Polytrauma. Periods of traumatic illness
RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2013
Multiple injuries unspecified (T07)
Traumatology and orthopedics, Surgery
general information
Short description
Approved by the minutes of the meeting
Expert commission on health development issues of the Ministry of Health of the Republic of Kazakhstan
No. 23 from 12/12/2013
Polytrauma- it's complicated pathological process caused by damage to several anatomical areas or limb segments with pronounced manifestation mutual burden syndrome, which includes the simultaneous onset and development of several pathological conditions and is characterized by profound disorders of all types of metabolism, changes in the central nervous system (CNS), cardiovascular, respiratory and pituitary-adrenal systems.
Multiple trauma- damage to two or more organs of one cavity, two or more anatomical formations musculoskeletal system, damage great vessels and nerves in various anatomical segments.
Combined injury- damage internal organs various cavities, joint injuries of internal organs and musculoskeletal system, joint injury of the musculoskeletal system and great vessels and nerves.
Currently, polytrauma must be considered in inextricable connection with the clinical and pathophysiological features of the course traumatic illness.
The concept of traumatic illness involves the study and assessment of the entire complex of phenomena that arise from severe mechanical damage to the body in inextricable connection with reactions of an adaptive nature in their complex relationships at all stages of the disease - from the moment of injury to its outcome: recovery (complete or incomplete) or death .
Situations in which polytrauma is always expected(according to 3. Muller, 2005):
In case of death of passengers or driver vehicle;
If the victim is thrown out of the car;
If the deformation of the vehicle exceeds 50 cm;
When compressed;
In case of an accident on high speed;
When hitting a pedestrian or cyclist;
If dropped from a height of more than 3 m;
In case of explosion;
When blocked with bulk materials.
I. INTRODUCTORY PART
Protocol name- Polytrauma
Protocol code:
ICD-10 codes:
T 02 - Fractures involving several areas of the body
T02.1 - Fractures in the area chest, lower back and pelvis
T 02.2 - Fractures involving several areas of one upper limb
T 02.3 - Fractures involving several areas of one lower limb
T 02.4 - Fractures involving several areas of both upper limbs
T 02.5 - Fractures involving several areas of both lower limbs
T 02.6 - Fractures involving several areas of the upper and lower extremities
T02.7 - Fractures involving the chest, bottom part back, pelvis and limb(s)
T02.8 - Other combinations of fractures involving multiple areas of the body
T02.9 - Multiple fractures, unspecified
T 03 - Dislocations, sprains and strains of the capsular-ligamentous apparatus of the joints, involving several areas of the body
T 03.2 - Dislocations, sprains and overstrain of the capsular-ligamentous apparatus of the joints of several areas of the upper limb(s)
T 03.3 - Dislocations, sprains and overstrain of the capsular-ligamentous apparatus of the joints of several areas of the lower limb(s)
T 03.4 - Dislocations, sprains and overstrain of the capsular-ligamentous apparatus of the joints of several areas of the upper and lower limb(s)
T 03.8 - Other combinations of dislocations, sprains of the capsular-ligamentous apparatus of joints and overstrains of several areas of the body
T 03.9 - Multiple dislocations, sprains and strains of the capsular-ligamentous apparatus of joints, unspecified
T06 - Other injuries involving multiple areas of the body, not elsewhere classified
T06.4 - Muscle and tendon injuries involving multiple areas of the body
T06.5 - Chest injuries combined with organ injuries abdominal cavity and pelvis
T06.8 - Other specified injuries involving multiple areas of the body
T07 - Multiple injuries, unspecified
T06 - other injuries involving several areas of the body, not classified elsewhere.
T06.3 - Injuries blood vessels involving several areas of the body
T06.4 - Muscle and tendon injuries involving multiple areas of the body
T06.5 - injuries of the chest organs in combination with injuries of the abdominal cavity and pelvis
T06.8 - other specified injuries involving several areas of the body
T07 - Multiple injuries, unspecified
S31 - Open wound of the abdomen, lower back and pelvis
S36 - Abdominal trauma
S37 - Trauma pelvic organs
S37.7 - Injury to multiple pelvic organs
S37.0 - Kidney injury
S36.8 - Injury to other intra-abdominal organs
S36.3 - Stomach trauma
S36.2 - Trauma to the pancreas
S37.6 - Uterine injury
S36.7 - Injury to multiple intra-abdominal organs
S36.5 - Trauma colon
S36.4 - Trauma small intestine
S36.1 - Injury to the liver or gallbladder
S36.0 - Injury to the spleen
S31.8 - Open wound of another and unspecified part of the abdomen
S 39.6 - Combined injury of intra-abdominal and pelvic organs
S 39.9 - Injury to the abdomen, lower back and pelvis, unspecified
S26 - Heart injury
S26.0 - Heart injury with hemorrhage into the heart sac
S26.8 - Other cardiac injuries S26.9 - Cardiac injury, unspecified
S27 - Trauma to Others and unspecified organs chest
S22.2 - Fracture of the sternum
S22.3 - Fracture of ribs
S22.4 - Multiple rib fractures
S22.5 - Sunken chest
S22.8 - Fracture of other parts of the bone sternum
S30.7 - Multiple superficial injuries of the abdomen, lower back and pelvis
S31.7 - Multiple open wounds abdomen, lower back and pelvis
Abbreviations used in the protocol:
ANF - external fixation device
AFO - anatomical and physiological field
URT - upper respiratory tract
IVL - artificial ventilation lungs
IT - intensive therapy
AOS - acid-base state
CT - computed tomography
LM - laryngeal mask
MIA - local infiltration anesthesia
SMP - combined mechanical damage
ESR - erythrocyte sedimentation rate
MODS - multiple organ failure syndrome
TDP - difficult airway
Ultrasound - ultrasonography
CVP - central venous pressure
CNAB - central neuraxial blockades
CNS - central nervous system
RR - respiratory rate
HR - heart rate
SHI - shock index
ZBIOS - closed blocking intramedullary osteosynthesis
CO2 - carbon dioxide
SpO2 - saturation
Date of protocol development: year 2013
Protocol users: traumatologists, anesthesiologists-resuscitators, emergency doctors, surgeons, neurosurgeons, maxillofacial surgeons, otorhinolaryngologists, urologists, angiosurgeons.
Classification
CLINICAL CLASSIFICATION
Pathogenetic classification of the course of traumatic disease:
1. Period acute reaction for trauma: corresponds to the period of traumatic shock and the early post-shock period; it should be considered as the period of the induction phase of MODS.
2. Period early manifestations traumatic disease: the initial phase of MODS - characterized by impaired or unstable functions individual organs and systems.
3. Period late manifestations traumatic illness: advanced phase of MODS - if the patient survived the first period of the course of the traumatic illness, then the course of this particular period determines the prognosis and outcome of the disease.
4. Rehabilitation period: when favorable outcome, characterized by complete or incomplete recovery.
The above concept calls for considering traumatic shock, blood loss, post-traumatic toxicosis, thrombohemorrhagic disorders, post-traumatic fat embolism, MODS, sepsis not as complications of polytrauma, but as pathogenetic related links of a single process - traumatic disease.
Scheme 1. Classification of injuries
Scheme 2. Classification of combined mechanical damage.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
Basic Research
1. History
2. Physical examination
3. General analysis blood: level of erythrocytes, leukocytes, hemoglobin, hematocrit, ESR, erythrocyte aggregation
4. Biochemical analysis blood: total protein, its fractions, urea, creatinine, bilirubin and its fractions, blood enzymatic activity, blood lipid composition, electrolytes
5. Hemostasiogram
6. Electrocardiography
7. Ultrasound of the abdominal organs, retroperitoneum, pelvis
8. Ultrasound pleural cavities
9. Echoencephaloscopy
10. X-ray of the skull
11. Chest X-ray
12. Radiography cervical region spine
13. X-ray thoracic spine
14. X-ray of the pelvis
15. Radiography of various segments of the musculoskeletal system, depending on the location of the damage
16. CT scan skull, thoracic, abdominal segments of the spine, pelvis - according to indications depending on the location of the damage, the mechanism of injury
Transporting the patient to the department radiology diagnostics for CT scanning is possible only after exclusion intra-abdominal bleeding and pathologies of the chest organs requiring surgical intervention.
1. CBS and blood gases
2. Serum osmolarity
3. Determination of lactate level
4. Magnetic resonance imaging
5. Angiography of pelvic vessels
6. Ultrasound of joints (in the area of damage)
7. Troponins, BNP, D-dimer, homocysteine (according to indications)
8. immunogram (according to indications)
9. cytokine profile (interleukin-6.8, TNF-α) (according to indications)
10. markers of bone metabolism (osteocalcin, deoxypyridinoline) (according to indications)
The patient’s condition should be assessed based on the results of examinations using integral prognostic scales
The TRISS scale, based on the age-adjusted RTS scale, is used to assess injury severity.
Table 3. Revised Trauma Score (RTS)
The probability of survival of the patient is determined by the formula:
Where b= b0+b1*(TS)+b2*(ISS)+b3*(A)
Ps - probability of survival;
E - Constant equal to 2.718282
A - victim’s age score:
Age under 55 years - 0 points
55 years or more - 1 point
B0 , b1 , b2 , b3 - coefficients obtained by the method regression analysis(different for closed and open trauma).
The APACHE II scale is used to assess the patient's condition.
Table 4. Acute and chronic condition health II - The Acute Physiology and Chronic Health Evaluation II (APACHE II)
A. Physiological health status 
C. Correction chronic diseases
For each case:
Liver cirrhosis confirmed by biopsy
Heart failure: NYHA functional class IV
Severe chronic obstructive pulmonary disease (hypercapnia, need for oxygen therapy at home)
Chronic dialysis
Immunodeficiency
2 points are added for elective surgery and neurosurgery, 5 points for emergency surgery
APACHE II calculation
A. Acute Rating Scale physiological state health
B. Age correction
C. Correction of chronic diseases
Table 5. Total APACHE II Scores
Anamnesis: primary information that can be provided by the victim’s relatives, eyewitnesses of the incident, or the team members who delivered the victim from the scene of injury is useful.
Timely and brief information information about the mechanism of injury, the time from the moment of injury, the amount of estimated blood loss at the site of injury can significantly facilitate the work of doctors and improve its results.
Physical examination:
It is carried out in parallel or after solving priority problems in providing emergency care.
The first step is to assess impairment of consciousness. For this purpose, it is more convenient to use the Glasgow Come Scale (GCS) (see Table 1)
Table 1. Glasgow Coma Scale
Gradations of disorders of consciousness
It is necessary to carefully examine the eyeballs, assess the width of the pupils and identify the presence of oculomotor disorders as a sign of an intracranial space-occupying process. Should be inspected scalp heads, oropharynx and everything skin in order to detect penetrating damage and foreign bodies(including prostheses eyeballs and false jaws).
Special attention should be given to the cervical spine.
It is advisable to assume that all patients with polytrauma “conditionally” have damage to the cervical spine. This concept requires the mandatory use of coaxial stabilization using a rigid removable collar, starting from the prehospital stage of care. medical care. Suspicion of damage to the cervical spine is removed only after X-ray control, even despite high level consciousness of the victim and the absence of pronounced focal symptoms!
When examining the chest, you should pay attention to the visible deformation and asymmetrical participation of the chest in the act of breathing. It is necessary to carefully examine the condition of the collarbones, ribs and carefully after turning the victim on his side - thoracic and lumbar regions spine. Deformation of the chest indicates injury to the chest with disruption of its frame function and the development of hemo- or pneumothorax. The presence of swelling of the jugular veins in the background low indicators systemic blood pressure in combination with chest deformation or the presence of a penetrating wound in the “dangerous” zone allows one to suspect a cardiac injury with the development of its tamponade.
“Dangerous” zones of cardiac injury:
Above - II rib;
Below - the edge of the costal arch;
On the right is the midclavicular line;
Left - mid-axillary line
A spinal deformity detected in a victim and pain on palpation may indicate damage to the spine. The victim's absence active movements in the lower extremities, pronounced abdominal type breathing with weak chest excursion may be a sign of spinal cord damage.
Initial examination front abdominal wall in case of polytrauma it is not informative enough. However, it is necessary to examine the skin in order to detect hemorrhages in the projection parenchymal organs. If the victim is conscious, palpation of the abdomen may reveal symptoms of peritoneal irritation. IN mandatory The perineum should be visually examined with rectal and vaginal examinations. Catheterization Bladder is carried out carefully, taking into account possible damage to the urethra. Gross hematuria is an indication for X-ray studies using contrast to exclude damage to the bladder and kidneys.
In case of absence of consciousness or significant depression of consciousness clinical methods(percussion determination of fluid level, auscultation, determination of an increase in abdominal circumference in dynamics) cannot exclude pathology of the abdominal organs. Then excluding pathology of the abdominal organs (primarily parenchymal) becomes a priority for the next diagnostic stage- “instrumental”.
Examination of the upper and lower extremities is aimed at identifying deformities and fractures tubular bones and joint damage. Particular attention should be paid to identifying possible fractures pelvic bones. Immobilization of fractures should be carried out on prehospital stage, otherwise this should be done immediately upon admission to the hospital.
Identification of fracture sites can help in a preliminary assessment of the amount of blood loss (see Table 2).
Table 2. Estimation of blood loss in injuries of the musculoskeletal system and surgical trauma
Indications for consultation with specialists:
All patients with polytrauma must be jointly examined by a traumatologist, resuscitator, surgeon, and neurosurgeon.
Consultations with other specialists - depending on the location of the damage (otorhinolaryngologist, maxillofacial surgeon, urologist) and the presence of combined trauma (combustiologist).
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Treatment
Goal of treatment: stabilization of the patient’s condition and prevention septic complications, acute syndrome lung damage, multiple organ failure.
Treatment tactics
Regimen depending on the severity of the condition - 1, 2, 3. Diet - 15; other types of diets are prescribed depending on concomitant pathology
Main directions of therapy
1. Ensuring airway patency and adequate ventilation.
2. Ensuring adequate tissue perfusion, which is achieved by correction acute blood loss, hypovolemic and metabolic disorders.
4. Treatment of organ dysfunctions.
5. Surgical treatment damage.
Maintaining airway patency
Absolute readings for endotracheal intubation (tracheal intubation and transfer to mechanical ventilation is carried out if at least one sign is present):
1. Lack of breathing
2. Lack of cardiac activity
3. Depression of consciousness on the Glasgow Coma Scale less than 8 points; violation of respiratory mechanics ( multiple fractures ribs with chest flotation).
Additional signs for endotracheal intubation(tracheal intubation and transfer to mechanical ventilation are performed if at least two signs are present):
1. Respiratory rate more than 29 or less than 10 per minute
2. Irrhythmic breathing pattern
3.PO2/FiO2 coefficient<300
4. PСO2>45 or<25 мм рт.ст. (при FiO2=0,21)
5.PO2<70 мм рт.ст. (при FiO2=0,21)
6.SpO2<90% (при FiO2=0,21)
7. Aspiration of blood and gastric contents
8. Presence of damage to the facial skeleton
9. Presence of burns to the head and neck
10. Presence of signs of damage to the cervical spine
11. Mean arterial pressure< 80 мм рт.ст.
12. Pre-existing chronic pulmonary disease
13. Depression of consciousness according to the Glasgow coma scale 9-13 points
14. Convulsive syndrome
15. The need to administer narcotic analgesics and sedatives
16. Significant associated damage
17. If there is any doubt regarding the condition of the respiratory tract
Algorithm for endotracheal intubation in patients with polytrauma:
1. Assessment of the condition of the respiratory tract with removal of foreign bodies from the oropharynx
2. Preoxygenation and assisted mask ventilation at FiO2 1.0
3. Manual coaxial stabilization
4. Removal of the front part of the cervical stabilizing collar
5. Pressure on the cricoid cartilage (Selick maneuver) during assisted mask ventilation and intubation
6. Local anesthesia (lidocaine) or general anesthesia (diazepam, ketamine, thiopental in standard induction or reduced doses). The use of muscle relaxants is not recommended for the first attempt at intubation.
8. Confirmation of the position of the endotracheal tube by auscultation and capnogram
9. Return of the front part of the stabilizing collar
Basic principles of intensive care
According to modern concepts, when carrying out intensive care of any critical condition, it is necessary to maintain a correspondence between the body's needs for oxygen and nutrients and the capabilities of their delivery: VO2 = DO2.
To create this correspondence, there are two areas of intensive care:
1. Reduced oxygen (VO2) and nutrient consumption - hypothermia induced by physical or pharmacological methods.
2. Increased delivery of oxygen and nutrients (DO).
The delivery of oxygen and nutrients depends on the following parameters:
DO2= MOC x Hb x (SaO2 - SvO,),
Where MOC is cardiac output,
Hb - hemoglobin level,
SaOn, SvO2—oxygen saturation of arterial and venous blood.
Increasing DO can be achieved:
Increasing MOC (infusion therapy with colloids and crystalloids, vasopressor and inotropic support);
Improving the rheological properties of blood (pentoxifylline, rheopolyglucin, hemodilution);
Correction of anemia.
Life Support First Aid Program(Guidelines from the World Association of Emergency and Disaster Medicine (WAEDM)).
1. Freeing the victim without causing him additional injuries.
2. Release and maintenance of patency of the upper respiratory tract (triple maneuver of P. Safar)
3. Carrying out expiratory methods of mechanical ventilation.
4. Stop external bleeding using a tourniquet or pressure bandage.
5. Giving a safe position to the unconscious victim (physiological position on the side).
6. Giving a safe position to the victim with signs of shock (with the head down).
Medical assistance to the victim at the scene of the incident
1. Identify vital disturbances and eliminate them immediately.
2. Examine the victim, establish the causes of life-threatening disorders and make a pre-hospital diagnosis.
3. Decide whether the patient needs to be hospitalized or not.
4. Determine the place of hospitalization of the patient based on the nature of the injuries*.
5. Determine the priority of hospitalization of victims (in case of mass trauma).
6. Ensure the maximum possible non-traumatic and speedy transportation to the hospital.
Dividing the victims into 4 groups based on an assessment of their general condition, the nature of the injuries and the complications that arose, taking into account the prognosis:
1 sorting group (black marking): victims with extremely severe injuries incompatible with life, as well as those in a terminal state (agonizing), who need only symptomatic therapy. The prognosis is unfavorable for life.
2nd sorting group (red marking)- severe injuries that pose a threat to life, i.e. victims with rapidly growing life-threatening disorders of the basic vital functions of the body (shock), the elimination of which requires urgent treatment and preventive measures. The prognosis can be favorable with timely provision of medical care.
3rd sorting group (yellow marking)- damage of moderate severity, i.e. not posing an immediate threat to life. Life-threatening complications may develop. The prognosis for life is relatively favorable.
4 sorting group (green marking)- easily affected, i.e. victims with minor injuries requiring outpatient treatment.
Primary tasks of the prehospital stage:
1. The problem of normalizing breathing.
2. Elimination of hypovolemia (crystalloids)
3. Problem of pain relief (tramadol, moradol, nabuphine, small doses of ketamine 1-2 mg/kg in combination with benzodiazepines).
4. Application of aseptic dressings and transport splints.
Protocol for resuscitation of patients with polytrauma at the prehospital stage:
1. Temporary stop of bleeding.
2. Score assessment of the severity of the patients’ condition: heart rate, blood pressure, Algover index (AI), pulse oximetry (SaO2).
3. With systolic blood pressure<80 мм рт.ст., пульсе >110 per minute, SaO2< 90%, ШИ >1.4 a complex of emergency intensive care is required.
4. Resuscitation benefits should include:
At SaO2< 94% - ингаляция кислорода через лицевую маску либо носовой катетер.
At SaO2< 90% на фоне оксигенотерапии - интубация трахеи и перевод на ИВЛ или ИВЛ.
Peripheral/central vein catheterization.
Infusion of HES drugs at a rate of 12-15 ml/kg/hour (or an adequate volume of crystalloids, excluding the introduction of a 5% glucose solution).
Anesthesia: promedol 10-20 mg, or fentanyl 2 mg/kg, droperidol 2.5 mg, diazepam 10 mg, local anesthesia at the fracture sites with a solution of 1% lidocaine.
Prednisolone 1-2 mg/kg
Transport immobilization.
5. Transportation to a medical facility, against the background of ongoing IT.
Hospital intensive care program
1. Stop bleeding
2. Pain relief
3. Assessment of the patient’s condition using integral prognostic scales adopted in the hospital!
4. Restoration of oxygen transport:
Replenishment of blood volume
Improving the rheological properties of blood
Stabilization of macro- and microdynamics
Restoration of oxygen carriers
Respiratory support
5. Nutritional support
6. Antibacterial therapy
7. Prevention of multiple organ failure
First stage activities
1. Catheterization of the main or peripheral vein
2. Oxygen inhalation or mechanical ventilation
3. Bladder catheterization
The rate of infusion therapy does not depend on the caliber of the vein into which the infusion is administered, but is directly proportional to the diameter and inversely proportional to the length of the catheter.
Damage control is a tactic for treating life-threatening and critical polytraumas, according to which, depending on the severity of the victim’s condition, assessed by objective indicators, in the early period only those methods are used that do not cause a serious deterioration in the patient’s condition.
Table 6. Classification of shock (according to Marino P., 1999).
Table 7. Principles of blood loss replacement depending on the degree of shock.
Criteria for the adequacy of the therapy:
1. Stabilization of blood pressure with a decrease in tachycardia
2. Increase in central venous pressure to 15 mm Hg.
3. Increase in diuresis rate more than 1 ml/(kg*h)
4. Increasing blood hemoglobin to 80-100 g/l
5. Increase in total protein and blood albumin
6. Increase and stabilize VO2
Surgery:
79.69 - surgical treatment of the site of an open fracture of another specified bone
79.39 - open reduction of bone fragments of another specified bone with internal fixation.
79.19 - closed reduction of bone fragments of another specified bone with internal fixation.
78.19 - use of an external fixation device on other bones.
77.60 - local excision of the affected area or bone tissue of unspecified localization
77.69 - local excision of the affected area or tissue of other bones
77.65 - local excision of the affected area or tissue of the femur.
78.15 - use of an external fixation device on the femur.
78.45 - other restorative and plastic manipulations on the femur.
78.55 - internal fixation of the femur without reduction of the fracture.
79.15 - closed reduction of bone fragments of the femur with internal fixation.
79.25 - open reduction of bone fragments of the femur without internal fixation.
79.35 - open reduction of femur fragments with internal fixation.
79.45 - closed reduction of fragments of the epiphysis of the femur
79.55 - open reduction of fragments of the epiphysis of the femur
79.85 - open reduction of hip dislocation.
79.95 - unspecified manipulation for bone injury of the hip
79.151 - Closed reduction of bone fragments of the femur with internal fixation by intramedullary osteosynthesis;
79.152 - Closed reduction of bone fragments of the femur with internal fixation with a locking extramedullary implant;
79.351 - Open reduction of bone fragments of the femur with internal fixation by intramedullary osteosynthesis;
79.65 - Surgical treatment of an open fracture of the femur.
81.51 - Total hip replacement;
81.52 - Partial hip replacement.
81.40 - reconstruction of the hip, not classified elsewhere
79.34 - open reduction of bone fragments of the phalanges of the hand with internal fixation.
79.37 - open reduction of bone fragments of the tarsal and metatarsal bones with internal fixation.
78.19 - use of an external fixation device on other bones.
45.62 - Resection of the small intestine
45.91 - Small intestinal anastomosis
45.71-79 Resection of the colon
45.94 - Colon anastomosis
46.71 - Suturing a duodenal rupture
44.61 - Suturing a gastric rupture
46.10 - Colostomy
46.20 - Ileostomy
46.99 - Other manipulations on the intestines
41.20 - Splenectomy
50.61- Closure of liver rupture
51.22 - Cholecystectomy
55.02 - Nephrostomy
55.40 - Partial nephrectomy
54.11 - Diagnostic laparotomy
54.21 - Laparoscopy
55.51 - Nephrectomy
55.81 - Suturing a kidney rupture
57.18 - Other suprapubic cystostomy
57.81 - Suturing a ruptured bladder
52.95 - Other restorative manipulations on the pancreas
31.21 - Mediastinal tracheostomy
33.43 - Thoracotomy. Suturing a lung rupture
34.02 - diagnostic thoracotomy
34.04 - Drainage of the pleural cavity
34.82 - suturing a ruptured diaphragm
33.99 - Other manipulations on the lung
34.99 - Other manipulations on the chest
Preventive measures:
The main activity is injury prevention.
Rehabilitation:
Exercise therapy. The classes include basic exercises for all muscle groups of the limbs and torso, all joints of healthy limbs and joints of damaged limbs free from immobilization.
Breathing exercises of a static and dynamic nature are performed in a ratio of 1:2.
In facilitated conditions, the patient performs active movements of the limbs, sliding along the surface of the bed, with the addition of a sliding plane or a roller cart),
To restore supportability, in particular the spring function of the limbs, classes include active movements of the toes, dorsal and plantar flexion of the feet, circular movements of the feet, axial pressure on the footrest, grasping small objects with the toes and holding them;
Isometric tension of the muscles of the back and limbs to prevent muscle atrophy and improve regional hemodynamics, the intensity of the tension is increased gradually, duration is 5-7 seconds. The number of repetitions is 8-10 per lesson;
The formation of temporary compensations during physical therapy exercises concerns, first of all, unusual motor acts, such as lifting the pelvis with the patient lying on his back, turning in bed and standing up.
The number of classes is gradually increased from 3-5 to 10-12 per day.
The question of the duration of bed rest after surgical treatment is decided in each case individually. Patients are taught to move with the help of crutches - first within the ward, then in the department. It must be remembered that the weight of the body when leaning on crutches should be on the hands, and not on the armpit. Otherwise, compression of the neurovascular formations may occur, which leads to the development of so-called crutch paresis.
Massage. An effective means of influencing the state of local blood flow and liquor dynamics, as well as the functional state of muscles, is massage. In the absence of contraindications, to improve peripheral blood circulation, massage of uninjured limbs is prescribed from the 3-4th day after surgery. The course of treatment is 7-10 procedures.
Physical methods of treatment. When indicated, physical factors are prescribed that reduce pain and reduce swelling and inflammation in the surgical area, improving sputum discharge:
Ultraviolet irradiation,
Inhalations with drugs,
Cryotherapy,
Low frequency magnetic field,
The course of treatment is 5-10 procedures.
Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
– this is the simultaneous or almost simultaneous occurrence of two or more traumatic injuries, each of which requires specialized treatment. Polytrauma is characterized by the presence of a syndrome of mutual aggravation 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.
POLYTRAUMA
Polytrauma is a complex pathological process caused by damage to several anatomical areas or segments of the limbs with a pronounced manifestation of mutual burden syndrome (MBS), which includes the simultaneous onset and development of several pathological conditions and is characterized by profound disorders of all types of metabolism, changes in the central nervous system. (CNS), cardiovascular, respiratory and pituitary-adrenal systems.
POLYTRAUMA
Mechanical injury to systems and organs is divided into two groups:
monotrauma (isolated) – injury to one organ (within one anatomical and functional segment [bone, joint], in relation to an internal organ – injury to one organ within one cavity [liver]
polytrauma
In each group, damage can be:
- mono- or polyfocal- for the musculoskeletal system - damage to one bone in several places (double, triple fractures); for internal organs – injury to one organ in several places.
complicated injuries- damage to the musculoskeletal system, accompanied by trauma to the great vessels and nerve trunks
The term “polytrauma” is a collective concept that includes the following types of mechanical damage: multiple, combined and combined.
POLYTRAUMA
Multiple trauma - in relation to mechanical injuries - damage to two or more anatomical and functional formations (segments) of the musculoskeletal system, for example, a fracture of the hip and forearm.
Combined injury- simultaneous damage to internal organs and the musculoskeletal system, for example, fractures of limb bones, traumatic brain injury and damage to the pelvic bones.
Combined injury - injury resulting 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.
POLYTRAUMA
Characterized by:
special severity of clinical manifestations, accompanied by significant disruption of the vital functions of the body,
difficulty of diagnosis,
complexity of treatment,
high percentage of disability,
high mortality (with isolated fractures - 2%, with multiple trauma it increases to 16%, and with combined trauma it reaches 50% or more (when damage to the musculoskeletal system is combined with trauma to the chest and abdomen).
POLYTRAUMA
The clinical course of polytrauma has the following features:
Mutual burden syndrome (MBS) is observed. For example, blood loss, since in polytrauma it is more or less significant, contributes to the development of shock, and in a more severe form, which worsens the course of the injury and the prognosis.
Against the background of SVO, the development of severe complications leading to a critical condition increases - massive blood loss, shock, toxemia, acute renal failure, fat embolism, thromboembolism.
There is a blurring of the manifestations of clinical symptoms in cases of cranioabdominal trauma, damage to the spine and abdomen, and other combined trauma. This leads to diagnostic errors and the viewing of damage to the internal organs of the abdomen.
Often, a combination of injuries creates a situation of incompatibility of therapy. For example, in case of injury to the musculoskeletal system, narcotic analgesics are indicated for assistance and treatment, but when a limb injury is combined with a traumatic brain injury, their administration is contraindicated. Or, for example, the combination of a chest injury and a shoulder fracture does not allow the application of an abduction splint or a thoracobrachial plaster cast.
POLYTRAUMA
The most common causes of polytrauma are road and railway accidents (collisions, pedestrian collisions), and falls from a height.
Treatment begun at the pre-hospital stage is continued in an inpatient setting. Thus, for those delivered by passing transport, good outcomes are only 47%, while with adequate assistance they can reach 80% or more.
When a patient with polytrauma is admitted to the emergency room, it is necessary to:
thorough and quick examination with the provision of qualified assistance;
checking dressings, immobilization, correctness of applied tourniquets and correcting identified deficiencies, catheterization of veins and bladder.
In case of severe combined injury, treatment can be divided into three periods: 1) resuscitation; 2) therapeutic; 3) rehabilitation.
POLYTRAUMA resuscitation period
Combating shock: complex therapy to stabilize hemodynamics, adequate pain relief, complete immobilization, oxygen therapy
The diagnosis (while still in the emergency room) is clarified by consultations with the necessary specialists and various research methods: ultrasound, X-ray, SCT, MRI, if possible without shifting the patient.
During this period, important points are the fight against multiple organ failure, the elimination of external respiration disorders and tissue hypoxia, the fight against hypercoagulation and the tendency to aggregation of red blood cells, the normalization of the protein-forming function of the liver, the control and fight against renal failure, the fight against secondary immunodeficiency.
Based on the diagnosis, surgical intervention is performed to correct all impaired body functions:
Drainage of the pleural cavity,
Laparocentesis,
Laparoscopy.
POLYTRAUMA treatment period
The main problem in polytrauma is the choice of the optimal timing and volume of surgical interventions. According to the degree of urgency of the operation and its volume, four groups of victims are distinguished.
First group consist of patients with injuries that quickly lead to death if emergency care is not provided. Bleeding from ruptures of parenchymal organs (liver, spleen), cardiac tamponade, extensive lung damage, “valvular” rib fractures, etc. In case of external arterial bleeding, only temporary hemostasis is performed: application of clamps, tourniquet. If limb fractures are identified, transport immobilization is performed.
In second group includes patients with polytrauma without profuse bleeding and deep breathing disorders. Injuries to the hollow organs of the abdomen, valvular pneumothorax, intracranial hematomas, open and closed severe injuries to the extremities. Operations are usually performed within the first hours after admission.
Third group consists of patients with severe, dominant injuries of the musculoskeletal system without massive bleeding. Surgical interventions are carried out only after the victims have recovered from traumatic shock.
IN fourth group includes patients with injuries to several segments of the limbs without traumatic shock. In the presence of open injuries, PSO and therapeutic immobilization of the limbs are performed. Osteosynthesis is performed using the most gentle methods using a compression-distraction apparatus.
POLYTRAUMA treatment period
When choosing tactics for the treatment of multiple fractures, one must strive not only to restore anatomical-functional relationships, but also to facilitate the care of the victim and ensure his earliest possible activation. More than 40% of patients with closed multiple fractures undergo conservative treatment: skeletal traction, application of plaster casts, and only after full compensation, surgical treatment is performed to quickly mobilize the patient.
Osteosynthesis using compression-distraction devices facilitates the care of operated patients and allows for early activation and loading of the limb. When two adjacent segments are damaged, a combination of several methods of stable osteosynthesis is usually used. For example, in case of a fracture of the femur and tibia, stable intramedullary osteosynthesis of the femur with a massive pin is performed and a compression-distraction device is applied to the lower leg. During this period, after the cessation of therapeutic immobilization, it is necessary to persistently strive to restore joint function through exercise therapy, physiotherapeutic and sanitary treatment, and swimming.
MINISTRY OF HEALTH OF UKRAINE
KHARKIV NATIONAL MEDICAL UNIVERSITY
“Confirmed”
at a methodical meeting
Department of Neurosurgery
Head of the department
Professor __________V.O.Pyatikop
“ “ __________ 2013
METHODICAL INSTRUCTIONS
for independent work of students during the hour of preparation before practical employment
Kharkiv KhNMU – 2013
Polytrauma: Methodical introductions for fifth-year students of the Medical and fourth-year students of the Dental Faculty that begin at the beginning of the credit-modular organization of the beginning / Authors: prof. V.O.Pyatikop, associate professor I.O.Kutovy – Kharkiv, KhNMU, 2013. - 22 p.
I.O.Kutovy
POLYTRAUMA
The purpose of the lesson is to familiarize students with the clinic, diagnosis and treatment of patients with polytrauma.
Students should know:
a) definition of the concept of polytrauma, features of etiopathogenesis, scales
assessing the condition of a patient with polytrauma,
b) be able to, based on complaints, objective, neurological data
examinations, additional examination methods to make a diagnosis and
choose a treatment method.
c) have an idea of the basic treatment and prophylactic procedures
Definition of the concept
The first mention of the term “multiple wounds” is found in “Military Field Surgery” by N.N. Elansky (1942). The “traumatic epidemic” of World War II first brought to the attention of pathologists and surgeons the frequent occurrence of injuries in several areas of the body. A working need arose to name and classify such injuries, bearing in mind a new criterion - the number of injuries and their localization by area in one wounded person.
Polytrauma This is a collective concept that includes multiple and combined injuries that have many similarities in etiology, clinical picture and treatment.
Multiple trauma- it is rational to consider damage to two or more internal organs in one cavity (injury of the small and large intestines, rupture of the liver and spleen, damage to both kidneys), injuries within two or more anatomical and functional formations of the musculoskeletal system (fracture of the hip and shoulder, fracture both calcaneal bones), damage to the great vessels and nerves in various anatomical segments of the limb or limbs.
Associated injury It was proposed to name damage to internal organs in various cavities (concussion and kidney injury), joint injury to the organs of support and movement and the main vessels and nerves. The most extensive group of combined injuries is represented by combined craniocerebral and musculoskeletal system injuries (brain contusion and hip fracture, rib fracture with lung rupture and pelvic fracture, fracture in the lumbar spine with spinal cord damage).
Prevalence
The share of polytrauma among other mechanical injuries is significant - from 15-20% [Pozharisky V.F., 1989].
The predominant injuries in polytrauma are traumatic brain injury (TBI), the proportion of which reaches 80%. Among those killed from combined trauma, the leading injury is also TBI (32.7%) [Lazovsky A. S., Shpita I. D., Shpita I. I., 1998].
Classification
Polytrauma is characterized by the involvement of several functional systems in the pathological process, which allows its classification based on the principle of injury localization.
Thus, they distinguish between polytrauma of the body of the scattered type, when damage is distributed in different areas without any pattern, and polytrauma in the form of a “traumatic knot”. By traumatic node we mean the concentration of several injuries in one area of the body in a certain pattern. There is a vertical location of the “traumatic node” with one-sided (left- or right-sided) localization and a horizontal location relative to the axis of the body - “transverse traumatic node”.
Based on this classification, when diagnosing closed injuries, the technique of three-dimensional projection of possible force lines of the direction of impact from any clearly defined point of damage to the body is used. So, for example, having identified an abrasion in the area of the right half of the chest, possible lines of impact are projected in 3 directions: vertically along the right side (possible rupture of the right lung, liver, right kidney), in the frontal plane (possible injury to the spleen), in the sagittal plane (possible damage to retroperitoneal organs, spine). This technique often makes it possible to identify the dominant injury to internal organs based on one minor injury.
To assess the degree of depression of consciousness, the GLASGOW scale is used:
|
Sign |
Points |
|
Opening your eyes |
|
|
free |
|
|
To the addressed speech |
|
|
To a painful stimulus |
|
|
Absent |
|
|
Verbal response |
|
|
Oriented complete |
|
|
Confused speech |
|
|
Incomprehensible words |
|
|
Inarticulate sounds |
|
|
No speech |
|
|
Motor reaction |
|
|
Executes commands |
|
|
Targeted at pain |
|
|
Not focused on pain |
|
|
Tonic flexion for pain |
|
|
Tonic extension for pain |
|
|
Absent |
Gradation of consciousness disorders:
1. Clear consciousness. The patient is fully oriented, adequate and active.
2. Moderate stun. Conscious, partially oriented, answers questions quite correctly, but reluctantly, in monosyllables, drowsy.
3. Deep stun. Conscious, pathologically drowsy, disoriented, answers only simple questions, in monosyllables and not immediately, only after repeated requests. Executes simple commands.
4. Stupor. Unconscious, eyes closed. Reacts only to pain and calling by opening his eyes, but cannot establish contact with the patient. Localizes pain well: withdraws the limb during injection, defends itself. Flexion movements in the limbs dominate.
5. Moderate coma. Unconscious. Unawakenability. Gives only a general reaction to pain (shudders, anxiety), but does not localize the pain and does not defend itself.
6. Deep coma. Unconscious. Unawakenability. Doesn't respond to pain. Muscular hypotonia. Extension movements dominate.
7. Extreme coma. Unconscious. Unawakenability. Doesn't respond to pain. Sometimes spontaneous extension movements. Muscular hypotonia and areflexia.
In the clinical practice of many hospitals, the scale of the Research Institute of Emergency Medicine named after. Dzhanelidze Yu.Yu. which is based on the criterion of the danger of this injury in relation to the life of the victim (Tsibin Yu.N., Galtseva I.V., Rybakov I.R., 1976).
Brain injuries:
Concussion - 0.1
Mild brain contusion - 0.5
Fracture of the vault, skull base, subarachnoid, subdural
hematoma - 4
Moderate to severe brain contusion-5
Chest injuries
Fracture of one or several ribs without hemopneumothorax and respiratory failure – 0.1
Rib fracture, lung injury with limited hemopneumothorax – 3
Fractured ribs, lung injury with extensive hemopneumothorax and severe acute respiratory failure - 6
Injuries of the abdomen and retroperitoneal organs
Abdominal bruise without injuries to internal organs, non-penetrating wound of the abdominal wall - 0.1
Trauma to hollow organs - 2
Trauma to parenchymal organs, bleeding - 10
Kidney injury with moderate hematuria - 2
Kidney injury with total hematuria, rupture of the bladder, urethra - 3
After which the points are summed up and the severity level is set and the severity level is set.
1. Mild and moderate polytrauma, points 0.1-2.9
2. Severe polytrauma without immediate threat to life, points 3-6.9
3. Extremely severe polytrauma with immediate threat to life, 7-10 points or more.
According to the degree of severity and threat to life, polytrauma is distinguished:
1) dominant injury - the most severe - compared to other injuries,
2) competitive - damage is equivalent,
3) concomitant injury - the injury is less severe compared to others.
When formulating a diagnosis, the characteristics of the injuries are arranged in descending order - from the dominant to the concomitant injury. At the end of the characteristics of the injuries, a description of the consequences of the injuries is given: 1) degree of shock, 2) blood loss, 3) acute respiratory failure. After these data, information is provided on concomitant other acute conditions (alcohol intoxication, poisoning), after which information is provided on concomitant diseases and complications of injuries and operations.
Features of the pathogenesis of polytrauma
I.V. Davydovsky (1960) defined the essence of a traumatic disease as an evolutionarily fixed cyclic multifactorial response of the body to injury, the ultimate goal of which is regeneration.
The multifactorial nature and multiplicity of combined injuries of the musculoskeletal system, chest, abdominal organs and central nervous system lesions have led to the formation of fundamentally new views on their pathogenesis, based on the concepts of “mutual burden” and “change of the leading link in the pathogenesis of combined injury” during a traumatic disease.
The main cause of death in patients with combined traumatic brain injury (CTBI) in the first 3 hours is shock and blood loss, acute respiratory failure, and the fulminant form of fat embolism, the prevention and treatment of which should be the primary focus of the physician's attention.
Despite the various causes and some features of pathogenesis, the main factor in the development of shock is vasodilation and, as a result, an increase in the capacity of the vascular bed, hypovolemia - a decrease in circulating blood volume (CBV) due to various factors: blood loss, redistribution of fluid between the vascular bed and tissues, or discrepancy between the normal blood volume increasing capacity of the vascular bed as a result of vasodilation. The resulting discrepancy between the blood volume and the capacity of the vascular bed leads to a decrease in the minute volume of the heart’s blood and a disorder of microcirculation.
The main pathophysiological process is caused by a violation of the microcirculation system, which unites the arteriole - capillary - venule system. A slowdown in blood flow in the capillaries leads to aggregation of formed elements, stagnation of blood in the capillaries, increased intracapillary pressure and the transition of plasma from the capillaries to the interstitial fluid. Blood thickening occurs, which, along with aggregation of erythrocytes and platelets, leads to sludge syndrome, and as a result of this, capillary blood flow completely stops.
Traumatic shock in victims with TBI has its own characteristics; when treating it, one should take into account, firstly, the multiplicity of sources of pain and shock impulses, which makes their blockade difficult and can lead to an overdose of the anesthetic, especially against the background of blood loss. During the initial examination, especially if the patient is in a comatose state, it is not always possible to identify all existing fractures. Unidentified and, therefore, not anesthetized fractures are the reason for the persistence of the state of shock and an obstacle to the recovery of the victim from shock. Most often, fractures of the ribs, vertebrae, and pelvis are not detected.
Secondly, as a rule, shock during traumatic brain injury develops against the background of blood loss, which sharply aggravates its course and complicates treatment. At low blood pressure (below 70-60 mm Hg), self-regulation of cerebral circulation is disrupted, and conditions are created for cerebral ischemia, which aggravates the course of TBI. Prerequisites for cerebral ischemia occur especially often with chest trauma (multiple rib fractures, pneumothorax, hydrothorax).
Acute blood loss leads to a decrease in blood volume, venous return and cardiac output, leads to activation of the sympathetic-adrenal system, which leads to spasm of blood vessels, arterioles and precapillary sphincters in various organs, including the brain and heart. There is a redistribution of blood in the vascular bed, autohemodilution (transition of fluid into the vascular bed) against the background of a decrease in hydrostatic pressure. Cardiac output continues to decrease, persistent spasm of arterioles occurs, and the rheological properties of the blood change (erythrocyte aggregation “sludge” is a phenomenon).
Subsequently, peripheral vascular spasm causes the development of microcirculation disorders and leads to irreversible hemorrhagic shock, which is divided into the following phases:
Vasoconstriction phase with decreased capillary blood flow
The vasodilation phase with expansion of the vascular space and a decrease in blood flow in the capillaries;
Disseminated intravascular coagulation (DIC) phase;
Irreversible shock phase.
In response to DIC, the fibrinolytic system is activated, clots are lysed and blood flow is disrupted.
Thirdly, with TBI, shock can develop against the background of an unconscious state (coma). Coma is not a barrier to the passage of pain impulses and does not prevent the development of shock. Therefore, all therapeutic and diagnostic measures associated with painful effects should be carried out in the same way as in patients whose consciousness is preserved (using various types of anesthesia).
In case of TBI, shock can develop against the background of primary or secondary (due to dislocation) damage to the brain stem. In this case, severe trunk disorders of cardiovascular activity and respiration develop, which are layered with disorders caused by shock and blood loss. A vicious circle arises when stem disturbances of vital functions support the same disturbances caused by shock, and vice versa.
Principles of diagnosing polytrauma
Diagnosis of injuries due to polytrauma is carried out in three stages:
1) indicative selective diagnostics aimed at identifying injuries and their consequences that are currently life-threatening and require resuscitation operations,
2) radical diagnostics aimed at identifying all possible damage,
3) final diagnosis, aimed at identifying the details of individual injuries, as well as possibly missed injuries at previous stages.
The specifics of polytrauma are:
1) acute lack of time,
2) limiting the possibility of even intrahospital transportation,
3) as a rule, the supine position and the inability to even turn the victim extremely limit the range of clinical and radiological methods and reduce their value.
4) adherence to the principle of four cavities - an active search for possible injuries to the skull, chest, abdomen and retroperitoneal space are the main tasks at all stages of diagnosis.
The main diagnostic methods of the first - indicative stage of selective diagnostics aimed at identifying life-threatening intracranial complications, internal bleeding and other threatening consequences of injury are:
I. To diagnose a traumatic brain injury: 1) objective status, 2) neurological status, 3) radiography of the skull in two projections, 4) CT examination of the brain.
II. To diagnose chest injuries: 1) clinical examination, 2) puncture of the pleural cavities, 3) puncture of the pericardium, 4) radiograph, in cases where the situation allows, laboratory tests: a/ hematocrit, b/ hemoglobin, c/ erythrocytes, d/ leukocytes .
III. To diagnose abdominal injuries: 1) clinical examination, 2) laparocentesis, 3) laboratory tests: a/ hematocrit content, b/ hemoglobin, c/ erythrocytes, d/ leukocytes.
IV. To diagnose a musculoskeletal system injury: 1) clinical examination, 2) x-ray examination of the affected anatomical and functional area.
For radical diagnosis, the entire arsenal of clinical, radiological, laboratory and instrumental research methods is used.
Principles of treating patients.
1. Immediate hemostasis and correction of the most dangerous dysfunctions of internal organs. Surgical interventions to stop bleeding (including laparotomy, thoracotomy), craniotomy (in case of compression of the brain, in cases of open fractures), tracheostomy (in case of airway obstruction) are considered anti-shock measures and are performed urgently. In case of profuse external bleeding in patients with massive open injuries to the organs of support and movement, only temporary hemostasis is performed where possible, followed by radical surgery after a persistent and sufficient increase in blood pressure. Tension pneumothorax is eliminated by thoracentesis with underwater drainage of the pleural cavity. The indication for thoracotomy is ongoing bleeding into the pleural cavity, unrecoverable despite intense aspiration of air, pneumothorax and open extensive chest injury. . Damage to the abdominal organs is a direct indication for urgent laparotomy. The intervention should be simple, minimally traumatic and maximally effective. Organ-preserving interventions (taking into account the severity of the victim’s condition) are preferable to resection and extirpation of hollow and parenchymal organs . The primary goal of resuscitation for severe traumatic brain injury (not requiring surgical treatment) is to combat respiratory failure, increasing cerebral edema and intracranial hypertension .
2. Restoration of adequate breathing, hemodynamics, tissue perfusion. The method of choice is mechanical ventilation in the mode of moderate hyperventilation, which not only eliminates hypoxemia, but also provides a therapeutic effect for traumatic cerebral edema. In case of severe traumatic brain injury, mechanical ventilation is carried out through a tracheostomy (the duration of mechanical ventilation is more than a day, in addition, through the tracheostomy it is possible to effectively drain the airways, etc.). In case of chest injury, mechanical ventilation is carried out with large tidal volumes (600-850 ml) in a relatively rare rhythm (18-20 cycles per minute) without active exhalation. In case of traumatic asphyxia syndrome, mechanical ventilation is the main method of resuscitation and should be started as early as possible to avoid irreversible hypoxic changes in the brain. Hypovolemia, hemodynamic and tissue perfusion disorders, and metabolic disorders are eliminated using massive multicomponent infusion therapy, regardless of the severity of the traumatic brain injury . Adequate hemodynamics prevents hypoxic cerebral edema. Safe hemodynamic parameters and adequate gas exchange are especially necessary to ensure when performing emergency surgical interventions.
3. Treatment of local damage to the organs of support and movement. During the period of resuscitation, they provide immobilization of damaged segments (position on a backboard for fractures of the spine and pelvis, transport and medical splints for fractures of the extremities). After stabilization of blood pressure within 80-85 mm Hg. Art. carry out blockades of bone fracture sites.
LIST OF MEASURES FOR RESTORING THE PERFORMANCE OF THE UPPER AIRWAY
1. Laying the victim on his back with his head turned on the side.
2. Cleaning the mouth and pharynx (with a gauze swab or catheter using a vacuum suction).
3. Insertion of an air duct or stitching of the tongue with a silk thread and fixation around the neck or to the chin splint.
4. Artificial ventilation of the lungs using a portable device using a mask.
5. If it is impossible to permanently restore the patency of the upper respiratory tract, tracheostomy is performed.
Technique for performing upper tracheostomy. The patient is placed on his back with a cushion under his shoulder blades. Under local infiltration anesthesia with a 0.5% solution of novocaine, the skin and subcutaneous tissue are cut 5 cm long along the midline of the neck downward from the cricoid cartilage. A sharp hook is used to pull this cartilage upward and forward, and a blunt hook is used to displace the isthmus of the thyroid gland downwards. The two upper rings of the trachea are crossed. A dilator is inserted through the hole, and then an external tracheostomy tube with a guidewire is inserted. The guidewire is removed and the internal tracheostomy tube is inserted. Layer-by-layer sutures are applied to the wound. The tube is secured to the neck with ribbons or fixed to the skin with sutures.
Technique for performing lower tracheostomy similar to upper tracheostomy, but the incision is made before the sternum is notched, and the isthmus of the thyroid gland is pulled upward.
TECHNIQUES FOR PERFORMING BASIC TREATMENT AND PREVENTIVE MANIPULATIONS
Application of an occlusive dressing. Treat the skin around the wound with an antiseptic. Wide sterile napkins are soaked in some ointment and applied to the wound. An oilcloth is placed on top of the napkin and the whole thing is tightly bandaged to the body. You can apply dry sterile wipes to the wound, and on top - a tile-shaped bandage made of wide strips of adhesive plaster.
Pleural puncture. It is best performed with the victim in a sitting position. Treat the skin with an antiseptic. In the seventh intercostal space between the scapular and posterior axillary lines, local anesthesia is performed with a 0.25-0.5% novocaine solution. Then the needle (with a rubber tube placed on its pavilion and clamped with a clamp) is inserted through the chest wall into the pleural cavity. The contents of the pleural cavity are sucked out with a syringe. If reinfusion of blood is expected, then the latter is collected in a sterile vial with 4°/o sodium citrate solution (10 ml of solution per 100 ml of blood).
Drainage of the pleural cavity from the front. In the second or third intercostal space along the midclavicular line, local anesthesia is performed with a 0.25-0.5% novocaine solution. A long, thin needle is passed through the chest wall. After making sure that there is blood or air in the pleural cavity, the syringe is removed, the skin is pierced with a scalpel next to the needle and through this wound a trocar is inserted into the pleural cavity along a needle, through a trocar-polyethylene or rubber drainage tube, which is connected to the system for aspiration or underwater drainage.
Drainage of the pleural cavity from below and behind performed similarly to drainage from the front, but the tube is inserted in the sixth - seventh intercostal space in the posterior axillary line. Blood and air are released through the drainage.
Intercostal blockade. Treat the skin with alcohol. Feel the lower edge of the rib. Sending a stream of 0.25-0.5% novocaine solution, inject the needle all the way into the lower edge of the rib. Then they “slide” off it, about moving the needle 2-3 mm under the lower edge of the rib. Inject 10 ml of 0.5% novocaine solution.
Paravertebral blockade carried out along the paravertebral line similarly to the intercostal line.
The blockade is retrosternal. A “lemon peel” is made with a 0.25-0.5% novocaine solution in the area of the jugular fossa. Bend a long thin needle at a right angle and put it on a 10-gram syringe. Preceding a stream of novocaine, carefully advance the needle behind the sternum to a depth of 2-3 cm and inject 60-80 ml of a 0.5% novocaine solution.
Perinephric blockade according to A.V. Vishnevsky. The patient is placed on his side with a bolster under his lower back. After treatment and anesthesia of the skin, a needle is inserted into the area of the apex of the angle formed by the long muscles of the back and the 12th rib, and in the perpendicular direction, using a novocaine solution, the posterior leaf of the lumbar fascia is pierced. In this case, the novocaine solution enters the perinephric space without resistance and, after removing the syringe, does not flow back through the needle. 60-120 ml of 0.25% novocaine solution is administered.
Blockade for fracture of the pelvic bones (according to Shkolnikov). The position of the victim is on his back. Stepping inwards 1 cm from the anterior superior spine, the skin is anesthetized with a 0.25-0.5% solution of novocaine and a long thin needle (14-16 cm) is passed under the anterior superior spine to the inner surface of the ilium. Preceding the introduction of novocaine, the needle, facing the cut plane towards the bone, is advanced, “sliding” along the bone, to a depth of 12-14 cm. 300-500 ml of a 0.25% novocaine solution is injected on one side or 150-250 ml on both sides.
Capillary (suprapubic) puncture of the bladder. Skin above the pubis By the midline is shifted with a finger 1.5-2 cm upward and a thin needle is inserted strictly perpendicularly to a depth of 5 cm. If urine does not flow out, it is sucked out with a syringe. Before puncture, you must make sure (by percussion or palpation) that the bladder is above the level of the pubic bones.
Anterior nasal tamponade. The nose is widened with a folding speculum, and a forceps, folded in half and soaked in Vaseline, is inserted into the nasal cavity using a forceps.
Oil a gauze swab 2 cm wide, which is filled with insert swabs that are shorter in length. A horizontal sling-shaped bandage is applied to the nose.
Posterior nasal tamponade. After anesthesia by lubricating the mucous membrane of the nose and pharynx with a 3% solution of dicaine, a rubber catheter is passed through the corresponding nasal passage into the nasopharynx. The end of the catheter protruding into the nasopharynx is grabbed with a forceps and brought out through the oral cavity. Two of three threads from a pre-prepared tampon (a tightly rolled and tightly tied wad of gauze) are attached to this end of the catheter. The catheter is withdrawn back from the nasal cavity, while it carries with it a double thread and a tampon. At the stage of passing the tampon beyond the soft palate, it should be pushed into the nasopharynx with the index finger inserted into the victim’s mouth. Using a double thread, the tampon is pulled tightly to the choanae and anterior nasal tamponade is performed. The ends of the double thread in the nostril area are tied with a “bow” over a gauze roll (“anchor”). A single thread protruding from the oral cavity and serving to remove the tampon from the nasopharynx is secured with an adhesive plaster on the cheek. A horizontal sling-shaped bandage is applied to the nose.
PRINCIPLES OF PRIMARY SURGICAL TREATMENT OF CRANIOBRAIN WOUNDS
When choosing the type of incision, one should take into account the shape of the wound, its location, the radial direction of the vessels and nerves, as well as subsequent cosmetic results. The incision is usually chosen to be bordering or arcuate. If only soft tissue is damaged, excision of the wound edges is carried out within healthy tissue to the periosteum.
Treatment of penetrating wounds of the skull is more difficult, since in this case it is necessary not only to treat the edges of soft tissues and bone defects, but also to remove damaged areas of the dura mater, foreign bodies, bone fragments, and in some cases, brain matter.
Preparing the patient. The hair is shaved from the wound to the periphery, wiped with a 5% alcohol solution of iodine.
Operation technique. A scalpel is used to dissect the skin and aponeurosis around the wound, retreating 0.5-1 cm from the edge within healthy tissue, while creating the most convenient shape of the wound (linear, elliptical) in order to ensure that its edges are brought together without tension when applying sutures. If there are contaminated subcutaneous pockets, it is necessary to open them with additional incisions. Thorough hemostasis of the skin wound is performed, the bone is exposed, and the periosteum is cut along the edge around the defect. Next, they begin to treat the bone wound. First, fragments of the outer plate are removed, and then the inner ones, the damaged parts of which usually extend under the healthy bone beyond the hole. To do this, widen the defect by biting off its edges with nippers. Then it becomes possible to remove loose fragments and foreign bodies, and the dura mater is exposed. In case of penetrating wounds of the skull with a small hole, it is advisable to expand access not from the side of the bone defect, but to make one or two burr holes at a distance of 1 cm from the edges of the defect and through them remove the required size of the bone. If the dura mater is not damaged and there are no signs of subdural or intracerebral hemorrhage, then it is not dissected. The skin wound is sutured tightly.
In cases of penetrating wounds of the skull with damage to the dura mater, surgical treatment of the wound of the skull is performed in the same way. Then the edges of the dura mater are excised, foreign bodies and bone fragments are removed from the brain matter, the wound is washed with warm saline, brain detritus, blood clots and small bone fragments are removed.
Questions for self-control
- 1. Definition of the concept – polytrauma.
- 2.
What is the Glasgow scale?
- 3. Features of traumatic shock in combined traumatic brain injury?
- 4. What is the principle of four cavities?
- 5. Technique of pleural puncture?
- 6. Principles of primary surgical treatment of craniocerebral wounds?
Literature
- Gvozdev M.P., Galtseva I.V., Tsibin Yu.N. Prediction of outcomes of traumatic brain injury combined with extracranial injuries complicated by shock // Vestn. hir. – 1981.-No. 5-S. 94-98.
- Grigoriev M.G., Zvonkov N.A., Likhterman L.B., Fraerman A.P. Combined traumatic brain injury. – Gorky: Volgo-Vyat. book publishing house, 1977. – 239 p.
- Diagnosis and treatment of patients with multiple and combined trauma: [Sb. Art.] / Kishin. state honey. Institute - Chisinau: Shtintsa, 1988. - 123 p.
- Lazovsky A. S., Shpita I. D., Shpita I. I. Modern aspects of organizing radiation examination of victims with polytrauma during their mass admission to medical institutions // News of radiation diagnostics - 1998. - No. 5 - P. 4-5.
- Krylov V.V., Ioffe Yu.S., Sharifullin F.A., Kuksova I.S. Surgical treatment of traumatic brain injury of sub- and supratentorial localization // Issues. neurosurgeon - 1991. - No. 6. - P. 33-36.
- Burunsus V.D. Features of the course of severe traumatic brain injuries,
combined with damage to the chest and thoracic organs
in the acute period of traumatic illness // Bulletin of the Ukrainian Association of Neurosurgeons - 1998. - No. 5. - Grinev M.V. Combined injury: the essence of the problem, solutions // Providing assistance with combined injury. - M., 1997. - P. 15-18.
- Rekhachev V.P., Nedashkovsky E.V. Severe combined injury as a surgical and resuscitation problem // Providing care for combined injury. - M., 1997. - P. 53-59.
Uchbov vidannya
POLYTRAUMA: Methodical instructions for fifth-year students of the Medical Faculty and fourth-year students of the Dental Faculty, which begin at the beginning of the credit-modular organization
I.O.Kutovy
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Editorial and publication section
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.
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, 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 great vessels and nerve trunks, should be considered as complicated injury.
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 Injuries are considered 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 extremity bones).
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). A greater number of options for simultaneous exposure to damaging factors is possible.
Multiple, combined and combined injuries are characterized by a particularly severe clinical manifestations, accompanied by significant disruption of the vital functions of the body, difficulty in diagnosis, complexity of treatment, high percentage of disability, and 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 injuries, 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 injury, in 10% - damage to the abdominal organs. 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 of general changes occurring in the body of a person who has been subjected to injury. 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 a 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 traumatic shock in the victim and is characterized by disruption of the functioning of vital 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, adult respiratory distress syndrome (ARDS), disseminated intravascular coagulation syndrome, and 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 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, 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 with a favorable course of the traumatic disease. 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 correct solution of treatment and tactical problems when providing medical care to victims with polytrauma, it is extremely important to identify leading (dominant) lesion, determining the current 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 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 the acute lack of time during mass admissions often lead to untimely diagnosis of injuries. 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).
An important feature of 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 - the appearance of a petechial rash and small hemorrhages on the chest, abdomen, internal 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 fat embolism. The peculiarity of fat embolism is that it develops and increases gradually. Droplets of fat enter the lungs (pulmonary form), but can pass through the pulmonary capillary network into the systemic circulation, causing damage to the brain (cerebral form). In some cases, a mixed form of fat embolism is noted, representing a combination of cerebral and pulmonary forms. In the pulmonary form of fat embolism, the picture of acute respiratory failure dominates, but brain disorders cannot be excluded. The brain form is characterized by the development after an obligatory light interval of headache, convulsive syndrome, and coma.
Prevention of fat embolism consists primarily of adequate immobilization of injuries and careful transportation of victims.
A big problem in providing medical care to victims with polytrauma is often the incompatibility of therapy. Thus, if in case of injury to the musculoskeletal system the administration 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. A chest injury makes it impossible to apply an abduction splint for a shoulder fracture, and extensive burns make it impossible to adequately immobilize this segment with a plaster cast for a 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.
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.
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 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 radiation for the manifestation of acute radiation sickness is I Gy.
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 problems develop, and meningeal signs appear. 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 the severity of 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 The victims' hair falls out and hemorrhagic syndrome develops. 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. Asthenia 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 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 specialized care; 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 questionable; complete 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 (ingress of radioactive dust or other particles onto the wound surface) contributes to 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.
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), have a toxic effect on tissues (hydrocyanic acid, dinitrophenol).
Neurotropic substances act on the conduction and transmission of nerve impulses
(carbon disulfide, organophosphorus compounds: thiophos, dichlorvos, etc.).
Metabolic poisons include substances that cause disturbances in 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.
When persistent toxic substances of blister action (mustard gas, lewisite) enter a wound or intact skin, deep necrotic changes develop, 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 the local processes occurring 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.
Features of providing assistance to victims with polytrauma
The severity of injuries, the frequency of development of life-threatening conditions in polytrauma, and the large number of deaths make the speed and adequacy of medical care especially 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.
First medical and first aid
The entire possible range of anti-shock measures is being carried out. In the area of radioactive or chemical damage, the victim is put on a gas mask, a respirator, or, in extreme cases, a gauze mask to prevent droplets of chemical agents or radioactive particles from entering the respiratory tract. Open areas of the body that have been exposed to chemical agents are treated using an individual anti-chemical package. In case of multiple bone trauma, due to the danger of fat embolism, transport immobilization should be approached with special care.
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 the damaging agent is known, the wounds are washed and the skin is treated with special solutions (for example, if affected by mustard gas, the skin is treated with 10% alcohol, and the wounds with 10% aqueous solutions of chloramine; if affected by lewisite, the wound is treated with Lugol’s solution, and the skin with iodine), if unknown - 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.
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 bulk are victims with shock of varying severity, which will serve as the basis for triage.
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 an aggravation of the negative effects of these substances. Primary surgical debridement aims not only to prevent the development of wound infection, but also to remove RV and OM 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 onset of radiation sickness. Extended excision of soft tissue during surgical treatment helps reduce the risk of infectious complications with this tactic.
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 of the radius in a 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 combined radiation injury in a victim with a closed fracture of the humerus and irradiation at 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 pelvic bone fracture is dominant. a) fracture of the pubic bone, fracture of the femur in the 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 first medical aid for 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 the initial period; d) operations are not allowed.
Is it permissible to apply primary sutures to a gunshot wound of the thigh in case of combined radiation injury of moderate severity?
a) permissible only in the absence of a gunshot fracture; b) permissible only in case of a through 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.
