Polytrauma: what is it, causes, symptoms, diagnosis and treatment. Combined radiation injuries

Department head

P. I. BESPALCHUK

POLYTRAUMA

(lecture for students of all faculties)

Lecture duration - 2 hours.

Lecture plan:

1. Introduction.

2. Definition of the concept of "polytrauma".

3. Characteristics of different types of polytrauma.

4. Provision of medical care at the prehospital stage.

5. Provision of qualified and specialized medical care in a hospital.

6. The urgency of the provision of operational benefits.

7. Surgical tactics.

8. Complications.

9. Conclusion.

Introduction

According to B.S. Preobrazhensky (1983), 9-15% of victims with injuries have multiple and combined injuries, including 70-75% of young and middle-aged laps. Among those who received polytrauma, 2/3 had multiple injuries of internal organs, more often the brain, combined with fractures. In catastrophes, the frequency of polytrauma is much higher.

Until recently, cases of multiple and combined injuries were considered as the sum of single injuries. However, if we conditionally analyze each injury separately, as one of the components of polytrauma, then although many of them may be considered not life-threatening, their total impact often leads to a sharp violation of the function of vital systems and the death of the victim. At present, polytrauma is recognized as a new type of pathology, with its inherent specific changes in all systems of the damaged organism and the development of a long-term traumatic disease.

The course of polytrauma is particularly severe: if with isolated injuries, severe shock is observed in 1% of the victims, then with multiple ones: fractures - in 21%, and with combined injuries - in 57% of the victims. The clinical picture in polytrauma does not always correspond to the localization of the dominant injury.

2. Definition of the concept of "polytrauma"

Polytrauma is a complex pathological process caused by damage to several anatomical regions or segments of the limbs, with a pronounced manifestation of the syndrome of mutual burdening, manifested by a profound violation of all types of metabolism, changes in the central nervous system, cardiovascular system, respiratory and pituitary-adrenal systems. In 30% of cases, multiple damages are caused by traffic accidents.

Characteristics of different types of polytrauma.

Distinguish:

a) dominant damage - the most severe,

b) competitive - equivalent or slightly inferior to the dominant injury,

i) concomitant - the damage is less severe.

In the early period of polytrauma, fat embolism, pulmonary edema, thromboembolic complications, and sleep are not uncommon.

With polytrauma, there is a high early mortality: more than 60% of the victims die in the first 6 hours and more than 70% - on the 1st day. Mortality with isolated injuries - up to 2%, with multiple skeletal trauma - 17%, with combinations of injuries - 45-55%,

Reasons for the increase in polytrauma:

1) a sharp increase in the number of cars,

2) increase in the speed of their movement,

3) an increase in the number of survivors with polytrauma (formerly it was the object of pathologists, now - traumatologists),

4) loss of fear of heights (catatrauma) and high-rise construction.

Polytrauma can be divided into 5 groups:

1. Multiple fractures of small and small bones that do not lead to a serious condition of the victims - 27.5% (hand, foot, collarbone, shoulder blade). The prognosis is favorable.

2. Multiple fractures of long tubular bones - 38.7% (11% have traumatic shock, lethality - 2.3%).

3 „ Multiple fractures + dominant focus of internal organs - 23.7% (traumatic shock - 28%, mortality - 18%).

4. Polytrauma, when the leading focus requires (share - 10%) emergency surgical intervention for health reasons, for example, fractures or avulsions of limbs, ruptures of internal organs (of which 86% come in states of shock, mortality - 38.1%).

5. Injury incompatible with life - 1.2%:

a) a severe brain contusion or a severe skull wound with extensive destruction of the brain substance and a pronounced impairment
vital functions;

b) chest injuries - closed injury or wounds of the chest with multiple, bilateral fractures of the ribs, severe deformity of the chest, with bilateral open or intense
pneumothorax or large hemothorax;

c) abdominal injuries - open or closed abdominal trauma with damage to internal organs, often with extensive destruction of the abdominal wall and eventration of damaged organs;

d) damage to the pelvis and pelvic organs: extensive closed injury
or injury to the thesis with severe damage to its organs;

e) prolonged (more than 7-8 hours) compression of both lower limbs throughout; multiple open fractures of long tubular bones, accompanied by severe traumatic
shock injuries of the cervical spine with the syndrome
complete violation of the conduction of the spinal cord in victims,
in a state of severe shock.

The provision of medical care for polytrauma is distinguished by a certain originality. The circumstances of the occurrence of multiple and combined injuries are so dramatic that the first desire of others, including medical workers, is the immediate transportation of the victim to the nearest medical facility. With polytrauma, first aid measures on the spot are carried out much less frequently than with single injuries. The introduction of analgesics to the victims, the production of novocaine blockades of fracture sites, the imposition of aseptic dressings on wounds and transport immobilization are carried out only in individual cases. According to many medical workers, the evacuation of victims on a standard stretcher without immobilization of damaged segments does not pose a great danger, and the risk of development and aggravation of shock is justified by gaining time to deliver them to a medical institution.

Such an unjustified tactic proves that medical personnel lack the necessary readiness to provide medical care to victims with multiple injuries, to perform the usual medical care techniques for ordinary injuries (bandage, transport immobilization).

According to a number of authors, 1/3 of the victims of disasters, who were recognized as dying, died slowly and could be saved with the timely application of resuscitation measures. Among them, 40% would not have died if the emergency response teams had performed resuscitation within 6 hours of the injury. Approximately 50% of deaths from injuries in catastrophes occurred within minutes as a result of injuries and airway obstructions.

Difficulties in providing medical care at the prehospital stage are associated with the following factors:

1. difficulties in assessing the severity of each injury;

2. the risk of additional damage during treatment
diagnostic measures and transportation;

3. the frequent need to provide emergency care at the same time
not many seriously injured.

The time from injury to the start of treatment determines the chances of both the survival of the patient and the quality of his health after treatment. Therefore, the optimal organization of the rescue service and the competence of doctors are decisive.

Prehospital treatment of patients with polytrauma should be based on a universal scheme suitable for all occasions and including 4 stages:

1. Resuscitation and general assessment of the situation;

2. Replacement or support of the functions of vital organs and systems;

3. Stabilization of vital functions and achievement of transportability;

4. Transportation.

The medical examination begins with a check of vital signs, i.e. breathing and circulation. If these functions are violated, resuscitation measures are carried out corresponding to the existing violations.

The priority in terms of urgency is the restoration of pulmonary ventilation and blood circulation, then it is necessary to provide reliable vascular access and conduct drug therapy, and only then transport the patient. After the immediate threat to life is eliminated and death does not threaten the patient in the next few seconds, his full detailed examination begins.

First of all, the neurological status is determined: the depth of the coma according to the Glasgow-Pittsburgh scale: eye opening, motor reactions, speech reaction, pupillary reaction to light, cranial nerve reaction, convulsions, spontaneous breathing, i.e. 7 signs on a 5-point scale = 35 - no coma; 7 - brain death.

After assessing the neurological status, a complete examination from the head to the extremities is carried out, which takes no more than 3 minutes.

The goal of this step is to ensure successful treatment of circulatory shock.

With polytrauma, this requires the following:

1. treatment of hypovolemia by replenishing the BCC;

3. effective analgesia.

To replenish the BCC, catheterization of several (usually two or four) vessels, including at least one central vein, and good fixation of the catheters are necessary.

Adequate ventilation and mechanical ventilation are possible with tracheal intubation.

Stage 3 provides for the implementation of the following measures:

stop bleeding;

Adequate replacement of BCC;

IVL (according to indications);

Carrying out drug therapy, analgesia and sedatives;

performing minor life-saving surgery.

Let's consider them in more detail:

I. stop bleeding produced with the help of measures that are determined by its nature and localization. It can be:

digital pressure on an artery

Applying a tourniquet to an injured limb

tamponade of the nose, etc. 0

2. Replenishment of the BCC carried out with solutions of both crystalloids and colloids (mainly dextrans). The volume of infusion depends on the severity of the injury; urine output is maintained at 30 ml/hour, constant monitoring is carried out, including oximetry.

Replenishment of OCC begins with the introduction of Ringer's solution at a dose of 20-30 ml/kg of body weight, if there is no effect, 500.0 ml of a colloid solution is added. In extremely severe cases, Ringer's solution and 1 liter of colloid solution are administered.

3. IVL or struggle - with ODN in other ways - a very important problem, since almost all cases of polytrauma are accompanied by severe hypoxemia. The sooner IVL is started, the better the prognosis.

4. Medical therapy provides, first of all, the introduction of analgesics and sedatives.

5. Minor surgical interventions, for example, reposition for fractures of limbs with displacement of fragments or drainage of the pleural cavity according to Belau with pneumothorax, are carried out according to indications and depending on the qualifications of the doctor.

After achieving stabilization of vital signs and transportability, the patient is taken to a clinic with adequate medical supplies and equipment. Medical transport should be adapted for cardiopulmonary resuscitation and mechanical ventilation.

After delivery to the hospital, all diagnostic measures for polytrauma should be simple to atraumatic. For example, laparocentesis, pleural puncture, radiography without changing the position of the victim.

The sequence of diagnostic techniques is carried out by a team of specialists as follows:

assessment of frequency and depth breathing , examination of the respiratory tract;
with severe respiratory disorders - intubation, less often - tracheostomy;

definition of frequency pulse, blood pressure and shock index (ratio of heart rate to maximum blood pressure - I and more)
indicates the presence of shock and significant blood loss; together with the implementation of effective anti-shock measures, replacement transfusion therapy is immediately started;

Inspection, percussion, auscultation chest ; overview
radiography, diagnostic puncture of the pleural cavity (when receiving blood and air - thoracocentesis, drainage, suction of air and blood, straightening the lung;

Inspection, palpation, percussion abdominal organs ; plain radiography, laparocentesis and "groping catheter", microlaparotomy with
peritoneal lovage (if there is blood in the abdominal cavity, intestinal contents, bile, urine, laparotomy is indicated);

palpation and quality assessment pulse in the peripheral arteries limbs in order to exclude damage to the main vessels; if damage is suspected - one-stage puncture
angiography, upon confirmation - an operation to restore the patency of the vessel (temporary shunting of the damaged vessel, vascular autoplasty, vascular suture);

feature evaluation central nervous system , the state of the brain and its membranes in order to establish indications for trepanation
skull (characteristic of the pulse in the periphery, the condition of the pupils, the fundus, the nipples of the optic nerves, spinal puncture and measurement of CSF pressure) if there is a suspicion of increased intracranial pressure syndrome;

digital examination of the rectum, bladder catheterization ("empty" bladder - one of the signs of its rupture, blood and difficulty in passing the catheter - damage to the urethra - indications for surgery), descending pyelourography, urethro- and cystography in case of suspected damage to these organs;

· determination of blood loss according to the specific gravity of blood by the Van Slyke-Barashkov method, hemoglobin, hematocrit or the table of B. G. Apanasenko.

Naturally, this diagnostic complex is complemented by the necessary laboratory tests that contribute to the fulfillment of the tasks of emergency diagnostics.

CLASSIFICATION OF MULTIPLE AND COMBINED INJURIES ACCORDING TO THE URGENTITY OF PROVIDING OPERATIONAL AID

Multiple and combined injuries

Requiring emergency assistance	Not requiring emergency assistance
Leading Damage:	Leading Damage:
main vessels;	open and closed bone fractures;
compression and increasing swelling of the brain;	thorax and abdomen without signs of damage to internal organs
open and intense hemopneumothorax;	wounds and bruises of soft tissues of all localizations
parenchymal and hollow abdominal organs	dislocations
bladder, urethra and rectum;
spinal cord with signs of its compression and abundant liquorrhea in case of damage to the cervical spine;
avulsions and crushing of limbs.
Emergency interventions are shown, including in patients in a state of shock, along with resuscitation and anti-shock measures.	Resuscitation and anti-shock measures are shown; post-shock surgery.

In the treatment of patients with multiple and combined injuries, the tactics of maximum sparing of the patient's strength with a restriction on the number of surgical interventions should be chosen. The additional injury that the operational allowance incurs is only justified if it is intended to save the life of the victim. It is advisable to postpone all other interventions and perform them in a planned manner, after days and further weeks (except for novocaine blockades of fractures, therapeutic immobilization, surgical treatment of wounds, elimination of dislocations).

From the foregoing, it follows that with multiple and associated injuries, surgical treatment takes on the character of successive stages, the deadline for which is determined by the condition of the victim:

I stage- emergency assistance for vital indications;

P stage- urgent interventions to recover from shock;

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

1. Terminology, classification, clinical manifestations

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

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

   Monotrauma (isolated injury) is called 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, wounding the small intestine in several places or breaking one bone in several places (double fractures).

   Damage to the musculoskeletal system, accompanied by trauma to the main vessels and nerve trunks, should be considered as complicated trauma.

   Term "polytrauma" is a collective concept that includes the following types of damage: 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 to internal organs in two or more cavities (for example, damage to the lung and spleen) or damage to internal organs and a segment of the musculoskeletal system (for example, traumatic brain injury and fracture of limb bones).

   Combined called injuries resulting from exposure to various traumatic factors: mechanical, thermal, radiation (for example, a hip fracture and a burn of any area of ​​the body or a craniocerebral injury and radiation exposure). Perhaps a greater number of options for the simultaneous impact of damaging factors.

   Multiple, combined and combined injuries are characterized by a particular severity of clinical manifestations, accompanied by a significant disorder of the vital functions of the body, the difficulty of diagnosis, the complexity of treatment, a high percentage of disability, and high mortality. Such injuries are much more often accompanied by traumatic shock, blood loss, threatening circulatory and respiratory disorders. Mortality rates testify to the severity of polytrauma. With isolated fractures, it is 2%, with multiple fractures - 16%, with combined injuries - 50% or more.

   In the group of victims with combined mechanical injuries, trauma to the musculoskeletal system is most often combined with craniocerebral trauma. Such combinations are observed in almost half of the victims. In 20% of cases with a combined injury, damage to the musculoskeletal system is accompanied by a chest injury, in 10% - damage to the abdominal organs. Often there is a simultaneous injury of 3 or even 4 areas of the body (skull, chest, abdomen and musculoskeletal system).

   There is a certain pattern in the dynamics of general changes occurring in the body of a person who has been injured. These changes are called "traumatic disease". Strictly speaking, traumatic disease develops with any, even minor damage. However, its clinical manifestations become noticeable and significant only in severe shockogenic (more often - multiple, combined or combined) lesions. Based on these positions, at present, a traumatic disease is understood as a pathological process caused by a severe injury and manifesting itself in the form of characteristic syndromes and complications.

   During a traumatic disease, 4 periods are distinguished, each of which has its own clinical symptoms.

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

   Second period determined by postresuscitation, postshock, postoperative changes. The length of this period is 4 -6 days. The clinical picture is quite variegated, largely depends on the nature of the dominant lesion and is most often represented by such syndromes as acute cardiovascular failure, adult respiratory distress syndrome (ARDS), disseminated intravascular coagulation syndrome, endotoxicosis. It is these syndromes and the complications associated with them that directly threaten the life of the victim in this period. In the second period of traumatic disease, 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, so treatment should be carried out comprehensively.

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

   The fourth period (recovery) occurs with a favorable course of traumatic disease. It is characterized by suppression of the immune background, delayed reparative regeneration, asthenia, dystrophy, and sometimes persistent dysfunctions of the internal organs and the musculoskeletal system. During this period, the victims require restorative treatment, medical, professional and social rehabilitation.

   For the correct solution of medical and tactical problems in the provision of medical care to victims with polytrauma, it is extremely important to identify leading (dominant) lesion, determining the severity of the condition at the moment and representing an immediate threat to life. Dominant damage during the course of a traumatic disease may vary depending on the effectiveness of the therapeutic measures taken. At the same time, the severity of the general condition of the victims, disturbances in their consciousness (up to the absence of contact), the difficulty of identifying the dominant injury, and an acute shortage of time in case of mass admissions often lead to untimely diagnosis of injuries. About 3 patients with concomitant trauma are diagnosed late, and 20% are erroneously diagnosed. Often one has to deal with blurring or even perversion of clinical symptoms (for example, with injuries of the skull and abdomen, spine and abdomen, as well as other combinations).

   An important feature of polytrauma is the development of the syndrome of mutual burdening. The essence of this syndrome lies in the fact that damage to one localization exacerbates the severity of another. At the same time, the overall severity of the course of a traumatic disease, depending on the amount of damage, does not increase in arithmetic, but rather in a 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, as a rule, for a short period of time

   neither passes into the decompensated stage, the total blood loss reaches 2-4 liters. The cases of development of DIC, 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 - the appearance of a petechial rash and small hemorrhages on the chest, abdomen, inner surfaces of the upper extremities, sclera, mucous membranes of the eyes and mouth - is noted only on the 2-3rd day, as well as the appearance of fat in urine. At the same time, the absence of fat in the urine cannot yet indicate the absence of a fat embolism. A feature of fat embolism is that it develops and grows gradually. Fat droplets enter the lungs (pulmonary form), but can pass through the pulmonary capillary network into the systemic circulation, causing damage to the brain (brain form). In some cases, a mixed form of fat embolism is noted, which is a combination of cerebral and pulmonary forms. In the pulmonary form of fat embolism, the picture of acute respiratory failure dominates, but brain disorders are not excluded. The brain form is characterized by the development after an obligatory light period of headache, convulsive syndrome, coma.

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

   A big problem in providing medical care to victims with polytrauma is often the incompatibility of therapy. So, if in case of injury of the musculoskeletal system, the introduction of narcotic analgesics is indicated to relieve pain, then when these injuries are combined with severe traumatic brain injury, the use of drugs becomes contraindicated. Trauma to the chest makes it impossible to apply an abduction splint in case of a fracture of the shoulder, and extensive burns make it impossible to adequately immobilize this segment with a plaster cast in case of a concomitant fracture. The incompatibility of therapy leads to the fact that sometimes the treatment of one, two or all injuries is forced to be incomplete. The solution to this problem requires a clear definition of the dominant lesion, the development of a treatment plan, taking into account the periods of the course of a traumatic disease, possible early and late complications. Priority, of course, should be given to saving 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 case of catastrophes, is occupied by combined lesions, when the injury is combined with exposure to radioactive (RW) or toxic (S) substances. Here the syndrome of mutual burdening is most clearly manifested. In addition, the affected become dangerous to others. In case of mass receipts, they are separated from the general flow of victims for sanitation. In this regard, the provision of medical care to them in some cases is delayed.

   1. Combined radiation injuries

      The accumulated experience in assessing the impact of ionizing radiation on humans suggests 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 exposed person, a dose of 0.25 to 0.5 Gy can cause minor temporary deviations in the composition of peripheral blood, a dose of 0.5 to 1 Gy causes symptoms of autonomic disorders and a mild decrease in the number of platelets and leukocytes.

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

      There are 4 periods in the clinical course of 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, dyspeptic syndrome, coordination disorders develop, meningeal signs appear. At the same

      time, these symptoms can be masked by manifestations of mechanical or thermal lesions.

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

      AT peak period of acute radiation sickness the victims lose their hair, develop hemorrhagic syndrome. In the peripheral blood - agranulocytosis, leukopenia, thrombocytopenia. This period is characterized by a violation of trophism and reparative regeneration of tissues. Necrosis appears in wounds, grafts are rejected, wounds suppurate. There is a great danger of generalization of wound infection, the formation of bedsores.

      Recovery period begins with the normalization of hematopoiesis. The rehabilitation period usually fluctuates from a month to a year. Asthenization and neurological syndromes persist for a long time.

      There are 4 degrees of severity of combined radiation injuries (in combination with mechanical injuries or burns).

      First degree (mild) develops with a combination of mild mechanical injury or burns of I-II degree up to 10% of the body surface with radiation 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 the provision of specialized assistance, complete recovery occurs only in 50% of the victims.

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

      Fourth degree (extremely severe) develops with a combination of mechanical trauma or deep burns over 10%) of the body surface with exposure to a dose of more than 4.5 Gy. The primary reaction develops in a few minutes, accompanied by indomitable vomiting. The prognosis is unfavorable.

      Thus, in view of the manifestation of the syndrome of mutual aggravation, the radiation dose required for the development of the same degree of severity of the lesion is 1–2 Gy lower with combined injuries than with isolated radiation injury.

      Infection of wounds with radioactive substances (getting radioactive dust or other particles on the wound surface) contributes to the development of necrotic changes in tissues at a depth of up to 8 mm. Reparative regeneration is disturbed, 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 a gauze bandage, where they accumulate, continuing to affect the body.

   2. Combined chemical lesions

      In case of accidents at chemically hazardous facilities, damage by potent toxic substances, suffocating, general toxic, neurotropic action, metabolic poisons is possible. Combinations of toxic effects are possible.

      Substances with asphyxiant properties (chlorine, sulfur chloride, phosgene, etc.) mainly affect the respiratory system. Pulmonary edema prevails in the clinical picture.

      Substances of general toxic action differ in the nature of the effect on the body. They can block the function of hemoglobin (carbon monoxide), have a hemolytic effect

      eat (arsenic hydrogen), have a toxic effect on tissues (hydrocyanic acid, dinitrophenol).

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

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

      Metabolic poisons include substances that cause disruption of synthetic and other metabolic reactions (bromomethane, dioxin).

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

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

      When persistent poisonous substances of a blistering effect (mustard gas, lewisite) get into a wound or onto intact skin, deep necrotic changes develop, a wound infection joins, and regeneration is significantly inhibited. The resorptive effect of these substances aggravates the course of shock and sepsis.

      Organophosphorus poisonous substances (sarin, soman) do not directly affect the local processes occurring in the wound. However, after 30-40 minutes, their resorptive effect is manifested (pupils narrow, bronchospasm increases, fibrillations of individual muscle groups are noted, up to a convulsive syndrome). Death in severe lesions may occur from paralysis of the respiratory center.

3. Features of rendering assistance to victims with polytrauma

   The severity of injuries, the frequency of development of life-threatening conditions in polytrauma, a large number of deaths make the speed and adequacy of medical care especially important. Its basis is the prevention and control of shock, acute respiratory failure, coma, since most often it is necessary to provide assistance to victims in the first and second periods of traumatic illness. At the same time, the multivariance of polytrauma, specific damaging factors, the difficulty of diagnosis, and the incompatibility of therapy caused some features.

   1. First medical and pre-medical aid

      The whole possible complex of anti-shock measures is being carried out. In the focus of radioactive or chemical damage, the victim is put on a gas mask, respirator, or, in extreme cases, a gauze mask to prevent droplets of OM or radioactive particles from entering the respiratory tract. Open areas of the body that have been exposed to agents are treated with an individual anti-chemical package. In case of multiple bone trauma, due to the risk of fat embolism, special care should be taken to perform transport immobilization.

   2. First aid

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

   3. Qualified medical care

      Affected by RS and persistent agents are sent for complete sanitization (washing the whole body with soap and water). The bulk are victims with shock of varying severity, which will serve as the basis for sorting.

      An important feature is the attitude to the primary surgical treatment of wounds. For those affected by RV and OV, this operation belongs to the activities not of the third, but of the second stage, since delay will lead to an aggravation of the negative impact of these substances. Primary surgical treatment aims not only to prevent the development of wound infection, but also to remove RV and OM from the wound surface.

      In case of combined radiation injury of moderate and severe degree, 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 onset of the peak period of radiation sickness. Extended excision of soft tissues during surgical treatment helps to reduce the risk of infectious complications with this tactic.

   4. Specialized medical care

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

Questions for self-control

Which of the following injuries are combined?

a) closed fracture of the right femur, open fracture of the left femur and lower leg; b) II degree burn of the forearm, fracture of the radius in a typical place;

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




Specify the severity of the combined radiation injury of the victim with a closed fracture of the humerus and exposure to a dose of 2.5 Gy.

a) I degree (mild);

b) II degree (moderate); c) III degree (severe);

d) IV degree (extremely severe).




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

b) fracture of the pelvis of the Malgenya type, rupture of the spleen;

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




Which of the following is included in the scope of first aid for combined radiation injuries?

a) prophylactic blood transfusion; b) partial sanitization;

c) complete sanitization;

d) primary surgical treatment of the wound;

e) the introduction of antidotes, antibiotics and tetanus toxoid.




In what period of radiation sickness is it desirable to perform operations on the victims (if there are indications)?

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

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

Is it possible to apply primary sutures to a gunshot wound of the thigh with a combined radiation injury of moderate severity?

a) is permissible only in the absence of a gunshot fracture; b) it is permissible only with a penetrating wound;

c) is acceptable in all cases;

d) not allowed under any circumstances.




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

a) first aid;

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




Where should a patient with a complicated injury of the lumbar spine and a radiation injury at a dose of 4 Gy be directed when qualified medical care is provided?

a) in antishock; b) to the operating room;

c) to the department of special processing; 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 - in; 5 - in; 6 - in; 7 -b, c, d, e; 8-b; 9-6; 10-a, b, d. Chapter 5. 1-b, d, e; 2 -b, d; 3 -b, d, e; 4-a, c.

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

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

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

Chapter 10. 1-a; 2 -d; 3-a, b, c; 4 - in; 5-a, d; 6 -b, c, e; 7-a, b, c; 8-6, c. Chapter 11. 1 -b, d, e; 2 -b, d; 3 -d; 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 - in; 6-a, c; 7-a, b, d. Chapter 14. 1-e; 2 -b, c, d; 3 -b; 4-a, c; 5-in.

Today, injuries are one of the causes of death for people under the age of forty. Every year, more than five million people receive injuries of varying severity as a result of traffic accidents, industrial accidents and falls from a height. The increase in the number of multiple injuries, which are characterized by high mortality, leads to the need to improve the provision of emergency medical care. In traumatology polytrauma (what is it, discussed below) used to be considered a problem when there was extensive fighting, but these days the amount of such damage has increased greatly.

Etiology

Usually, polytraumas are considered in 15% of all cases of injury, in extreme situations - up to 40%. At the same time, considering what is polytrauma in an accident, it should be noted that this is the most common type of injury, accounting for half of all cases. Representatives of the stronger sex suffer more often than women. Typically, men between the ages of eighteen and forty are injured. Very often there is a fatal outcome (in half of all cases).

Such injuries are in third place in terms of mortality after oncology and cardiovascular diseases. Death occurs as a result of the development of traumatic shock or large blood loss, as well as the appearance of concomitant complications in the form of brain disorders, pneumonia, infections and thromboembolism. In 30% of cases, multiple injuries lead to disability.

Epidemiology

Polytrauma (ICD 10)- these are multiple injuries that are in several areas of the body (T00-T07) and include bilateral injuries of the limbs with similar levels of lesions, as well as those that capture two or more areas of the body. 5% of all injuries occur in children who have suffered as a result of accidents and traffic accidents. In this case, damage to the limbs and craniocerebral injuries are most often observed. In adults, the limbs, chest, brain, abdomen, spine, and bladder are most commonly affected in road accidents. The life of a person depends on how serious the injuries of the brain, abdominal cavity and chest will be. When falling from a height, it is mainly the brain that suffers, with suicide, the limbs. Also in these cases, there is a rupture of intrathoracic vessels, which develops hemorrhagic shock.

Peculiarities

We know that according to the ICD, polytrauma has the number T00-T07. Its distinctive features are:

1. Traumatic disease and the syndrome of mutual aggravation.
2. Uncharacteristic symptoms that make diagnosis difficult.
3. Frequent development of traumatic shock and profuse blood loss.
4. Multiple complications, frequent deaths.

Polytrauma: classification

In traumatology, it is customary to distinguish between several degrees of severity of injury:

1. The first degree is characterized by minor damage without the presence of shock. Over time, all functions of the organs and systems of the body are fully restored.
2. The second degree is caused by damage of an average level of severity, the appearance of shock. In order for the human body to recover, rehabilitation is necessary for a long period of time.
3. The third degree is characterized by severe injuries, the appearance of shock. The functions of organs and systems are partially restored, and some of them are completely lost, which leads to disability.
4. The fourth degree is caused by extremely severe injuries, the presence of severe shock, disruption of the functioning of systems and organs. In this case, the probability of death is increased both at the beginning of treatment and in the subsequent time.

Kinds

There are several types of polytrauma, which depend on the anatomical features:

1. A multiple injury is characterized by two or more lesions in one of the anatomical regions. It can be, for example, various fractures.
2. Combined polytrauma caused by two or more lesions in different areas. This may be, for example, a head and chest injury, a fracture of the lower leg and damage to the spleen, and so on.
3. Combined trauma is characterized by damage due to the simultaneous influence of various traumatic factors. These include, for example, burns with broken limbs, poisoning with toxins with hip fractures, and so on.

Also, combined and multiple polytraumas can be part of a combined injury.

Danger of Consequences

Polytrauma (what is it), we already know) may be different depending on the danger of the consequences. In medicine, it is customary to distinguish the following types:

1. A non-life-threatening injury is damage that does not lead to severe disruption of the organs and systems of the body, and also does not pose a danger to the life of the person who was injured.
2. A life-threatening injury is characterized by damage to organs, the work of which can be restored by surgery or intensive care.
3. Fatal injury is caused by damage to important organs, the work of which cannot be restored even with timely assistance.

Diagnostics

Usually polytrauma (what is it, described above) involves simultaneous diagnosis and treatment. These measures depend on the severity of the person's condition and the high risk of developing shock. First, doctors assess the condition of the victim, consider life-threatening injuries. First of all, a vital diagnosis is carried out to determine the traumatic shock, then they proceed to the study of minor injuries, if the condition of the person allows. Be sure to conduct a blood and urine test, identify the blood type, measure blood pressure and pulse. They also do x-rays of the limbs, chest, pelvis, skull, and so on. In some cases, echoencephalography and laparoscopy are performed. Diagnosis is carried out with the participation of a traumatologist, resuscitator, surgeon and neurosurgeon.

Treatment

The victim is sent to Anti-shock therapy is carried out here. With bleeding, they are stopped, all fractures are immobilized. If hemothorax is observed, doctors drain the chest cavity, often using laparotomy. Depending on the damage, appropriate surgical interventions are performed. If extensive bleeding is observed, the operation is carried out by two teams of doctors. Treatment of fractures is usually carried out after the traumatic shock has been eliminated. In this case, infusion therapy is used. Then the victims are prescribed medication to restore the functioning of organs and systems, and various manipulations are performed, for example, dressings. After the patient's condition returns to normal, he is transferred to a traumatology or surgical department and continues treatment, rehabilitation is carried out.

Complications

With polytrauma, various complications often occur, which can be both life-threatening and non-dangerous. The second complications include technical (deformation of fixators, etc.) and functional (impaired gait, posture, etc.). Dangerous include non-infectious (disorders of the gastrointestinal tract, pneumothorax, tracheal stricture, etc.), infectious (pneumonia, dysbacteriosis, bedsores, cystitis, and so on), as well as postoperative complications (necrosis, abscesses, limb amputations, etc.).

Thus, it is very important for doctors to provide emergency assistance to the victims in time. The further formation of complications and the safety of human life depend on this. An important point is the treatment of traumatic shock, which can cause death. It is also important to make a correct diagnosis in order to carry out therapeutic measures.

- simultaneous (or almost simultaneous) occurrence of two or more traumatic injuries, each of which requires specialized treatment. Polytrauma is characterized by the presence of a syndrome of mutual burdening and the development of a traumatic disease, accompanied by violations of homeostasis, general and local adaptation processes. With such injuries, as a rule, intensive care, emergency operations and resuscitation are required. The diagnosis is made on the basis of clinical data, the results of radiography, CT, MRI, ultrasound and other studies, the list of which depends on the type of injury.

Polytrauma is a generalizing concept, meaning that the patient has several traumatic injuries at the same time. In this case, it is possible both to damage one system (for example, the bones of the skeleton), and several systems (for example, bones and internal organs). The presence of polysystemic and multiple organ lesions negatively affects the patient's condition, requires intensive therapeutic measures, increases the likelihood of traumatic shock and death.

The classics of traumatology considered polytrauma primarily as a wartime problem. Nowadays, in connection with the mechanization of industry and the widespread use of road transport, the number of polytraumas received in peaceful conditions as a result of road accidents and industrial accidents has sharply increased. Treatment of polytrauma is usually carried out by traumatologists with the participation of resuscitators. In addition, depending on the type and localization of injuries, thoracic surgeons, abdominal surgeons, urologists, neurosurgeons and other specialists may be involved in the diagnosis and treatment of polytrauma.

Etiology and epidemiology of polytrauma

The most common are polytraumas as a result of road accidents (more than 50%), the second place is occupied by accidents at work (more than 20%), the third - falls from a height (more than 10%). Men are affected about twice as often as women. According to WHO, polytrauma ranks third in the list of causes of death in men aged 18-40, second only to oncological and cardiovascular diseases. The number of deaths in polytrauma reaches 40%. In the early period, death usually occurs due to shock and massive acute blood loss, in the late period - due to severe brain disorders and related complications, primarily thromboembolism, pneumonia and infectious processes. In 25-45% of cases, the outcome of polytrauma is disability.

In 1-5% of the total number of cases of polytrauma, children suffer, the main reason is participation in road accidents (young children - as passengers, in older age groups, cases of collisions with children-pedestrians and cyclists predominate). In children with polytrauma, injuries of the lower extremities and TBI are more often observed, and injuries of the abdominal cavity, chest and pelvic bones are detected less frequently than in adults.

In adults with polytrauma as a result of road accidents, injuries of the extremities, TBI, chest injuries, abdominal injuries, pelvic fractures, bladder ruptures and injuries of the cervical spine predominate. The greatest influence on the prognosis for life is exerted by injuries of the abdominal cavity, chest and craniocerebral injuries. In case of accidental falls from a great height, a severe craniocerebral injury is more often detected, in case of suicide attempts - multiple injuries of the lower extremities, since patients almost always jump with their feet forward. Falls from a height are often accompanied by rupture of intrathoracic vessels, which leads to the rapid development of hemorrhagic shock.

Features and classification of polytrauma

The distinguishing features of polytrauma are:

• Mutual burden syndrome and traumatic disease.
• Atypical symptoms that make diagnosis difficult.
• High probability of developing traumatic shock and massive blood loss.
• Instability of compensation mechanisms, a large number of complications and deaths.

There are 4 degrees of severity of polytrauma:

• Polytrauma 1 degree of severity- there are slight injuries, there is no shock, the outcome is a complete restoration of the function of organs and systems.
• Polytrauma 2 severity- there are injuries of moderate severity, shock of I-II degree is detected. Long-term rehabilitation is necessary to normalize the activity of organs and systems.
• Polytrauma grade 3- there are severe injuries, shock II-III degree is detected. As a result, partial or complete loss of functions of some organs and systems is possible.
• Polytrauma 4 severity- there are extremely severe injuries, shock III-IV degree is detected. The activity of organs and systems is grossly impaired, there is a high probability of death both in the acute period and in the process of further treatment.

Taking into account the anatomical features, the following types of polytrauma are distinguished:

• Multiple trauma- two or more traumatic injuries in the same anatomical region: fracture of the lower leg and fracture of the femur; multiple rib fractures, etc.
• Associated injury- two or more traumatic injuries of different anatomical regions: TBI and damage to the chest; shoulder fracture and kidney injury; clavicle fracture and blunt abdominal trauma, etc.
• Combined injury- traumatic injuries as a result of simultaneous exposure to various traumatic factors (thermal, mechanical, radiation, chemical, etc.): burn in combination with a hip fracture; radiation injury in combination with a fracture of the spine; poisoning with toxic substances in combination with a pelvic fracture, etc.

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

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

• Non-life-threatening polytrauma- injuries that do not cause gross violations of life and do not pose an immediate danger to life.
• Life-threatening polytrauma- damage to vital organs that can be corrected by timely surgical intervention and / or adequate intensive care.
• Fatal polytrauma- damage to vital organs, the activity of which cannot be restored even by providing timely specialized assistance.

Taking into account localization, polytrauma is distinguished with damage to the head, neck, chest, spine, pelvis, abdomen, lower and upper extremities.

Diagnosis and treatment of polytrauma

Diagnosis and treatment of polytrauma often represent a single process and are carried out simultaneously, due to the severity of the condition of the victims and the high probability of developing traumatic shock. First of all, the general condition of the patient is assessed, injuries that may be life-threatening are excluded or detected. The volume of diagnostic measures for polytrauma depends on the condition of the victim, for example, when a traumatic shock is detected, vital studies are carried out, and the diagnosis of minor injuries is carried out, if possible, in the second place and only if this does not aggravate the patient's condition.

All patients with polytrauma undergo urgent blood and urine tests, and also determine the blood type. In case of shock, bladder catheterization is performed, the amount of urine excreted is monitored, blood pressure and pulse are regularly measured. During the examination, a 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 can be prescribed. Patients with polytrauma are examined by a traumatologist, neurosurgeon, surgeon and resuscitator.

At the initial stage of treatment of polytrauma, antishock therapy comes to the fore. In case of bone fractures, complete immobilization is carried out. In case of crush injuries, detachments and open fractures with massive bleeding, a temporary stop of bleeding is performed using a tourniquet or hemostatic clamp. With hemothorax and pneumothorax, drainage of the chest cavity is performed. If the abdominal organs are damaged, an emergency laparotomy is performed. With compression of the spinal cord and brain, as well as with intracranial hematomas, appropriate operations are performed.

If there is damage to internal organs and fractures that are a source of massive bleeding, surgical interventions are carried out simultaneously by two teams (surgeons and traumatologists, traumatologists and neurosurgeons, etc.). If there is no massive bleeding from fractures, open reposition and osteosynthesis of fractures, if necessary, are performed after the patient is taken out of shock. All activities are carried out against the background of infusion therapy.

Then, patients with polytrauma are hospitalized in the intensive care unit or intensive care unit, infusions of blood and blood substitutes are continued, drugs are prescribed to restore the functions of organs and systems, and various therapeutic measures are taken (dressings, change of drains, etc.). After the condition of patients with polytrauma improves, they are transferred to the traumatological (less often, neurosurgical or surgical department), treatment procedures are continued and rehabilitation measures are carried out.

Mechanical trauma of systems and organs is divided into isolated ( monotrauma) and polytrauma. An isolated injury, a monotrauma, is an injury to one organ or, in relation to the musculoskeletal system, an injury within one anatomical and functional segment (bone, joint).

For internal organs, this is damage to one organ within one cavity; in case of damage to the main vessels and nerve trunks - their injury in one anatomical region. In each of the considered groups, lesions can be mono- or polyfocal. For example, polyfocal damage to the small intestine - a wound in several places, for the musculoskeletal system - damage to one bone in several places (double, triple fractures).

Injuries to the musculoskeletal system, accompanied by trauma to the main vessels and nerve trunks, should be considered as a complicated injury. In this case, the diagnosis should be formulated as follows: "Closed fractures of the diaphysis of the right femur, complicated by damage to the femoral artery."

The term polytrauma is a collective concept that includes the following types of mechanical damage: multiple, combined, combined.

To multiple mechanical injuries include damage to two or more internal organs in one cavity, damage to two or more anatomical and functional formations (segments) of the musculoskeletal system, such as the liver and intestines, fractures of the hip and forearm.

Combined damage simultaneous damage to internal organs in two or more cavities or damage to internal organs and the musculoskeletal system are considered. For example, damage to the spleen and bladder, damage to the organs of the chest cavity and fractures of the bones of the limbs, traumatic brain injury and damage to the pelvic bones.

Combined damage called an injury received from various traumatic factors: mechanical, thermal, radiation. For example, a hip fracture and a burn to any area of ​​the body is called a combined injury. A greater number of variants of combinations of the impact of damaging factors is also possible.

Multiple, combined and combined trauma is characterized by a particular severity of clinical manifestations, accompanied by a significant disorder of the vital functions of the body, the difficulty of diagnosis, the complexity of treatment, a high percentage of disability, significant mortality. This kind of damage is often accompanied by traumatic shock, large blood loss, circulatory and respiratory disorders, sometimes a terminal condition. This category of victims in trauma hospitals is 15-20%. Mortality rates testify to the severity of multiple and concomitant trauma. With isolated fractures, it is 2%, with multiple trauma, it rises to 16%, and with a combined one, it reaches 50% or more (with a combination of damage to the musculoskeletal system with trauma to the chest and abdomen).

Polytrauma is characterized by the following features.

1. There is a so-called mutual burden syndrome. The essence of this syndrome lies in the fact that, for example, blood loss, since it is more or less significant in polytrauma, contributes to the development of shock, and in a more severe form, and this worsens the course of the injury and the prognosis.

2. Quite often the combination of injuries creates a position of therapy incompatibility. For example, in case of injury of the musculoskeletal system, narcotic analgesics are indicated in the provision of assistance and treatment, however, when a limb injury is combined with a traumatic brain injury, their administration becomes contraindicated or, for example, a combination of chest injury and a fracture of the shoulder does not make it possible to apply an abduction splint or thoracobrachial splint. plaster bandage.

3. The development of such severe complications that lead the patient to a critical condition, such as massive blood loss, shock, toxemia, acute renal failure, fat embolism, and thromboembolism, is becoming more frequent.

4. There is a blurring of the manifestations of clinical symptoms in cranio-abdominal trauma, damage to the spine and abdomen, and other concomitant trauma. This leads to diagnostic errors and viewing damage to the internal organs of the abdomen.

The most common cause of polytrauma is road and railway accidents (collisions, collisions with a pedestrian), falling from a height. In most cases, young people between the ages of 20 and 50 are affected. The provision of care and treatment with multiple and combined trauma is associated with difficulties associated with the severity of the general condition of patients and the complexity of diagnosing the leading injury.

Traumatology and orthopedics. Yumashev G.S., 1983