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UDC 616.712-089
IMPLEMENTATION OF MODERN TECHNOLOGIES IN COMBINATION TREATMENT OF POLYTRAUMA PATIENTS WITH DOMINANT CHEST TRAUMA
Altai State Medical University, Barnaul
Regional Clinical Hospital of Emergency Medical Care, Barnaul Ye.A. Tseimakh, A.V. Bondarenko, A.A. Menshikov, A.A. Timoshnikova
Mutual aggravation of state by polytrauma considerably complicates the diagnostic and treatment process, delaying the provision of specialized help, for example, by concomitant craniocerebral and thoracic trauma or skeletal injuries and chest injuries, there are imposed stringent requirements for choosing the amount of diagnostic and therapeutic measures.
Research objective: the improvement of the efficiency of сombination treatment of patients with severe concomitant injury with dominant chest trauma by means of minimally invasive methods of treatment. There was elaborated a diagnostic and treatment algorithm of management of patient with SCCT. There are defined indications for emergency thoracotomy, emergency and urgent video-assisted thoracoscopy, local fibrinolytic therapy by clotted hemothorax and post-traumatic are formulated at curtailed hemothorax and posttraumatic pleural empyema, valvular bronchial blockage by tension and long-term pneumatothorax, indications for osteosynthesis of fragment rib fractures by angle stable plates.
The implementation of minimally invasive methods allowed to reduce the number of operated patients and increase the number of discharged recovered patients.
Key words: severe concomitant injury with dominant chest trauma, hemothorax, pneumatothorax, fragment rib fractures, treatment.
Mutual aggravation of state by polytrauma considerably complicates the diagnostic and treatment process, delaying the provision of specialized help, for example, by concomitant craniocerebral and thoracic trauma or skeletal injuries and chest injuries, there are imposed stringent requirements for choosing the amount of diagnostic and therapeutic measures [1, 2, 3, 4].
Objective: the improvement of the efficiency of combination treatment of patients with severe concomitant injury with dominant chest trauma (SCCT) by means of minimally invasive methods of treatment.
Materials and methods
There were analyzed the results of treatment of 263 patients with SCCT being under medical treatment in the Federal State Budgetary Healthcare Institution "Regional Clinical Hospital of Emergency Medical Care". Male patients constituted 208 (79,0%), female patients - 55 (21,0%). The age of patients ranged from 15 to 79 years. The causes of trauma were various. The most common cause of SCCT were road accidents - 97 (36,8%) patients. Less common were home accidents - 72 (27,4%), criminal accidents - 50 (19,1%), occupational accidents - 30 (11,4%) and falls from height 14 (5,3%).
The majority of patients were taken to the department of severe concomitant injury during the first two hours since getting injured - 152 (57,9%),
during the period from 3 to 24 hours - 55(20,9%), from 24 to 72 hours - 39 (14,8%), in 72 hours - 17 (6,4%).
The estimation of the injury severity was performed according to ISS scale [5]: in 109 (41,5%) patients it was under 25 points, in 120(45,6%) -from 25 to 40 points, and in 34 (12,9%) - over 40 points.
Out of 263 patients 109 (41,5%) patients were included into the main group, 154(58,5%) - into the comparison group. The patients of the main group were exposed to modern minimally invasive interventions (differentiated local fibrinolytic therapy, valvular bronchial blockage, video-assisted thoracoscopy (VTS), rib osteosynthesis by angle stable plates). Patients of the comparison group received conventional treatment (blind thoracosto-my, thoracotomy, etc.).
Unilateral thoracic injuries were registered in 219 (83,2%) patients, bilateral - in 44(16,8%). In 198 (75,2%) patients chest trauma was accompanied by subcutaneous and intermuscular emphysema. The groups were comparable to each other according to the stated parameters.
The type of intrathoracic complications in the examined patients is presented in Table 1.
In the overwhelming majority of cases severe chest trauma by concomitant injury was accompanied by multiple fractures of ribs and other chest bones, which lead to the deformation of rib cage, mechanical acute and\or contusional effect on internal organs (Table 2).
Table 1
Complications of polytrauma patients with dominant chest trauma
Complications Groups Р Both groups
main comparison
abs. number % abs. number % abs. number %
Pneumatothorax 40 36,8 55 35,7 >0,5 95 36,1
Hemothorax 21 19,2 28 18,2 >0,5 49 18,6
Hemopneumothorax 48 44,0 71 46,1 >0.5 119 45,3
Total: 109 100 154 100 263 100
Table 2
Chest fractures in patients with SCCT
Fractures Groups P Both groups n=263
Main n=109 Comparison n=154 abs. number %
abs. number % abs. number %
3-6 ribs 75 68,8 84 54,5 >0,5 159 60,4
More than 6 ribs 34 31,2 70 45,5 >0,5 104 39,6
Fragment rib fractures with thoracic wall floatation 17 15,6 46 29,8 >0,5 63 23,9
Thoracic vertebra 14 12,8 24 15,5 >0,25 38 14,4
Breast bone 7 6,4 6 4,8 >0,5 13 4,9
We elaborated the diagnostic and treatment approach to the management of SCCT patients. Indications for emergency thoracotomy were considered big and total hemothorax, hemopericardi-um with cardiac tamponade, hemomediastinum with compression of respiratory passages and major vessels, major chest penetrating wound with открытым пневмотораксом and massive pulmonary injury. Indications for emergency VTS were injures of the "thoracicoabdominal zone", middle and small hemothorax, post-traumatic pleural em-pyema.
Emergency VTS was conducted by continuous intrapleural bleeding with blood effusion into drainages over 200ml/hour and absence of signs of hemostasis [6]. By clotted hemothorax and formation of post-traumetic empyema with pleural cavity segmentation there was implemented differentiated local fibrinolytic therapy. By tension and long-term pneumatothorax not eliminated by drainage (during 4-5 days) there was used valvular bronchial blockage [7,8]. By multiple fractures of ribs with deformation of rib cage accompanied by paradoxical respiration, there was conducted open reduction of rib fractures by rib valve and osteosynthesis by angle stable plates.
Local fibrinolytic therapy was performed by means of streptokinase medicines. The dose of streptokinase constituted 1500000 IU. The drug 56
was dissolved in 20 ml physiological solution and injected into the pleural cavity. The exposition in pleural cavity constituted 3-24 hours, after what the drug and exudate were removed, and the pleural cavity was washed by antiseptic solution. The introduction of fibrinolysis activators was made daily or in a day, 1-3 time in total. By the reduction of plasminogen activity in the pleural exudate up to lower than 7% there was implied the method of intrapleural injection of streptokinase with fresh frozen plasma elaborated in the hospital [9]. The amount of removed exudate ranged from 50 to 2000 ml per day.
In order to fuse the pulmonary-pleural fistula by pneumothorax we have elaborated and clinically approved the method of the fistulous bronchus occlusion by an original endobronchial valve (registration certificate № 01.03.2006 (5625-06 of 21.12.2006).
VTS was performed under operating conditions under endotracheal anesthesia without separate bronchus intubation.
To restore the ribcage and eradicate paradoxical respiration of the rib valve there was performed open reposition and osteosynthesis of fragment rib fractures by angle stable plates under endotra-cheal anesthesia. Osteosynthesis was conducted in the first two days.
Results and discussion
By the comparison of results of treatment of clotted hemothorax in the 2nd group (with intrapleural injection of streptokinase, 23 patients), recovery was observed in 15 (65,2%) patients, chronization of process - in 8 (34,8%), 6(26,1%) of whom were further operated. In the 1st group of patients exposed to intrapleural fresh frozen plasma injections activated by streptokinase (15 patients), 14(93,3%) patients were dismissed after recovery, in 1(6,7%) patients there was registered the carbonization of process, further he was operated. The number of discharged recovered patients. in the 1st group was 1,4 times higher (p<0,02).
Anteriolateral thoracotomy for continuous in-trapleural bleeding, suspected heart wound or thoracicoabdominal injury was performed in patients of the main group in 3 (3,8%) cases, in patients of the comparison group - in 14(12,5%) cases (p<0,05).
Valvular bronchial blockage in patients with post-traumatic pneumothorax was preformed in 11(32,4%) patients. The duration of occlusion of the fistulous bronchus occlusion in the main group constituted averagely 21,3+2,7 days. Combination treatment of post-traumatic pneumothorax in all patients of the main group allowed to reach lung expansion and closure of pulmonary-pleu-ral fistula. In the comparison group 4(7,8%) patients were operated for persistent pneumothorax and functioning bronchopleural fistula.
The implementation of the elaborated algorithm of patient management allowed to reduce the number of operated patients by 3,8 times, increase the number of discharged recovered patients by 1,4 times.
Out of 63(23,9%) patients with multiple fragment rib fractures with thoracic wall floatation the osteosynthesis of ribs of was conducted in 17(26,9%) patients, in all patients there was restored the rib cage and stabilize "paradoxical respiration" of the rib fragment. Total duration of artificial lung ventilation after osteosynthesis constituted averagely 3,2+0,8 days. While by conventional treatment its duration by fragment rib fractures was 9,2+0,6 days (p<0,001). No postoperative complications were registered.
The implementation of rib osteosynthesis by multiple fragment rib fractures with thoracic wall floatation allowed to reduce the duration of artificial lung ventilation by 2,8 times.
The elaborated technology of management of patients with severe concomitant injury with dominant chest trauma allowed to increase the number of discharged recovered patients by 1,3 times (p<0,05) and to reduce the number of chronic patients by 2,1 times (p<0,05) (Table 3).
Long-term results of treatment of the majority of SCCT patients were traced within the terms from 6 months to 4 years.
Table 3
Immediate results of treatment of patients with SCCT by means of minimally invasive technologies
Indexes Groups P
Main Comparison
abs. number % abs. number %
Recovery 75 68,8 83 53,8 <0,05
Chronization 11 10,0 33 21,4 <0,05
Died 23 21,2 38 26,7 >0,25
Total 109 100 154 100
Table 4
Long-term results of treatment of SCCT patients by means of minimally invasive technologies
Indexes Groups P
Main Comparison
abs. number % abs. number %
Recovery 55 87,3 40 61,5 <0,01
Chronization 4 6,3 18 27,7 <0,002
Died 4 7,3 7 10,8 >0,5
Total 63 100 65 100
At late times the number of recovered patients in the main group was by 25,8% higher than in the comparison group (p<0,01). The number of chronic patients in the main group was by 5,0
times lower than in the comparison group (p<0,002) (Table 4).
To illustrate the efficiency of minimally invasive methods in treatment of polytrauma patients with
severe chest injury there is presented the clinical observation.
A 22-year-old patients was admitted to the hospital on 07.09.2011 in 1 hour 20 minutes after the occupational trauma (was covered with soil in a trench) with complaints of intensive chest and stomach pains, dyspnoea at rest, dizziness, expressed fatigue.
Upon admission, the state of patient was extremely severe. Pale skin cover with cold sweat, cyanosis of nasolabial triangle, fingers and toes. The number of breaths - 36 times per 1 minute. Arterial blood pressure - 80/40 mm.hg. Pulse -120 beats per minute, obscure. X-ray radiography of breast: lungs collapsed on both sides, pressed against the hiluses, mediastinum not shifted, sinuses unrevealed (Figure 1).
The patient underwent laparoscopy - in the abdominal cavity there were discovered 500 ml liquid blood, multiple ruptures of the right lobe of liver, primarily on the diaphragm surface.
On the basis of clinical data, laboratory and instrumental examination methods, there was established a diagnosis: severe concomitant trauma, blunt chest trauma, bilateral post-traumatic hemo-pneumothorax, blunt intraabdominal injury, multiple fractures of the right lobe of liver, hemoperi-toneum, hemorrhagic shock of degree III.
The patient's state corresponds to 42 points according to ISS (injury severity score).
The patient was operated for emergency indications. There was made the drainage of the right pleural cavity in II intercostal space along the mid-clavicular line and in VI intercostal space along the back axillary line and of the left pleural cavity in II intercostal space along the midclavicular line. The laparotomy was performed. The abdominos-copy showed multiple fractures of the right lobe of liver, primarily on the diaphragm surface, with intensive bleeding, round and falciform ligament of liver are raptured. There was conducted the sealing of liver raptures.
The drainages of the right pleural cavity indicated an intensive air and blood shunt. Per 1 hour there were released about 400ml blood, positive test of Ruvilua-Greguara. Under intubation anesthesia there was performed anteriolateral thoracotomy in VI intercostal space on the right. The abdomi-noscopy showed multiple fractures and of the lower and middle lobes of the right lung with intensive bleeding. There was conducted an atypical resection of the lower and middle lobes of the right lung and suturing of the upper lobe of the right lung. During the operation there was registered expressed bleeding.
The patient was admitted to the intensive therapy unit for extended artificial lung ventilation and inotropic support.
12.09.2011 - the patient's condition worsened, hemoperitoneum and subacute peritonitis were
diagnosed, therapeutic relaparotomy was performed. In all areas of abdominal cavity there was revealed lysed blood, in the lesser pelvis and down the right flank there were deleted blood clots. Small intestine is swollen up to 5sm in diameter, on the serous membrane - fibrin assemblies. There was performed the decompression of small intestinal content into the large intestine.
19.09.2011 - the X-ray radiography of thoracic organs revealed free fluid in the right pleural cavity not diffluent by X-ray radiography in prone position (Figure 2).
The computer tomography of thoracic organs of 20.09.2011 revealed the reduction of the right lung volume due to the resection of lower and middle lobes and the presence of free air in pleural cavity. The observed lung tissue with areas of infiltration.
Ultrasonic scanning revealed the presence of fluid in pleural cavity with hyperechogenic inclusions and fibrin, signs of clotted hemothorax on the right (Figure 4).
By the puncture of the right pleural cavity there was obtained a small amount of laky blood with clots. 20.09.2011 - to eliminate clotted hemotho-rax there was made an injection of 50 mg Actilise into the pleural cavity. 21.09.2011 - drainage of the right pleural cavity in VI intercostal space along the scapular line, through the drainage there were released 900 ml laky blood. The control X-ray radiography of 22.09.2011: right lung partially collapsed, small amount of fluid with horizontal level on the right (Figure 5).
Ultrasonography of pleural cavity: on the right side of pleural cavity there was located small amount of fluid with linear inclusions, small pleural fillings (Figure 6).
Considering the severity of condition, the preserved intensive air shunt through the drainages from right pleural cavity, on 21.09.2011 there was performed bronco-fibroscopy under local anesthesia and insertion of the endobronchial valve №15 into the intermediate bronchus, air shunt through the drainage reduces considerably, in 4 days - terminated.
After valvular bronchial blockage the patient continued to receive the course of massive antibacterial therapy, cryoplasm-antienzyme complex, infusion and detoxication therapy. During 8 days the hemodynamics was sustained by sympath-omimetic infusion. For 10 days the patients was exposed to extended artificial lung ventilation. In the intensive therapy unit and surgical department the patient received 2700 ml polyglucin, 2800 ml rheopolyglucin, 2040 ml one-group erythrocyte concentrate and 3400 ml fresh frozen plasma.
20.10.2011 - broncofibroscopy there was performed. The bronchial blocker was deleted by biopsy forceps. The mucous membrane of the intermediate bronchus at the point of blocker presence
was characterized by slight edema ad hyperemia. X-ray radiography of thoracic organs of 22.10.2011: on the right the front costodiaphragmatic sinus is shaded, agraffes in the root, lung tissue expanded. On the left no focal and infiltrative shadows (Figure 7).
The patient was discharged with improvement. Examination was performed in 2 and 10 months, healthy (Figures 8, 9).
Thus, the current study shows, that the implementation of minimally invasive methods in combination treatment of hemothorax and pneumothorax in the patient with concomitant severe trauma contributed to the recovery of the patient.
Conclusion
The implementation of minimally invasive methods allowed to improve the effectiveness of combination treatment of polytrauma patients with dominant chest trauma.
References
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Contacts:
Corresponding author - Tseimakh Yevgeny Alek-sandrovich, Doctor of Medical Sciences, Professor, Head of the Department of general surgery, operative surgery and topographic anatomy of the FSBEI HE Altai State Medical University of the Ministry of Health of the Russian Federation, Barnaul. 656038, Barnaul, Molodezhnaya Ulitsa, 7. Tel.: (3852) 364601. Email: yea220257@mail.ru
