abdomen, as well as other combinations).

   Important feature polytrauma is the development of mutual burden syndrome. The essence of this syndrome is that damage to one location aggravates the severity of another. At the same time, the overall severity of the course of a traumatic disease, depending on the number of injuries, increases not in arithmetic, but rather in geometric progression. This is primarily due to qualitative changes in the development of shock with the summation of blood loss and pain impulses coming from several foci, as well as the depletion of the body’s compensatory resources. Shock, usually for a short period of time,

   does not enter the decompensated stage, the total blood loss reaches 2-4 liters. Cases of development of disseminated intravascular coagulation syndrome, fat embolism, thromboembolism, acute renal failure, and toxemia are also significantly increasing.

   Fat embolism is rarely recognized in a timely manner. One of the characteristic symptoms is the appearance of a petechial rash and minor hemorrhages on the chest, abdomen, internal surfaces upper limbs, sclera, mucous membranes of the eyes and mouth - noted only on the 2-3rd day, as well as the appearance of fat in the urine. At the same time, the absence of fat in the urine cannot yet indicate the absence of fat embolism. The peculiarity of fat embolism is that it develops and increases gradually. Fat droplets enter the lungs (pulmonary form), but can pass through the pulmonary capillary network V big circle blood circulation, causing brain damage (cerebral form). In some cases, a mixed form of fat embolism is noted, representing a combination of cerebral and pulmonary forms. At pulmonary form fat embolism is dominated by the picture of acute respiratory failure, however, brain disorders cannot be ruled out. The brain form is characterized by the development of headaches after the obligatory light interval, convulsive syndrome, coma.

   Prevention of fat embolism consists primarily of adequate immobilization of injuries and careful transportation of victims.

   Big problem When providing medical care to victims with polytrauma, there is often an incompatibility of therapy. So, if in case of injury to the musculoskeletal system the administration of narcotic analgesics is indicated for relief pain syndrome, then when these injuries are combined with severe traumatic brain injury, the use of drugs becomes contraindicated. Injury chest does not make it possible to apply an abduction splint in case of a shoulder fracture, and extensive burns make adequate immobilization of this segment impossible plaster cast at concomitant fracture. Incompatibility of therapy leads to the fact that sometimes the treatment of one, two or all injuries is forced to be carried out incompletely. Solving this problem requires a clear definition of the dominant lesion, development of a treatment plan taking into account the periods of the traumatic disease, possible early and late complications. Priority, of course, should be given to preserving the life of the victim.

2. Features of the clinical course of combined lesions

   A special place, both in terms of the severity of the clinical course and the nature of the medical care provided in disasters, is occupied by combined injuries, when the injury is combined with exposure to radioactive (R) or toxic (CH) substances. This is where the mutual burden syndrome manifests itself most clearly. In addition, those affected become dangerous to others. In case of mass arrivals, they are separated from the general flow of victims for sanitary treatment. Due to this, the provision of medical care to them is delayed in some cases.

   1. Combined radiation injuries

      The accumulated experience in assessing the impact of ionizing radiation on humans allows us to believe that external gamma radiation in a single dose of 0.25 Gy (1 Gy -100 rad) does not cause noticeable deviations in the body of the irradiated person; a dose of 0.25 to 0.5 Gy can cause minor temporary deviations in the composition peripheral blood, a dose of 0.5 to 1 Gy causes symptoms autonomic disorders and a mild decrease in the number of platelets and leukocytes.

      The threshold dose of external uniform irradiation for the manifestation of acute radiation sickness is I Gr.

      There are 4 periods in clinical course combined radiation injury:

      Primary reaction period (from several hours to 1-2 days) manifests itself in the form of nausea, vomiting, hyperemia of the mucous membranes and skin ( radiation burn). In severe cases develop dyspeptic syndrome, coordination problems, appear meningeal signs. At the same

      Over time, these symptoms may be masked by manifestations of mechanical or thermal damage.

      Hidden or latent period characterized by manifestations of non-radiation injuries (symptoms of mechanical or thermal injury predominate). Depending on severity radiation injury The duration of this period is from 1 to 4 weeks, but the presence of severe mechanical or thermal injury shortens its duration.

      IN period of height of acute radiation sickness victims experience hair loss and develop hemorrhagic syndrome. In peripheral blood - agranulocytosis, leukopenia, thrombocytopenia. This period is characterized by disruption of trophism and reparative regeneration of tissue. Necrosis appears in the wounds, grafts are rejected, and the wounds fester. There is a high risk of generalization of wound infection and the formation of bedsores.

      Recovery period begins with the normalization of hematopoiesis. The rehabilitation period usually ranges from a month to a year. Long time asthenia and neurological syndromes persist.

      Select 4 degree of severity combined radiation injuries (in combination with mechanical injuries or burns).

      First degree (mild) develops when a mild mechanical injury or burns of I-II degree up to 10% of the body surface is combined with irradiation at a dose of 1-1.5 Gy. The primary reaction develops 3 hours after irradiation, the latent period lasts up to 4 weeks. Such victims, as a rule, do not need specialized medical care. The prognosis is favorable.

      Second degree (moderate) develops with a combination of mild injuries or superficial (up to 10%) and deep (3- 5%) burns with irradiation at a dose of 2-3 Gy. The primary reaction develops after 3-5 hours, the latent period lasts 2-3 weeks. The prognosis depends on the timeliness of provision specialized assistance, full recovery occurs in only 50% of victims.

      Third degree (severe) develops when mechanical injuries or deep burns of up to 10% of the body surface are combined with irradiation at a dose of 3.5-4 Gy. The primary reaction develops after 30 minutes and is accompanied by frequent vomiting and severe headaches. The latent period lasts 1-2 weeks. The prognosis is doubtful full recovery, as a rule, does not occur.

      Fourth degree (extremely severe) develops when a mechanical injury or deep burns of more than 10%) of the body surface is combined with irradiation at a dose of more than 4.5 Gy. The primary reaction develops within a few minutes and is accompanied by uncontrollable vomiting. The prognosis is unfavorable.

      Thus, due to the manifestation of the mutual aggravation syndrome, the radiation dose required for the development of the same degree of injury severity in case of combined injuries is 1-2 Gy lower than in case of isolated radiation injury.

      Infection of wounds with radioactive substances (radioactive dust or other particles entering the wound surface) promotes the development of necrotic changes in tissues at a depth of up to 8 mm. Reparative regeneration is disrupted, as a rule, a wound infection develops, as a result of which the formation of trophic ulcers is very likely. Radioactive substances are almost not absorbed from the wound and, together with the wound discharge, quickly pass into the gauze bandage, where they accumulate, continuing their effect on the body.

   2. Combined chemical injuries

      In case of accidents at chemically hazardous objects, injuries from potent toxic substances, asphyxiating, general toxic, neurotropic effects, and metabolic poisons are possible. Combinations of toxic effects are possible.

      Substances with asphyxiating properties (chlorine, sulfur chloride, phosgene, etc.) primarily affect the respiratory system. The clinical picture is dominated by pulmonary edema.

      Generally toxic substances differ in the nature of their effect on the body. They can block the function of hemoglobin (carbon monoxide), have a hemolytic effect

      eat (arsenic hydrogen), render toxic effects on fabric (hydrocyanic acid, dinitrophenol).

      Substances with neurotropic action act on the conduction and transmission of nerve impulses

      (carbon disulfide, organophosphorus compounds: thiophos, dichlorvos, etc.).

      Metabolic poisons include substances causing disturbances synthetic and other metabolic reactions (bromomethane, dioxin).

      In addition, some substances have both a suffocating and generally toxic effect (hydrogen sulfide), asphyxiating and neurotropic effects (ammonia).

      When providing assistance to victims, it is necessary to take into account the possible penetration of toxic substances into the wound.

      If persistent toxic substances get into a wound or intact skin vesicant action(mustard gas, lewisite) develop deep necrotic changes, a wound infection occurs, and regeneration is significantly inhibited. The resorptive effect of these substances aggravates the course of shock and sepsis.

      Organophosphate toxic substances (sarin, soman) do not directly affect local processes flowing in the wound. However, already after 30-40 minutes their resorptive effect appears (the pupils narrow, bronchospasm increases, fibrillation of individual muscle groups is noted, up to a convulsive syndrome). Death in severe cases can occur from paralysis of the respiratory center.

3. Features of providing assistance to victims with polytrauma

   Severity of damage, frequency of development life-threatening conditions with polytrauma, big number deaths make the speed and adequacy of medical care particularly important. Its basis is the prevention and fight against shock, acute respiratory failure, coma, since most often it is necessary to provide assistance to victims in the first and second periods of a traumatic illness. At the same time, the multivariability of polytrauma, specific damaging factors, the difficulty of diagnosis, and the incompatibility of therapy led to some features.

   1. First medical and first aid

      The entire possible range of anti-shock measures is being carried out. In the source of radioactive or chemical damage, the victim is put on a gas mask, respirator or as a last resort gauze mask to prevent droplets of chemical agents or radioactive particles from entering Airways. Open areas of the body that have been exposed to chemical agents are treated using an individual anti-chemical package. For multiple bone injury Due to the danger of fat embolism, transport immobilization should be approached with special care.

   2. First aid

      Affected agents or radioactive substances are dangerous to others, so they are immediately separated from the general flow and sent to the site partial sanitization. In case of radioactive damage, victims who have a radioactive background of more than 50 mR/h at a distance of 1.0-1.5 cm from the skin surface are considered dangerous to others. Further, since RV and OM are accumulated in the dressing, all these victims are treated in the dressing room replacing a dressing with a wound dressing. If a damaging agent is known, the wounds are washed and treated skin special solutions (for example, when affected by mustard gas, the skin is treated with 10% alcohol, and wounds - 10% aqueous solutions chloramine; if affected by lewisite, the wound is treated with Lugol's solution, and the skin with iodine), if unknown - with isotonic sodium chloride solution. To relieve the manifestations of the primary reaction, a tablet of etaprazine (an antiemetic) is given. Further sorting and assistance are carried out depending on the nature of the mechanical or thermal damage. Victims with IV degree of combined radiation injuries remain for symptomatic therapy.

   3. Qualified medical care

      Those affected by RVs and persistent agents are sent for complete sanitary treatment (washing the entire body with soap and water). The majority are victims of shock varying degrees gravity, which will serve as the basis for sorting.

      An important feature is the attitude towards the primary surgical treatment of wounds. In those affected by RV and OV, this operation belongs to the measures not of the third, but of the second stage, since delay will lead to worsening negative impact these substances. Primary debridement aims not only to prevent the development of wound infection, but also to remove radioactive substances and agents from the surface of the wound.

      In case of moderate to severe combined radiation injury, primary sutures are applied to any wound after primary surgical treatment.

      This is due to the fact that it is necessary to achieve primary healing before the beginning of the height of radiation sickness. Reduce danger infectious complications With this tactic, extended excision of soft tissue during surgical treatment helps.

   4. Specialized medical care

The provision of specialized medical care to victims with polytrauma is carried out depending on the dominant lesion. Help is provided during all periods of traumatic illness, the fight against wound complications comes to the fore, and in the future - issues of patient rehabilitation.

Questions for self-control

Which of the following injuries are classified as combined?

a) closed fracture of the right femur, open fracture of the left femur and tibia; b) second degree burn of the forearm, fracture radius V typical place;

c) fracture of the IV-VI ribs on the right, concussion; d) fracture of the pelvic bones with damage to the bladder.




Indicate the severity of the combined radiation injury of the victim with closed fracture humerus and irradiation at a dose of 2.5 Gy.

a) I degree (mild);

b) II degree (moderate); V) III degree(heavy);

d) IV degree (extremely severe).




Specify the injuries in which the pelvic bone fracture is dominant. a) fracture pubic bone, hip fracture middle third;

b) Malgenya type pelvic fracture, splenic rupture;

c) central dislocation of the hip, fracture of the neck of the humerus; d) Malgenya type pelvic fracture, III-IV degree burn of the hand; e) rupture of the symphysis, intracranial hematoma.




Which of the following is included in the scope of the first medical care with combined radiation injuries?

a) preventive blood transfusion; b) partial sanitary treatment;

c) complete sanitary treatment;

d) primary surgical treatment of the wound;

e) administration of antidotes, antibiotics and antitetanus serum.




In what period of radiation sickness is it advisable to perform operations on victims (if indicated)?

a) in the latent period; b) during the peak period;

c) in initial period; d) operations are not allowed.

Is it permissible to apply primary sutures to a gunshot wound of the thigh with combined radiation damage? medium degree gravity?

a) permissible only in the absence of a gunshot fracture; b) permissible only when penetrating wound;

c) acceptable in all cases;

d) is unacceptable in any case.




When providing what type of medical care is it first necessary to remove the protective bandage from a victim with a soft tissue wound of the shoulder (without symptoms of ongoing bleeding) and damage from organophosphorus agents?

A) first aid;

b) first aid; c) qualified assistance; d) specialized assistance.




Where should a victim with a complicated lumbar spine injury and radiation injury at a dose of 4 Gy be sent to provide qualified medical care?

a) anti-shock; b) to the operating room;

c) to the special processing department; d) to the hospital.

Answers to questions for self-control

Chapter 2. 1 -b; 2 -c, d; 3 - b, c; 4 - b, c; 5 -a, c, d, e; 6 -c, d; 7 -g.

Chapter 4. 1 -b; 2 -a, b, c, d, e; 3 -a, c, d; 4 -c; 5 -c; 6 -c; 7 - b, c, d, d; 8-b; 9-6; 10 -a, b, d. Chapter 5. 1 -b, d, e; 2 - b, d; 3 - b, d, d; 4 -a, c.

Chapter 6. 1 - b, c; 2 -c, d; 3 -g; 4 -c; 5 -a, c, d; 6-b; 7 -c; 8 -c; 9 – a, c; 10 -b. Chapter 7. 1 -a, b; 2 -d, e; 3 -c, d; 4 -c, d; 5 - b, d; 6-6.

Chapter 8. 1 -d, d; 2 -a; 3 -g; 4 - b, c, d; 5 -c; 6 -c; 7 -a; 8 -a, v.

Chapter 9. 1 -a, c, d; 2-6; 3 -g; 4 -d; 5 -a, d; 6th century

Chapter 10. 1 -a; 2 -g; 3 -a, b, c; 4 -c; 5 -a, d; 6 - b, c, d; 7 -a, b, c; 8-6, c. Chapter 11. 1 - b, d, d; 2 - b, d; 3 -g; 4 -a; 5 -g.

Chapter 12. 1 -6; 2 -a, d; 3 - in; 4 -a; 5 B.

Chapter 13. 1 -c, d; 2 -a, b, c, d, e; 3 - in; 4 - b, c; 5 -c; 6 -a, c; 7 -a, b, d. Chapter 14. 1 -d; 2 - b, c, d; 3 -b; 4 -a, c; 5-in.

Volgograd State Medical University
Department of Hospital Surgery
POLYTRAUMA
head of education
Ph.D. Matyukhin V.V.

Definition of the concept

Trauma is a violation of integrity and
tissue (organ) functions as a result
external influence, overall result
effects on the human body
environmental factors,
exceeding endurance limit
biological structures.

Definition of the concept

Damage - violation
anatomical integrity or
functional state of the tissue,
organ or body part caused by
external influence.
The damage serves as a morphological
substrate of injury.

Definition of the concept

An isolated (single) injury is
injury in which one
damage to tissues and internal organs
or segments of the musculoskeletal
apparatus.

Definition of the concept

Multiple trauma is an injury with
the simultaneous emergence of two and
more damage within one
anatomical area of ​​the body or one
anatomical segment.

Definition of the concept

There are 7 such areas:
- head
- neck
- breast
- belly
- pelvis
- spine
- upper and lower limbs.

Definition of the concept

Combined injury - at the same time
injury to two or more organs
belonging to different anatomical and functional systems.

Definition of the concept

Combined injury is an injury with
the occurrence of two or more
traumatic foci when exposed to
various damaging factors.

Definition of the concept

Polytrauma is severe or extremely
severe combined or multiple
developmental trauma
acute disorders vital
functions. At the same time, the multiplicity and
combination of injuries is not
a simple sum of injuries, but qualitatively
new condition of the patient with
multi-organ and multi-system
violations.

10. Definition of the concept

Traumatic illness is
a set of general and local
changes, pathological and
adaptive reactions,
occurring in the body during the period from
moment of injury until its final
outcome.

11. Periods of traumatic illness

I – period of acute life disorders
important functions. Covers time from
moment of injury until the end
resuscitation measures.
Duration – first 12 hours;
includes prehospital and
resuscitation stages of treatment in
hospital.

12. Periods of traumatic illness

II – period of relative stabilization
vital functions.
Duration – 12-48 hours after
injuries; corresponds to the stage
intensive care.

13. Periods of traumatic illness

III – period of possible development
complications. Time interval – 3-10
days after injury. Characterized by
organ dysfunction, developmental threat
non-infectious, and in later periods
infectious complications.

14. Periods of traumatic illness

IV – period of complete stabilization
vital functions. Doesn't have
time boundaries; corresponds to the stage
specialized treatment.
V – period of rehabilitation of victims.

15. Epidemiology

16. Epidemiology

According to the latest data on
causes of death in 2008, which were
released in 2011, in 2008 in
57 million people died worldwide.
From injuries caused by external
causes, 5 million died
Human.

17. Epidemiology

Severe combined and multiple
injuries in economically developed
countries among the causes of death
occupy 3rd place and 1st place among people
under 40 years old!
According to WHO, the average lifespan
“unlived” life among victims in
under 40 years of age is 2.7 times more,
than from diseases
cardiovascular system and
neoplasms taken together.

18. Epidemiology

Mortality in severe combined
injury ranges from 44 to 50%, and with
severe combined injury with
negative prognosis for life
reaches 68-80%.
More than 1/3 of convalescents,
who have suffered polytrauma, become
disabled people.

19. Assessing the severity of injury

20. Assessing the severity of injury

When assessing the severity of injury, assess
severity of injury (anatomical
scales and indices) and severity of the condition
victim (functional scales
and indexes).

21. Assessing the severity of damage

damage.
To calculate ISS, the body is divided by 6
areas:
1) head and neck
2) face
3) chest
4) stomach, abdominal organs and
pelvis
5) bones of the pelvis and limbs
6) leather and soft tissues

22. Assessing the severity of damage

The severity of damage to an individual
regions are ranked according to a 6-point system
from 0 to 6:
0 – no damage
1 – slight damage
2 – moderate damage
3 – severe damage, not dangerous to
life
4 - severe injury, life-threatening
5 – critical damage, in which
survival is doubtful
6 – damage incompatible with life

23. Assessing the severity of damage

Fracture of clavicle, sternum, scapula
2
Fractured ribs (up to three)
2
Multiple rib fractures
3
Tension pneumothorax
3
Lung contusion or rupture
3
Heart bruise
4
Heart injury
5
Rupture of the trachea, main bronchi
5
Aortic rupture
6

24. Assessing the severity of damage

ISS – sum of squares of the three most
high scores in each area
Brain concussion
1
Lung contusion
Diaphragm rupture
3
3
Splenic rupture
4
Fracture of forearm bones
2
Femur fracture
3
ISS=3*3+4*4+3*3=34

25. Assessing the severity of damage

ISS (Injury Severity Scale) - severity scale
damage:
< 17 - легкие повреждения
17-25 – stable
26-40 – borderline
>40 - critical

26. Assessing the severity of the condition

RTS (Revised Trauma Score) –
revised injury severity scale:
Main settings
NPV, min
Points
13-15
SBP, mm
Hg
>89
10-29
4
9-12
6-8
76-89
50-75
>29
6-9
3
2
4-5
1-49
1-5
1
3
0
0
0
GCS, points

27. Glasgow Coma Scale

28. Assessing the severity of the condition

RTS (Revised Trauma Score)< 4 баллов –
indication for hospitalization in
specialized traumatology
center.

29. Assessing the severity of the condition

Health Evaluation)

30. Assessing the severity of the condition

APACHE (Acute Physiology and Chronic
Health Evaluation)

31. Assessing the severity of the condition

APACHE (Acute Physiology and Chronic
Health Evaluation)
< 10 баллов – стабильное состояние
10-20 points – moderate condition
>20 points – critical condition

32. Primary examination First stage

The purpose of the first stage of the survey is
identify damage that represents
immediate threat to life
patient, and take measures to
elimination.

33. Primary examination First stage

During the initial examination
carry out quick (5 minutes)
assessment of the victim's condition according to
diagram A B C D E.

34. Primary examination First stage

A (airway) – release of respiratory
pathways, cervical spine control
spine
B (breathing) – ensuring breathing
C (circulation) – control of blood circulation and
stop bleeding
D (disability) – assessment of neurological
status
E (exposure) – release from clothing

35. Maintaining airway patency

- aspirate the contents of the respiratory tract
ways
- support the chin
- bring the lower jaw forward
- if necessary, intubate the trachea
- if necessary, perform
surgery for
ensuring airway patency
pathways (cricothyroidotomy)

36. Maintaining airway patency

37. Maintaining airway patency

38. Prevention of spinal cord injuries

- semi-rigid collar splint (up to
carrying out x-ray control)
- special long hard stretchers with
rollers
- fixing the patient to the stretcher
For fractures of the lower thoracic and
lumbar vertebrae use of rigid
stretcher without bolsters can
destabilize the damage.

39. Prevention of spinal cord injuries

40. Breathing and ventilation

- tension pneumothorax: no
breath sounds, shortness of breath,
tympanic percussion sound; possible
also swelling of the jugular veins and displacement
trachea towards the healthy lung
- tense hemothorax: absence
breathing sounds; also possible
displacement of the trachea towards the healthy side
lung, dullness of percussion sound,
unstable hemodynamics

41. Breathing and ventilation

42. Breathing and ventilation of the lungs

- fenestrated rib fracture: paradoxical
breath
- open pneumothorax: suction
air through a chest wall wound
- cardiac tamponade: unstable
hemodynamics, fear of death, swelling
neck veins (if there is no significant
decrease in BCC)

43. Breathing and ventilation

44. Breathing and ventilation of the lungs

The above states
detected during physical examination
research.
Treatment begins without
X-ray confirmation.

45. Breathing and ventilation

- oxygen is absolutely necessary for life,
has a powerful inotropic effect,
therefore he must do so without restriction
- for cardiac tamponade, infusion therapy
and pericardiocentesis may temporarily improve
the patient's condition, but is usually required
emergency surgery

46. ​​Breathing and ventilation

47. Breathing and ventilation

- absence of respiratory sounds in the patient
with hemodynamic disorders requires
emergency pleural puncture with
subsequent drainage of the pleural
cavities
- when providing emergency medical care
help pleural cavity usually
drained into the 5th intercostal space along the anterior or
midaxillary line

48. Breathing and ventilation of the lungs

49. Breathing and ventilation of the lungs

- with total hemothorax, as a rule
components need to be transfused
blood
- if possible, blood from the pleural
cavities are collected and used for
reverse transfusion (reinfusion)

50. Breathing and ventilation

- after any interventions it should be repeated
evaluate the effectiveness of ventilation
- reliable methods for assessing effectiveness
ventilation are:
pulse oximetry, capnography, research
arterial blood gases

51. Breathing and ventilation of the lungs

- you should make sure that it is correct
position of endotrachial and drainage
tubes (if necessary, carry out
chest x-ray)

52. Breathing and ventilation of the lungs

53. Blood circulation

When providing emergency medical care
helping patients with trauma, shock in all
cases should be considered
hemorrhagic.

54. Blood circulation

Signs of impaired tissue perfusion:
- pale cold skin, sticky sweat
- slow capillary refill
after pressing
- depression of consciousness
- decreased diuresis (<0,5 мл/кг/ч)
- weak or thready pulse

55. Blood circulation

Tachycardia is the most common symptom
hemorrhagic shock.
You cannot judge the presence of shock only by
blood pressure level
- in the elderly, severe shock may occur when
relatively normal blood pressure
- in children, a decrease in blood pressure is the most
late symptom of shock

56. Blood circulation

Systolic blood pressure when maintained
pulsation:
- on the carotid artery ≥ 60 mm Hg.
- on the femoral artery ≥ 70 mm Hg.
- on the radial artery ≥ 80 mm Hg.
- on the artery of the dorsum of the foot ≥ 100 mm Hg.

57. Blood circulation

In case of hemorrhagic shock it is necessary
find the source of bleeding
- the patient is examined from all sides
head to toe
- during physical examination
assess bone integrity
limbs and pelvis
- informative: abdominal ultrasound and
pleural cavities, Ro-graphy
chest and pelvis, diagnostic
peritoneal lavage

58. Blood circulation

Liquid in
space
Morrison
Liquid in
Douglas
pocket

59. Blood circulation

60. Blood circulation

External bleeding is stopped
pressing (pressure bandage, tourniquet).
If a bleeding vessel is visible in the wound,
it can be bandaged.
For unstable pelvic fractures, for
to reduce its volume use
a sheet that is tied tightly
around the patient's pelvis (anti-shock
pelvic bandage).

61. Blood circulation

62. Blood circulation

Two venous catheters are installed
large diameter.
Adults are prescribed 2 liters of saline
solutions in the form of rapid intravenous infusion.
Children are given a rapid infusion from
calculation 20 ml/kg.
All fluids for IV infusion must
be warmed up.
If necessary (Hb<70 г/л) проводят
transfusion of red blood cells.

63. Neurological examination

- evaluate using the Glasgow Coma Scale.
- assess the size of the pupils and their reaction
into the light
- evaluate motor reactions and their
symmetry
- perform a CT scan of the head (contraindicated
with unstable hemodynamics)

64. Liberation from clothes

To fully examine the patient and
detect all damage, you need to remove it from
all his clothes.
In a trauma patient, hypothermia may
lead to death.
The most reliable way of prevention
hypothermia - stopping bleeding.
Everything should be warm: sick
cover with preheated
blanket and placed in a warm room,
solutions are heated before intravenous administration.

65. Research and interventions carried out in the first stage

- gastric decompression
- bladder catheterization
- catheterization of central veins
- ECG
- pulse oximetry
- Ro (CT) of the chest, pelvis
- Ultrasound
- laboratory tests (blood type,
Hb, Ht, coagulogram, biochemistry, GAK, tests
for alcohol and drugs)
- capnography

66. Second stage of examination

The second stage of the examination includes
history taking and quick but
thorough research that is not
should delay the start
specialized assistance.

67. History

Z - diseases
A - allergy
L - medicines
P - last meal
O - circumstances of injury
M - mechanism of injury

68. Second stage of examination

Head – inspect and palpate
scalp to avoid wounds
and open fracture of the calvarium.
Eyes - the patient is asked in consciousness,
does he see well? The patient is unconscious
you need to protect your eyes.
Ears - examine the auricle,
external auditory canal and tympanic
membrane on both sides, evaluate the sharpness
hearing
Face – carefully examined and palpated
face.

69. Second stage of examination

Neck - during the examination, the assistant should
keep your head and neck in neutral
position When examining the anterior
surfaces of the neck pay attention to
soreness of the larynx, swelling and crepitus
fabrics. Palpation of the posterior surface
allows you to identify deformation and
soreness.
Chest and abdomen - inspection, palpation,
percussion and auscultation.

70. Second stage of examination

Genitals, perineum and posterior
passage - inspect and palpate.
Musculoskeletal system – examined
all limbs, evaluate motor
reactions, sensitivity and blood supply.
The back and spine are examined and
palpate the back, carefully rolling
the patient's side.
Nervous system – assesses muscle
strength, symmetry of motor reactions
and sensitivity.

71. Untimely detection

- damage, the identification of which requires
contact with the patient
- damage to hollow organs
- tunnel syndrome
- damage to the diaphragm
- vertebral fracture
- ligament damage
- fractures of distal bones
limbs
- nerve damage
- wounds of the scalp

72. Treatment

73. Treatment periods

- resuscitation period (first 3 hours)
- first operating period (up to 72
hours) during which they perform
surgeries for life-saving reasons
- stabilization period (up to several
days)
- second operating period (period
delayed interventions)
- rehabilitation period

74. Resuscitation period

Priority problems are asphyxia,
cardiac arrest, profuse
bleeding, tense or
open pneumothorax.
Carry out active invasive
surgical diagnosis: puncture
pleural cavity, laparocentesis,
thoracoscopy, laparoscopy,
spinal puncture, trepanation
skull, immobilization of fractures.

75. Resuscitation period

Intensive therapy for shock:
- compensation of BCC
- correction of metabolic acidosis
- vasodilation
- anesthesia and sedation
- oxygen therapy
- breathing and ventilation of the lungs under
positive pressure
- impact on the hemostatic system
- prevention of organ damage

76. First operating period

- thoracotomy for ongoing
intrapleural bleeding,
cardiac tamponade
- laparotomy for intra-abdominal
bleeding, injury to the aorta and
great vessels, liver rupture
and spleen
- operations on great vessels
if they are damaged (ligation,
vascular suture, anastomosis, temporary
shunting)
- limb amputation

77. First operating period

- laminectomy, reclination and fixation
spine with unstable
fractures with neurological deficit
- treatment of pelvic wounds, external fixation
for unstable pelvic fractures
rings
- stable synthesis of all fractures
(primarily hips)
- fasciotomy for compartment syndrome
- surgical treatment of bleeding
wounds

78. Stabilization period

- monitoring and express control
vital functions
- maintaining the body's defenses,
replacement of fluids, proteins, carriers
energy
- temporary replacement of vital
body functions
- prevention or correction
multiple organ dysfunction

79. Period of deferred operations

- wound treatment
- surgical treatment of complications
- restoration operations
- final stabilization of fractures

80. Rehabilitation period

Months of rehabilitation for survivors
victims in conditions
specialized centers.

81. Multi-stage surgical tactics “Damage Control”

82. Multi-stage surgical tactics “Damage Control”

Multi-stage surgical tactics –
programmed multi-stage
treatment of victims delivered
in hospital in critical condition,
the use of traditional
approaches associated with
unfavorable outcomes.

83. Multi-stage surgical tactics “Damage Control”

ISS, points
GCS, points
Syst. Blood pressure mmHg
Heart rate
NPV
Hb, g/l
Ht, %
Number of patients, %
>40
<7
<60
>120
Dyspnea
<60
<18
15

84. Multi-stage surgical tactics “Damage Control”

- inability to stop bleeding
in a direct way, especially if there is
multifocal and multicavity
sources
- combined and multiple injuries
several anatomical areas,
equal in severity and priority
- damage requiring complex
reconstructive interventions

85. Multi-stage surgical tactics “Damage Control”

- large amount of internal damage
organs in which radical
correction exceeds physiological
limits of the victim
- hemodynamic instability,
electrical instability of the myocardium
- presence of acute massive blood loss (45 l)

86. Multi-stage surgical tactics “Damage Control”

- severe disorders of homeostasis with
development of hypothermia (body temperature
<35ºС), метаболического ацидоза (рН <7,3),
severe coagulopathy
- the presence of additional aggravating
factors in a critically ill patient
condition (operational time
interventions more than 90 min., volume
blood transfusion of more than 10 doses
red blood cell mass)

87. Multi-stage surgical tactics “Damage Control”

The first phase is the implementation of the “reduced”
emergency surgery for diagnosis
catastrophic damage, application
simplest methods to stop
bleeding and rapid elimination
identified damage using
modern devices.

88. Multi-stage surgical tactics “Damage Control”

Stopping bleeding:
- application to a bleeding vessel
ligatures, clamps or use of lateral
vascular suture, temporary bypass,
ligation
- resection, tamponade, application
hemostatic gels, sponges, thrombin with
bleeding from parenchymal organs
- angiography, embolization of damaged
vessel while continuing, despite
intervention performed, bleeding

89. Multi-stage surgical tactics “Damage Control”

Stopping bleeding:

90. Multi-stage surgical tactics “Damage Control”

Stopping bleeding:

91. Multi-stage surgical tactics “Damage Control”

Stopping bleeding:

92. Multi-stage surgical tactics “Damage Control”

Stopping bacterial contamination:
- injuries to hollow organs are eliminated
by imposing a ligature, hardware
resection, closing with a stapler
- if the common bile duct is damaged, it is created
terminal choledochostomy or simple
drainage
- in case of damage to the pancreas
use wide closed
suction drainage

93. Multi-stage surgical tactics “Damage Control”

94. Multi-stage surgical tactics “Damage Control”

Temporary closure of the abdominal cavity:
- suturing is most preferable
only leather with a continuous seam using threads from
non-absorbable material
- with increased intra-abdominal
pressure use multilayer
adhesive bandages, thin adhesive
plastic films, meshes

95. Multi-stage surgical tactics “Damage Control”

96. Multi-stage surgical tactics “Damage Control”

performing mechanical ventilation, identification
existing damage.

97. Multi-stage surgical tactics “Damage Control”

Second phase – continuation of activities
intensive care in order to maximize
rapid stabilization of hemodynamics,
body temperature, correction of coagulopathy,
performing mechanical ventilation, monitoring intra-abdominal
pressure, identification of available
damage.

98. Multi-stage surgical tactics “Damage Control”

The third phase is performing reoperation,
removal of temporary devices (tampons,
temporary vascular shunts), repeated
audit and restoration
operations (vascular reconstruction,
restoration of the gastrointestinal tract, anatomical
liver resection).

Polytrauma in English literature - multiple trauma, polytrauma.

Combined injury is a collective concept that includes the following types of injuries:

• multiple - damage to more than two internal organs in one cavity or more than two anatomical and functional formations (segments) of the musculoskeletal system (for example, damage to the liver and intestines, fracture of the femur and forearm bones),
• combined - simultaneous damage to two or more anatomical areas of two cavities or damage to internal organs and the musculoskeletal system (for example, the spleen and bladder, thoracic organs and fractures of the limbs, traumatic brain injury and damage to the pelvic bones),
• combined - damage caused by traumatic factors of various nature (mechanical, thermal, radiation), and their number is unlimited (for example, a fracture of the femur and a burn of any area of ​​the body).

ICD-10 code

The principle of multiple coding of injuries should be used as widely as possible. Combined rubrics for multiple injuries are used when there is insufficient detail of the nature of individual injuries or in primary statistical developments, when it is more convenient to register a single code; in other cases, all components of the injury should be coded separately

T00 Superficial injuries involving several areas of the body

• T01 Open wounds involving multiple areas of the body
• T02 Fractures involving several areas of the body
• T03 Dislocations, sprains and damage to the capsular-ligamentous apparatus of joints, involving several areas of the body
• T04 Crushed injuries involving several areas of the body
• T05 Traumatic amputations involving several areas of the body
• T06 Other injuries involving multiple areas of the body, not elsewhere classified
• T07 Multiple injuries, unspecified

In case of combined injury, it may be necessary to code injuries caused by other factors:

• T20-T32 Thermal and chemical burns
• T33-T35 Frostbite

Sometimes some complications of polytrauma are coded separately.

• T79 Some early complications of trauma, not elsewhere classified

Epidemiology of polytrauma

According to WHO, up to 3.5 million people die from trauma every year worldwide. In economically developed countries, injuries occupy third place in the list of causes of death, in Russia - second. In Russia, in men under 45 years of age and in women under 35 years of age, traumatic injuries are the main cause of death, with 70% of cases being severe combined injuries. Victims with polytrauma make up 15-20% of the total number of patients with mechanical injuries. The prevalence of polytrauma is subject to significant fluctuations and depends on the specific conditions of a particular area (demographic indicators, production characteristics, predominance of rural or urban populations, etc.). However, in general, there is a trend in the world towards an increase in the number of victims with multiple injuries. The incidence of polytrauma has increased by 15% over the past decade. Mortality with it is 16-60%, and in severe cases - 80-90%. According to American researchers, in 1998, 148 thousand Americans died from various traumatic injuries, and the mortality rate was 95 cases per 100 thousand population. In the UK in 1996, there were 3,740 deaths due to serious traumatic injuries, which amounted to 90 cases per 100 thousand population. In the Russian Federation, large-scale epidemiological studies have not been carried out, however, according to a number of authors, the number of fatal cases of polytrauma per 100 thousand population is 124-200 (the last figure is for large cities). The estimated cost of treating acute-phase traumatic injuries in the United States is $16 billion per year (the second-highest cost in the medical industry). The total economic loss from injuries (taking into account the death and disability of victims, lost income and taxes, and the cost of medical care) in the United States is $160 billion per year. Approximately 60% of victims do not survive to receive qualified medical care, but die within a short period of time after the injury (on the spot). Among hospitalized patients, the highest mortality rate is observed in the first 48 hours, which is associated with the development of massive blood loss, shock, damage to vital organs and severe TBI. In the future, the leading causes of death are infectious complications, sepsis and MODS. Despite the achievements of modern medicine, mortality from polytrauma in intensive care units has not decreased over the past 10-15 years. 40% of surviving victims remain disabled. In most cases, the working population aged 20-50 years suffers, and the number of men is approximately 2 times greater than women. Injuries in children are recorded in 1-5% of cases. Newborns and infants are more likely to suffer as passengers in road accidents, and at older ages - as cyclists and pedestrians. When assessing the damage from polytrauma, it should be noted that in terms of the number of years lost, it significantly exceeds that from cardiovascular, oncological and infectious diseases combined.

Causes of polytrauma

The most common cause of combined injury is car and train accidents, falls from a height, violent injuries (including gunshot and mine-explosive wounds, etc.). According to German researchers, in 55% of cases, polytrauma is the result of an accident, in 24% - industrial injuries and outdoor activities, in 14% - falls from a height. The most complex combinations of injuries are noted after road accidents (57%), with chest injuries occurring in 45% of cases, TBI in 39%, and limb injuries in 69%. TBI, trauma to the chest and abdominal cavity (especially with bleeding that was not stopped at the prehospital stage) are considered important for prognosis. Damage to the abdominal organs and pelvic bones as a component of polytrauma occurs in 25-35% of all cases (and in 97% they are closed). Due to the high incidence of soft tissue injuries and bleeding, mortality in pelvic injuries is 55% of cases. Spinal injuries as a component of polytrauma occur in 15-30% of all cases, and therefore a spinal injury is suspected in every unconscious patient.

The mechanism of injury has a significant impact on the prognosis of treatment. In the event of a collision with a vehicle:

• Pedestrians experience a head injury in 47% of cases, injuries to the lower extremities in 48%, chest injuries in 44%,
• among cyclists, in 50-90% of cases there are injuries to the extremities and in 45% - head injuries (and the use of protective helmets significantly reduces the number of severe injuries), chest trauma is rare.

In passenger car accidents, the use of seat belts and other safety features determines the types of injuries:

• In persons not wearing seat belts, severe TBIs predominate (75% of cases), while in those using them, abdominal (83%) and spinal injuries are more common.
• Side impacts often cause injuries to the chest (80%), abdomen (60%), and pelvic bones (50%).
• In rear impacts, the cervical spine is most often affected.

The use of modern safety systems significantly reduces the number of cases of severe injuries to the abdominal organs, chest and spine.

Falls from heights can be either an accident or a suicide attempt. In cases of unexpected falls, severe head injuries are more often noted, and in cases of suicide, injuries to the lower extremities are often observed.

How does polytrauma develop?

The mechanism of development of combined injury depends on the nature and type of injuries received. The main components of pathogenesis are acute blood loss, shock, traumatic disease:

• the simultaneous occurrence of several foci of nociceptive pathological impulses leads to disintegration of compensatory mechanisms and failure of adaptive reactions,
• the simultaneous existence of several sources of external and internal bleeding makes it difficult to adequately assess the volume of blood loss and its correction,
• early post-traumatic endotoxicosis observed with extensive soft tissue damage.

One of the most important features of the development of polytrauma is mutual aggravation due to the multiplicity of mechanical damage and the multifactorial impact. Moreover, each injury aggravates the severity of the general pathological situation, is more severe and with a greater risk of developing complications, including infectious ones, than with an isolated injury.

Damage to the central nervous system entails disruption of the regulation and coordination of neurohumoral processes, sharply reduces the effectiveness of compensatory mechanisms and significantly increases the likelihood of purulent-septic complications. Chest trauma inevitably leads to worsening manifestations of ventilation and circulatory hypoxia. Damage to the organs of the abdominal cavity and retroperitoneal space is accompanied by severe endotoxicosis and a significant increase in the risk of infectious complications, which is due to the structural and functional characteristics of the organs of this anatomical region, their participation in metabolism, and functional connection with the vital activity of the intestinal microflora. Trauma to the musculoskeletal system increases the risk of secondary damage to soft tissues (bleeding, necrosis), and increases pathological impulses from each affected area. Immobilization of damaged body segments is associated with prolonged physical inactivity of the patient, aggravating the manifestations of hypoxia, which, in turn, increases the risk of infectious, thromboembolic, trophic and neurological complications. Thus, the pathogenesis of mutual burden is represented by many diverse mechanisms, but for most of them the universal and most important link is hypoxia.

Symptoms of polytrauma

The clinical picture of a combined injury depends on the nature, combination and severity of its components; an important element is mutual aggravation. In the initial (acute) period, there may be a discrepancy between visible damage and the severity of the condition (degree of hemodynamic disorders, resistance to therapy), which requires increased attention from the doctor for timely recognition of all components of polytrauma. In the early post-shock period (after stopping bleeding and stabilizing systemic hemodynamics), victims are quite likely to develop ARDS, acute disorders of systemic metabolism, coagulopathic complications, fat embolism, hepatic and renal failure. Thus, a distinctive feature of the first week is the development of MODS.

The next stage of a traumatic disease is characterized by an increased risk of infectious complications. Various localizations of the process are possible: wound infection, pneumonia, abscesses in the abdominal cavity and retroperitoneal space. Both endogenous and nosocomial microorganisms can act as pathogens. There is a high probability of generalization of the infectious process - the development of sepsis. The high risk of infectious complications in polytrauma is due to secondary immunodeficiency.

During the period of convalescence (usually protracted), the phenomena of asthenia predominate, and a gradual correction of systemic disorders and functional disorders in the functioning of internal organs occurs.

The following features of combined injury are distinguished:

• objective difficulties in diagnosing damage,
• mutual burden
• a combination of injuries that exclude or make it difficult to carry out certain diagnostic and therapeutic measures,
• high incidence of severe complications (shock, acute respiratory failure, acute renal failure, coma, coagulopathies, fatty and thromboembolism, etc.)

There are early and late complications of injury.

Early complications (first 48 hours):

• blood loss, hemodynamic disorders, shock,
• fat embolism,
• coagulopathy,
• disturbance of consciousness,
• breathing disorders,
• deep vein thrombosis and pulmonary embolism,
• hypothermia.

Late period complications:

• infectious (including nosocomial) and sepsis,
• neurological and trophic disorders,

Domestic researchers combine early and late manifestations of polytrauma with the concept of “traumatic illness.” Traumatic disease is a pathological process caused by severe mechanical trauma, and a change in the leading factors of pathogenesis determines the natural sequence of periods of the clinical course.

Periods of traumatic illness (Bryusov P G, Nechaev E A, 1996):

• shock and other acute disorders - 12-48 hours,
• MON - 3-7 days,
• infectious complications or special risk of their occurrence - 2 weeks - 1 month or more,
• delayed convalescence (neurological and trophic disorders) - from several weeks to several months.

Classification of polytrauma

According to the distribution of traumatic injuries:

• isolated injury - the occurrence of an isolated traumatic focus in one anatomical area (segment),
• multiple - more than two traumatic foci in one anatomical area (segment) or within one system,
• combined - the occurrence of more than two traumatic foci (isolated or multiple) in different anatomical areas (segments) or damage to more than two systems or cavities, or cavities and a system,
• combined - the result of exposure to more than two physical factors.

According to the severity of traumatic injuries (Rozhinsky M M, 1982):

• the injury is not life-threatening - all variants of mechanical damage without pronounced disturbances in the body’s functioning and immediate danger to the life of the victim,
• life-threatening - anatomical damage to vital organs and regulatory systems, removable surgically with timely provision of qualified or specialized care,
• fatal - destruction of vital organs and regulatory systems that cannot be eliminated surgically even with timely qualified assistance.

According to the location of traumatic injuries: head, neck, chest, abdomen, pelvis, spine, upper and lower extremities, retroperitoneal space.

Diagnosis of polytrauma

Interviewing the patient makes it possible to clarify complaints and the mechanism of injury, which greatly facilitates the diagnostic search and examination. Often, collecting an anamnesis is difficult due to impaired consciousness in the victim. Before examination, the victim should be completely undressed. Pay attention to the general appearance of the patient, the color of the skin and mucous membranes, the state of the pulse, the location of wounds, abrasions, hematomas, the position of the victim (forced, passive, active), which makes it possible to roughly identify damage. Using percussion and auscultation methods, the chest is examined and the abdomen is palpated. They examine the oral cavity, remove mucus, blood, vomit, removable dentures, and fix the sunken tongue. When examining the chest, pay attention to the volume of its excursion, determine whether there is retraction or bulging of parts, absorption of air into the wound, swelling of the neck veins. An increase in dullness of heart sounds detected during auscultation may be a sign of cardiac damage and tamponade.

To objectively assess the condition of the victim, the severity of injuries and prognosis, the Glasgow Coma Scale, APACHE I, ISS, TRISS are used.

Most of the activities presented in the figure are carried out simultaneously.

In stable patients, a CT scan of the skull and brain is performed before examining the abdomen.

If in patients in an unstable condition (there are focal neurological symptoms, according to ultrasound and peritoneal lavage - free fluid in the abdominal cavity), infusion therapy manages to maintain safe blood pressure values, then a CT scan of the head is performed before laparotomy.

Before assessing the neurological status of the victims, they try not to prescribe sedatives. If the patient has breathing disorders and/or impaired consciousness, then it is necessary to ensure reliable airway patency and constant monitoring of blood oxygenation.

To select the correct treatment tactics and sequence of surgical interventions, it is necessary to quickly determine the dominant injuries (which currently determine the severity of the victim’s condition). It is worth noting that over time, various injuries may take the leading place. Treatment of polytrauma is conventionally divided into three periods: resuscitation, treatment, and rehabilitation.

Instrumental research

Urgent research

• peritoneal lavage,
• CT scan of the skull and brain,
• X-ray (chest, pelvis), if necessary - CT,
• Ultrasound of the abdominal and pleural cavities, kidneys

Depending on the severity of the condition and the list of necessary diagnostic procedures, all victims are conventionally divided into three classes:

1. The first is severe, life-threatening injuries, there are pronounced neurological, respiratory and hemodynamic disorders. Diagnostic procedures: chest radiography, ultrasound of the abdominal organs, echocardiography (if necessary). In parallel, resuscitation and emergency treatment measures are carried out: tracheal intubation and mechanical ventilation (for severe head injury, respiratory dysfunction), puncture and drainage of the pleural cavity (for massive pleural effusion), and surgical stop of bleeding.
2. The second is severe injuries, but despite massive infusion therapy, the condition of the victims is relatively stable. The examination of patients is aimed at finding and eliminating potentially life-threatening complications: ultrasound of the abdominal organs, x-ray of the chest organs in four positions, angiography (with further embolization of the source of bleeding), CT of the brain.
3. The third - the victims are in stable condition. To quickly and accurately diagnose injuries and determine further tactics, such patients are recommended to undergo a CT scan of the whole body.

Laboratory research

All necessary laboratory tests are divided into several groups:

Available within 24 hours, results ready in an hour

• determination of hematocrit and hemoglobin concentration, differentiated counting of leukocytes,
• determination of blood concentrations of glucose, Na+, K\chlorides, urea nitrogen and creatinine,
• determination of hemostasis and coagulogram parameters - PTI, prothrombin time or INR, APTT, fibrinogen concentration and platelet count,
• general urine analysis.

Available within 24 hours, the result is ready in 30 minutes, and in patients with severe oxygenation and ventilation problems they are performed immediately:

• gas analysis of arterial and venous blood (paO2, SaO2, pvO2, SvO2, paO2/FiO2), indicators of acid-base balance

Available daily:

• microbiological determination of the pathogen and its sensitivity to antibiotics,
• determination of biochemical parameters (CPK, LDH with fractions, serum a-amylase, ALT, AST, concentration of bilirubin and its fractions, alkaline phosphatase activity, γ-glutamyl transpeptidase, etc.),
• control of the concentration of drugs (cardiac glycosides, antibiotics, etc.) in biological fluids of the body (desirable).

When a patient is admitted to a hospital, his blood type and Rh factor must be determined, and tests for blood-borne infections (HIV, hepatitis, syphilis) are carried out.

At certain stages of diagnosis and treatment of victims, it may be useful to study the concentration of myoglobin, free hemoglobin and procalcitonin.

Monitoring

Constant observations

• heart rate and heart rate control,
• pulse oximetry (S 02),
• CO2 concentration in the exhaled gas mixture (for patients on mechanical ventilation),
• invasive measurement of arterial and central venous pressure (if the patient’s condition is unstable),
• core temperature measurement,
• invasive measurement of central hemodynamics by various methods (thermodilution, transpulmonary thermodilution - in case of unstable hemodynamics, shock, ARDS).

Regular observations

• measuring blood pressure with a cuff,
• SW measurement,
• determination of body weight,
• ECG (for patients over 21 years old).

Invasive methods (catheterization of peripheral arteries, right heart) are indicated for victims with unstable hemodynamics (resistant to treatment), pulmonary edema (during infusion therapy), as well as patients who need monitoring of arterial oxygenation. Right heart catheterization is also recommended for patients with ALI/ARDS who require respiratory support.

Necessary equipment and facilities for the intensive care unit

• Equipment for respiratory support.
• Resuscitation kits (including an Ambu bag and face masks of various sizes and shapes) - for transferring patients to mechanical ventilation.
• Endotracheal and tracheostomy tubes of various sizes with low-pressure cuffs and uncuffed (for children).
• Equipment for aspiration of the contents of the oral cavity and respiratory tract with a set of disposable sanitary catheters.
• Catheters and equipment for providing permanent venous vascular access (central and peripheral).
• Kits for thoracentesis, drainage of pleural cavities, tracheostomy.
• Special beds.
• Cardiac pacemaker (equipment for pacemaker).
• Equipment for warming the victim and controlling the temperature in the room.
• If necessary, devices for renal replacement therapy and extracorporeal detoxification.

Indications for hospitalization

All victims with suspected polytrauma are hospitalized for examination and treatment in a hospital with the ability to provide specialized care. It is necessary to adhere to a logical strategy of hospitalization, which ultimately allows for the fastest possible recovery of the victim with the least number of complications, and not simply to deliver the patient to the nearest medical facility as quickly as possible. In most victims with combined trauma, the condition is initially assessed as severe or extremely severe, so they are hospitalized in the ICU. If surgical intervention is necessary, intensive therapy is used as preoperative preparation; its goal is to maintain vital functions and provide minimal sufficient preparation of the patient for surgery. Depending on the nature of the injuries, patients need hospitalization or transfer to specialized hospitals - spinal cord injury, burns, microsurgery, poisoning, psychiatric.

Indications for consultation with other specialists

Treatment of victims with severe combined trauma requires the involvement of specialists from various fields. Only by combining the efforts of intensive care doctors, surgeons of various specializations, traumatologists, radiologists, neurologists and other specialists can we hope for a favorable outcome. Successful treatment of such patients requires consistency and continuity in the actions of medical personnel at all stages of care. A necessary condition for obtaining the best results in the treatment of polytrauma is trained medical and nursing personnel, both at the hospital and pre-hospital stages of care, effective coordination of the patient’s hospitalization in a medical institution, where specialized care will be immediately provided. Most patients with polytrauma after the main course require long-term recovery and rehabilitation treatment with the involvement of doctors of relevant specialties.

Treatment of polytrauma

The goals of treatment are intensive therapy for victims with concomitant trauma - a system of therapeutic measures aimed at preventing and correcting violations of functions important for life, ensuring normal body responses to damage and achieving sustainable compensation.

Principles of providing assistance at the initial stages:

• ensuring patency of the airways and tightness of the chest (in case of penetrating wounds, open pneumothorax),
• temporary stop of external bleeding, priority evacuation of victims with signs of ongoing internal bleeding,
• ensuring adequate vascular access and early initiation of infusion therapy,
• anesthesia,
• immobilization of fractures and extensive injuries with transport tires,
• careful transportation of the victim to provide specialized medical care.

General principles of treatment of victims with polytrauma

• the fastest possible restoration and maintenance of adequate tissue perfusion and gas exchange,
• if general resuscitation measures are necessary, they are carried out in accordance with the ABC algorithm (Airways, Breath, Circulation - airway patency, artificial respiration and chest compressions),
• adequate pain relief,
• ensuring hemostasis (including surgical and pharmacological methods), correction of coagulopathies,
• adequate provision of energy and plastic needs of the body,
• monitoring the patient's condition and increased alertness regarding the possible development of complications.

Therapy of circulatory disorders

• Constant monitoring of the victim's condition is necessary.
• Victims often present with symptoms of hypothermia and vasoconstriction, which can mask and complicate the timely recognition of hypovolemia and peripheral circulatory disorders.
• The first stage of hemodynamic support is the administration of infusion solutions to quickly restore adequate perfusion. Isotonic crystalloid and isooncotic colloid solutions have the same clinical efficacy. To maintain hemodynamics (after restoration of volemic status), the administration of vasoactive and/or cardiotonic drugs is sometimes indicated.
• Monitoring oxygen transport makes it possible to detect the development of multiple organ dysfunction before it occurs. clinical manifestations(they are observed 3-7 days after injury).
• When metabolic acidosis increases, it is necessary to check the adequacy of intensive therapy, exclude hidden bleeding or necrosis of soft tissues, AHF and myocardial damage, acute renal failure.

Correction of respiratory disorders

All victims are recommended to immobilize the neck until fractures and instability of the cervical vertebrae are excluded. First of all, exclude neck injury in unconscious patients. For this purpose, an X-ray examination is carried out, and the victim is examined by a neurologist or neurosurgeon.

If the patient is undergoing mechanical ventilation, then before stopping it it is necessary to ensure the stability of hemodynamics, the satisfactory state of gas exchange indicators, the elimination of metabolic acidosis, and adequate warming of the victim. If the patient’s condition is unstable, then it is advisable to delay the transfer to spontaneous breathing.

If the patient is breathing spontaneously, oxygen must be supplied to maintain adequate arterial oxygenation. With the help of non-depressing, but effective anesthesia, a sufficient depth of breathing is achieved, which prevents atelectasis of the lungs and the development of secondary infection.

When predicting long-term mechanical ventilation, the rapid formation of a tracheostomy is indicated.

Transfusion therapy

Adequate oxygen transport is possible when the hemoglobin concentration is more than 70-90 g/l. However, in victims with chronic diseases of the cardiovascular system, severe metabolic acidosis, low CO and partial pressure of oxygen in mixed venous blood, it is necessary to maintain a higher value - 90-100 g/l.

In case of recurrent bleeding or development of coagulopathy, a supply of red blood cells, matched by group and Rh, is required.

Indications for prescribing FFP are massive blood loss (loss of bcc per day or half of it in 3 hours) and coagulopathy (thrombin time or aPTT more than 1.5 times longer than normal). The recommended initial dose of FFP is 10-15 ml/kg of patient's body weight.

It is necessary to maintain a platelet count of more than 50x10 9 /l, and in victims with massive bleeding or severe head injury - more than 100x10 9 /l. The initial volume of donor platelets is 4-8 doses or 1 dose of platelet concentrate.

The indication for the use of blood coagulation factor VIII (cryoprecipitate) is a decrease in fibrinogen concentration to less than 1 g/l. Its initial dose is 50 mg/kg.

In the intensive treatment of severe bleeding in closed injuries, the use of blood coagulation factor VII is recommended. The initial dose of the drug is 200 mcg/kg, then after 1 and 3 hours - 100 mcg/kg.

Anesthesia

Adequate pain relief is necessary to prevent the development of hemodynamic instability and increased respiratory excursion of the chest (especially in patients with injuries to the chest, abdomen and spinal injury).

Local anesthesia (in the absence of contraindications such as local infection and coagulopathy), as well as patient-controlled analgesia methods, contribute to better pain relief.

Opioids are used in the acute period of injury; NSAIDs are more effective in relieving pain in bone injuries. However, they can cause coagulopathy, stress ulcers of the gastric and intestinal mucosa, and impaired renal function.

When determining indications for pain relief, it is necessary to remember that anxiety and agitation of the victim can be caused by reasons other than pain (brain damage, infection, etc.)

Nutrition

Early administration of nutritional support (immediately after normalization of central hemodynamics and tissue perfusion) leads to a significant reduction in the number of postoperative complications.

Total parenteral or enteral nutrition, or combinations thereof, can be used. While the victim is in serious condition, the daily energy value of food is at least 25-30 kcal/kg. It is necessary to transfer the patient to complete enteral nutrition as early as possible.

Infectious complications

The development of infectious complications largely depends on the location of the injury and the nature of the injury (open or closed, whether the wound is contaminated). Surgical debridement, tetanus prophylaxis, and antibacterial therapy (from a single dose to treatment over several weeks) may be required.

Intravenous catheters installed during emergency and resuscitation measures (sometimes without observing aseptic conditions) must be replaced.

Patients with polytrauma have an increased risk of developing secondary infections (in particular, infections of the respiratory tract and wound surfaces associated with catheterization of large vessels, the abdominal cavity and retroperitoneal space). For their timely diagnosis, it is necessary to conduct regular (once every 3 days) bacteriological studies of body fluids (blood, urine, tracheobronchial aspirate separated from drains), as well as monitor possible foci of infection.

Peripheral damage and complications

When limbs are injured, damage to nerves and muscles, thrombosis of blood vessels, and disruption of blood supply often occur, which can ultimately lead to the development of compartment syndrome and rhabdomyolysis. With regard to the development of these complications, increased vigilance is necessary in order, if necessary, to perform corrective surgery as soon as possible.

For the prevention of neurological and trophic disorders (bedsores, trophic ulcers) use special techniques and equipment (in particular, special anti-bedsore mattresses and beds that allow for full-fledged kinetic therapy).

Prevention of major complications

To prevent the development of deep venous thrombosis, heparin drugs are prescribed. Their use is especially important after orthopedic operations on the lower extremities, pelvis, as well as during prolonged immobilization. It should be noted that the administration of low doses of low molecular weight heparins is associated with fewer hemorrhagic complications than treatment with unfractionated drugs.

Proton pump inhibitors are most effective for the prevention of stress ulcers of the gastrointestinal tract.

Prevention of nosocomial infection

Regular monitoring of patients' condition is necessary for timely detection and correction of possible late complications (pancreatitis, non-calculous cholecystitis, MODS), which may require repeated laparotomies, ultrasound, and CT.

Drug treatment of polytrauma

Resuscitation stage

If tracheal intubation is performed before catheterization of the central vein, then adrenaline, lidocaine and atropine can be administered endotracheally, increasing the dose by 2-2.5 times compared to that required for intravenous administration.

To replenish the bcc, it is most advisable to use saline solutions. The use of glucose solutions without glycemic monitoring is undesirable due to the adverse effects of hyperglycemia on the central nervous system.

During resuscitation, adrenaline is administered starting with a standard dose - 1 mg every 3-5 minutes; if it is ineffective, then the dose is increased.

Sodium bicarbonate is administered for hyperkalemia, metabolic acidosis, and prolonged circulatory arrest. However, in the latter case, the use of the drug is possible only with tracheal intubation.

Dobutamine is indicated for patients with low CO and/or low mixed venous blood saturation, but adequate changes in blood pressure in response to infusion load. The drug can cause a decrease in blood pressure and tachyarrhythmias. In patients with signs of deterioration of organ blood flow, administration of dobutamine may improve perfusion parameters by increasing CO. However, routine use of the drug to maintain central hemodynamic parameters at a supranormal level [cardiac index more than 4.5 l/(minhm 2)] is not accompanied by a significant improvement in clinical outcomes.

Dopamine (dopamine) and norepinephrine effectively increase blood pressure. Before using them, it is necessary to ensure adequate replenishment of the blood volume. Dopamine increases CO, but its use in some cases is limited due to the development of tachycardia. Norepinephrine is used as an effective vasopressor drug.

Phenylephrine (Mezaton) is an alternative drug for increasing blood pressure, especially in patients prone to tachyarrhythmias.

The use of adrenaline is justified in patients with refractory hypotension. However, side effects are often noted when using it (for example, it can reduce mesenteric blood flow and provoke the development of persistent hyperglycemia).

To maintain an adequate value of mean blood pressure and CO, simultaneous separate administration of vasopressor (norepinephrine, phenylephrine) and inotropic drugs (dobutamine) is possible.

Non-drug treatment of polytrauma

Indications for emergency tracheal intubation:

• Obstruction of the respiratory tract, including with moderate and severe damage to the soft tissues of the face, bones of the facial skull, and burns of the respiratory tract.
• Hypoventilation.
• Severe hypoxemia due to O2 inhalation.
• Depression of consciousness (Glasgow coma scale less than 8 points).
• Heart failure.
• Severe hemorrhagic shock.

• The main method is orotracheal intubation with a direct laryngoscope.
  • If the patient has preserved muscle tone (the lower jaw cannot be retracted), then pharmacological drugs are used to achieve the following goals:
    • neuromuscular blockade,
    • sedation (if necessary),
    • maintaining a safe level of hemodynamics,
    • prevention of intracranial hypertension,
    • prevention of vomiting.

Increasing the safety and effectiveness of the procedure depends on:

• from the doctor's experience,
• pulse oximetry monitoring,
• maintaining the cervical spine in a neutral (horizontal) position,
• pressure on the area of ​​the thyroid cartilage (Selick maneuver),
• CO2 level monitoring.

The laryngeal mask is an alternative to conicotomy if there is insufficient experience in performing it.

Surgical treatment of polytrauma

The main problem with polytrauma is the choice of the optimal timing and volume of surgical interventions.

In patients requiring surgical control of bleeding, the interval between the time of injury and surgery should be as short as possible. Victims in a state of hemorrhagic shock with an established source of bleeding (despite successful initial resuscitation measures) are operated on immediately to definitively stop it surgically. Victims in a state of hemorrhagic shock with an unknown source of bleeding are immediately examined additionally (including ultrasound, CT and laboratory methods).

Operations performed for polytrauma are divided into:

• urgent first-line - urgent, aimed at eliminating a direct threat to life,
• urgent second stage - designed to eliminate the threat of life-threatening complications,
• urgent third-line - provide prevention of complications at all stages of traumatic disease and increase the likelihood of a good functional outcome.

In the longer term, reconstructive operations and interventions for developed complications are performed.

When treating victims in extremely serious condition, it is recommended to adhere to “damage control” tactics. The main postulate of this approach is to perform surgical interventions in a minimal volume (short time and least traumatic) and only to eliminate a momentary threat to the patient’s life (for example, stopping bleeding). In such situations, the operation can be suspended for resuscitation measures, and after correction of gross disturbances of homeostasis, it can be resumed. The most common indications for the use of “damage control” tactics:

• the need to speed up the completion of surgery in victims with massive blood loss, coagulopathy and hypothermia,
• sources of bleeding that cannot be eliminated immediately (for example, multiple ruptures of the liver, pancreas with bleeding into the abdominal cavity),
• inability to suture the surgical wound in the traditional way.

Indications for emergency operations are ongoing external or internal bleeding, external respiration disorders of a mechanical nature, damage to vital internal organs, and those conditions requiring anti-shock measures. After their completion, complex intensive therapy is continued until the main vital parameters are relatively stabilized.

The period of relatively stable condition of the victim after recovery from shock is used to perform urgent second-line surgical interventions. The operations are aimed at eliminating the syndrome of mutual aggravation (its development directly depends on the timing of full-fledged surgical treatment). Particularly important (if not performed during the first stage of operations) is the early elimination of disturbances in the main blood flow in the extremities, stabilization of damage to the musculoskeletal system, elimination of the threat of complications in the event of damage internal organs.

Fractures of the pelvic bones with disruption of the integrity of the pelvic ring must be immobilized. For hemostasis, angiographic embolization and surgical arrest, including packing, are used.

Physical inactivity is one of the important pathogenetic mechanisms of mutual burden syndrome. To eliminate it as quickly as possible, surgical immobilization of multiple fractures of the limb bones with lightweight extrafocal fixation rod devices is used. If the condition of the victim allows (there are no complications, for example, hemorrhagic shock), then the use of early (in the first 48 hours) surgical reposition and fixation of bone injuries leads to a significant reduction in the number of complications and reduces the risk of death.

Prognosis of polytrauma

Among the more than 50 classifications proposed to quantify the severity of traumatic injuries and prognosis, only a few have gained widespread acceptance. The main requirements for scoring systems are high predictive value and ease of use:

• TRISS (Trauma Injury Severity Score), ISS (Injury Severity Score), RTS (Revised Trauma Score) are specially designed to assess the severity of injury and prognosis for life.
• APACHE II (Acute Physiology And Chronic Health Evaluation - a scale for assessing acute and chronic functional changes), SAPS (SimpliFied Acute Physiology Score - a simplified scale for assessing acute functional changes) are used to objectively assess the severity of the condition and predict the outcome of the disease for most patients in the ICU (APACHE II not used to assess the condition of burn victims).
• SOFA (Sequential Organ Failure Assessmen) and MODS (Multiple Organ Dysfunction Score) allow dynamic assessment of the severity of organ dysfunction, assessment and prediction of treatment results.
• GCS (Glasgow Coma Score) is used to assess the severity of impaired consciousness and prognosis of the disease in patients with brain damage.

Currently, the international standard for assessing the condition of patients with polytrauma is the TRISS system, which takes into account the patient’s age and the mechanism of injury (it consists of the ISS and RTS scales).

Often in the medical history of a person who has fallen from a considerable height or been in a car accident, one can observe such a term as polytrauma. What is it and why is it so important to help the patient? This is exactly what the article will discuss. We will also find out how a passerby can save the life of a car accident victim, as well as what diagnostic and treatment methods are used in this case.

Description

Two or more traumatic injuries to different organs and tissues are called polytrauma. What is it and what are the symptoms characteristic of this condition? Polytrauma is severe multisystem and multiorgan lesions in which a pathological process occurs. It is based on violations of local and general adaptation processes and homeostasis.

This condition is dangerous because it does not manifest itself fully. Only external damage can be obvious:

• traumatic shock;
• acute bleeding;
• respiratory arrest;
• loss of consciousness.

Other symptoms occur depending on the type of polytrauma.

Degrees

1. There is no shock. Lungs damaged. The functions of the organs are completely restored.
2. Shock of 1 or 2 degrees is observed. Moderate organ damage. Rehabilitation of the function of internal organs requires a long period of time.
3. Shock 2 or 3 degrees. The damage is severe. There is a partial or complete loss of functions of the affected organs.
4. Shock stage 3 or 4. The damage is very severe, life-threatening, not only in the acute period, but also during treatment.

Consequences

Various multiple and combined injuries in terms of life hazard can vary widely, so it is necessary to classify them into the following categories:

• life-threatening;
• non-life-threatening;
• fatal polytrauma.

What is it and how does each type differ?

Non-life-threatening damage does not cause disruption to the body’s vital functions and does not pose a threat to life.

Life-threatening injury affects important organs and systems that can be cured with timely and qualified assistance.

Fatal damage is the destruction of internal organs that cannot be restored, even by surgery.

First aid

A person who is far from medicine will not be able to provide full medical care to a victim who has suffered as a result of a car accident, an industrial accident, etc. However, first aid for polytrauma must be provided. Immediately before the medical team arrives, a passer-by or a person you know should carry out the following simple manipulations with the victim that will alleviate his condition:

• Stop the bleeding using a tourniquet or any other available means.
• Free the victim from clothes (if necessary).
• Raise the victim's torso slightly.

No other manipulations should be carried out. After all, it will be impossible for a person far from medicine to understand which type of polytrauma was received. This can only be determined by a doctor, and then only after a thorough examination of the patient.

Carrying out vital activities

After the team of doctors arrives, the patient should already be provided with support for such a systemic lesion as polytrauma. medical staff in this case is as follows:

• Restoring the patency of the upper respiratory tract. Specialists remove mucus and vomit from the mouth, insert a special tube or put on a laryngeal mask for clean and smooth breathing.
• Getting rid of hypoxia. Doctors resort to artificial ventilation.
• Complete cessation of external bleeding.

These manipulations should take no more than 4 minutes to complete.

Transferring the patient

Treatment of polytrauma should be carried out within the walls of the hospital. Therefore, the victim must be taken to a medical facility. And for this it is important to correctly place the patient on a stretcher, a special mattress or a shield (depending on where and how the spine was damaged).

There are often times when polytrauma was sustained as a result of a traffic accident. In this case, the victim after the accident is in a coma or is pinned under the body of the car. In this case, even before removing the victim from the car, it is necessary to ensure normal patency of the upper respiratory tract. This can be done with the help of a special one capable of fixing the cervical spine.

Diagnostic plan

When a patient is admitted to the intensive care unit, the following measures are taken with him:

1. Urgent inspection. The specialist checks whether the person is stable or not, decompensated or dying. The doctor also examines breathing and blood pressure at the same time.
2. A team of specialists carries out measures that can support the patient’s life: providing access to veins, airway patency, drainage of the pleural cavity, life-saving operations.
3. Connecting the patient to an oxygen apparatus that normalizes breathing, ventilation monitoring.
4. Carrying out emergency diagnostics:

• Examination of the chest, head, abdomen, spine, limbs.
• Using a bladder catheter.
• Diagnostics of peripheral pulsation.

5. Laboratory indicators:

• Blood clotting.
• Hemogram.
• Blood group, compatibility test.
• Toxicological screening.

6. Sonography.
7. X-ray.
8. Computed tomography.

with polytrauma in the hospital

After the victim is brought to the hospital, specialists should immediately begin to deal with him. After the tests have been performed, the patient is prepared for surgery to stop severe bleeding (for example, from the spleen, vascular damage, etc.).

Along with surgical intervention, care for polytrauma is accompanied by intensive treatment of shock. The patient is injected with special drugs.

Possible operations for polytraumas:

• Craniotomy for brain damage.
• Surgical treatment of wounds that bleed heavily.
• Limb amputation.
• Treatment of open fractures, joints, blood vessels, nerves.

After surgical intervention, the patient is further carried out, the goal of which is to normalize the functioning of the cardiovascular and respiratory systems. At this stage, the patient undergoes studies such as:

• tomogram of the skull;
• X-ray of the pelvis, chest, abdomen, limbs.

Psychological rehabilitation

People who have suffered trauma need to undergo recovery to fully adapt to life in society. And not only on a physical, but also on a psychological level. Such restoration is simply necessary for people who have reduced functional abilities, social relationships, basic self-care skills, etc. Psychological assistance for polytrauma should come from both specialists and the victim’s relatives. During the rehabilitation period, relatives should help the patient, always be there, but under no circumstances try to do everything for him. It happens that after polytrauma a patient loses basic self-care skills. The task of relatives is to help the victim recover faster and adapt to life again.

Psychological and social rehabilitation should include items such as:

• Teaching the victim self-care.
• Educational program for the patient's family.
• Organization of the patient’s everyday life (adaptation of the room in which the person lives to his needs).
• Life skills training.
• Providing continuous social interaction.
• Constant observation and work with a psychologist.

Rehabilitation specialists

The following doctors should provide psychological and physical assistance for polytrauma:

• Rehabilitologist.
• Psychologist.
• Physiotherapy specialist.
• Defectologist.
• Oculist.
• Psychotherapist.
• Neuropathologist.
• Orthopedist.

Principles of the treatment process for patients

1. Efficiency. Comprehensive diagnostics should be carried out within 1 hour after the incident.
2. Safety. No manipulations performed on the patient should threaten his life.
3. Simultaneity. All therapeutic and diagnostic measures must be carried out synchronously.

Specifics of polytrauma

It is difficult for doctors to deal with people who have been seriously injured as a result of an accident. The features of polytrauma, and hence the difficulties, are:

• Acute lack of time.
• Limitation of the possibility of normal transportation of the victim, even within the hospital.
• Limitation of the range of diagnostic and therapeutic methods due to the fact that the patient is always in a supine position and cannot be turned.
• Prompt search for injuries to the abdomen, skull, chest, peritoneum, rapid diagnosis and elimination of problems.

conclusions

In this article, you have become acquainted with such an important and relevant topic as first aid for a diagnosis of polytrauma. What it is and to what extent such damage is distributed has also been clarified. We realized that the efficiency, clarity and competence of the actions of medical personnel allows a person not only to survive after an incident, but also to fully recover.

– 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 mutual burden syndrome and the development of a traumatic disease, accompanied by disturbances of homeostasis, general and local adaptation processes. Such injuries usually require intensive care, emergency operations and resuscitation measures. The diagnosis is made based on clinical data, results of radiography, CT, MRI, ultrasound and other studies. The list of treatment procedures is determined by the type of injury.

ICD-10

T00-T07

General information

Polytrauma is a general concept that means that the patient simultaneously has several traumatic injuries. In this case, it is possible to damage either one system (for example, skeletal bones) or several systems (for example, bones and internal organs). The presence of multisystem and multiorgan lesions negatively affects the patient’s condition, requires intensive therapeutic measures, and increases the likelihood of developing traumatic shock and death.

Classification

The distinctive features of polytrauma are:

• Mutual burden syndrome and traumatic illness.
• 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 1st degree of severity– there are minor injuries, there is no shock, the outcome is complete restoration of the function of organs and systems.
• Polytrauma 2nd degree of severity– there are injuries of moderate severity, shock of I-II degree is detected. Long-term rehabilitation is necessary to normalize the functioning of organs and systems.
• Polytrauma 3rd degree of severity– there are severe injuries, shock of II-III degree is detected. As a result, partial or complete loss of the functions of some organs and systems is possible.
• Polytrauma 4 degrees of severity– there are extremely severe injuries, shock of III-IV degree is detected. The functioning 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 area: fracture of the tibia and fracture of the femur; multiple rib fractures, etc.
• Combined injury– two or more traumatic injuries of different anatomical areas: TBI and chest injury; shoulder fracture and kidney damage; collarbone 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 damage combined with a spinal fracture; poisoning with toxic substances in combination with a pelvic fracture, etc.

Combined and multiple injuries may be part of a combined injury. Combined injury can occur with the simultaneous direct action of damaging factors or develop as a result of secondary damage (for example, when fires appear after the collapse of an industrial structure, which causes a limb fracture).

Taking into account the danger of the consequences of polytrauma for the patient’s life, the following are distinguished:

• Non-life-threatening polytrauma– damage that does not cause gross impairment of life and does not pose an immediate danger to life.
• Life-threatening polytrauma– damage to vital organs that can be corrected through timely surgery 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 the localization, polytrauma is distinguished with damage to the head, neck, chest, spine, pelvis, abdomen, lower and upper extremities.

Diagnostics

Diagnosis and treatment for polytrauma often represent a single process and are carried out simultaneously, which is due to the severity of the condition of the victims and the high likelihood of developing traumatic shock. First of all, the general condition of the patient is assessed, injuries that may pose a danger to life are excluded or identified. The scope of diagnostic measures for polytrauma depends on the condition of the victim, for example, when 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 their blood type is determined. In case of shock, bladder catheterization is carried out, the amount of urine excreted is monitored, and 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, anti-shock therapy comes to the fore. For bone fractures, complete immobilization is carried out. In case of crushing, avulsions and open fractures with massive bleeding, a temporary stop of bleeding is performed using a tourniquet or hemostatic clamp. For hemothorax and pneumothorax, drainage of the chest cavity is performed. If the abdominal organs are damaged, an emergency laparotomy is performed. In case of compression of the spinal cord and brain, as well as in intracranial hematomas, appropriate operations are performed.

If there are injuries to internal organs and fractures, which are a source of massive bleeding, surgical interventions are performed simultaneously by two teams (surgeons and traumatologists, traumatologists and neurosurgeons, etc.). If there is no massive bleeding from fractures, open reduction and osteosynthesis of fractures, if necessary, are performed after the patient is brought 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 ward, infusions of blood and blood substitutes are continued, drugs are prescribed to restore the functions of organs and systems, and various therapeutic measures are carried out (dressings, changing drains, etc.). After the condition of patients with polytrauma improves, they are transferred to a traumatology department (less often, a neurosurgical or surgical department), treatment procedures are continued, and rehabilitation measures are carried out.

Prognosis and prevention

According to WHO, polytrauma ranks third in the list of causes of death in men 18-40 years old, second only to cancer 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 associated complications, primarily thromboembolism, pneumonia and infectious processes. In 25-45% of cases, the outcome of polytrauma is disability. Prevention consists of carrying out measures aimed at preventing road, industrial and household injuries.