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II. ДИАГНОСТИКА
UDC 616-00 0 08 MODERN PRINCIPLES OF DIAGNOSIS AND
TREATMENT OF PATIENTS WITH SEVERE
About the author:
Nazim A. Kasumov - Associate Professor of General Surgery I department of the ASATID n/a Aliyev, dr.med.
CONCOMITANT INJURIES AND POLYTRAUMAS
Kasumov N.A., Verdiev V.G., Ibragimov F.I.
Azerbaijan State Advanced Training Institute for Doctors named after A. Aliyev, Azerbaijan, Department of Surgery I, Department of Traumatology and Orthopedics of the Clinical hospital № 3, Baku
Key words: Abstract
poiytrauma,severe concomitant The analytical review reflects the social, expert, organizational aspects of the integrated and mm di^Mity surgiaii am. comprehensive study of the problem of the treatment of severe concomitant injuries and polytrauma.
Ауыр аралас жаракаттармен жэне полижаракаттары бар ауруларды диагностика-лау жэне емдеудщ замануи ка^даттары
Авторлар туралы: Касумов H.A., Вердиев В.Г., Ибрагимов Ф.И.
Касумов Назим Акиф оглы
А.Алиев атындаш Дэр1герлердщ бшктЫпн жет1лд1ру бойынша Эзербайжан мемлекеттк институты, I Хирургия кафедрасы, Баку к,.
- жалпы хирургия бол1м1н1н доценты.
Ацдатпа
Талдау шолуда ауыр аралас жаракаттарды жэне полижаракаттарды емдеу проблемасыныц жаракаты, мугедектк, кешенд1 жэне жан-жакты зерттеу бойынша элеуметтк, сараптамалык, ±йымдастырушылык аспектшер1 хирургиялык комек корсету. керсетшген.
Тушн сездер:
полижаракат, ауыр аралас
Об авторе:
Касумов Назим Акиф оглы - доцент кафедры Общей хирургии IАГИУВ им. Алиева, д.м.н.
Ключевые слова:
политравма, тяжелая сочетанная травма, инвалидность, хирургическая помощь.
Современные принципы диагностики и лечения больных с тяжелыми сочетанны-ми травмами и политравмами
Касумов H.A., Вердиев В.Г., Ибрагимов Ф.И.
Азербайджанский государственный институт усовершенствования врачей им. А.Алиева, Кафедра хирургии I,
Отделение травматологии и ортопедии клинической больницы № 3, г. Баку Аннотация
В аналитическом обзоре отражены социальные, экспертные, организационные аспекты по комплексному и всестороннему исследованию проблемы лечения тяжелых сочетанных травм и политравм.
One of the priorities of health care is to reduce the disability and mortality among patients with severe concomitant injuries (SCI) and polytraumas (PT). Mortality after such injuries remains high, reaching 28.6%. In 90-100% cases treatment of patients after severe traumas is associated with the development of complications of a different nature [1,2].
As built on the basis of the relative principles emergency first aid to patients with SCI and PT does not give the desired results, preclinical and clinical activities should be revised or improved. It is important to the formation of a single, integrated and progressive scan therapeutic approach to cooperation between the work teams of emergency, intensive care and surgical care, starting from the scene to stabilize the patient's condition. As well as the improvement of tactical approaches to provide skilled medical care to these patients.
Materials and methods. In the period 20092012, in the Clinical Hospital № 3 490 patients with SCI and PT were delivered. For a retrospective comparative analysis, the patients who received treatment in 2009-2010 was provisionally designated as the comparative group, and patients of 2011-2012, as the main group.
The main group included 205 (41.8%), while in the comparative - 285 (52.2%) of these 490 patients.
Assistance provided to the patients of the main group, was carried out under strict observance of the principles of «damage control». For this purpose, first of all, we measured the degree of injury severity.
The term "Damage control" was first introduced into medical practice as early as the 90s of the last century, but, nevertheless, in many countries, this concept is interpreted in different ways and does not necessarily reflect its real essence. Until now, when SCI and PT in the case of low blood pressure or severe traumatic brain injury and other critical states a number of scientists recommend the implementation by two, and sometimes three surgical teams of simultaneous operations (such as amputation or open extrafocal osteosynthesis with intra-abdominal and other interventions). Any surgical intervention in such a situation is a factor not eliminating, but rather aggravating shock state of these patients and can not be recommended in practice.
To apply the principles of "Damage control" in practice three important features should be evaluated.
1. The severity of the primary injury ("First hit")
2. The biological constitution of the patient (age, weight, concomitant diseases, etc.)
3. The number of absolutely necessary surgical interventions, the expected time of their execution, injury rate and possible blood loss. These operations for patients with SCI and PT are "secondary stroke» (second hit).
Thus, the principles of "Damage control" implies the implementation of primarily urgent operations on the organs of the chest cavity,
abdomen and skull. However, it is advisable to divide these operations into two, and sometimes into three stages. In the first stage, for example, the elimination of hemopneumothorax using drainage of the pleural cavity, then performance of a laparotomy to stop intra-abdominal bleeding by clamping vessels, tamponade, insulation of damaged intestines from the free abdominal cavity and so on. At this stage, the abdomen is temporarily closed with provisionally skin sutures. Parallel to this, the intensive resuscitation support to stabilize the central hemodynamics, respiratory and cordial activity is carried out. In most cases, if it is possible to stabilize the basic vital functions, these patients in the next 24-36 hours are subject to definitive surgical correction, and laparotomy wound is finally sutured.
When injuries of the musculoskeletal system at the first stage it is expedient of imposition of immobilization devices (splints, immobilizers, etc.) and less apparatus for external fixation. In patients with SCI and PT correction of open fractures, amputations and surgical treatment of wounds are not carried out. In this case, it is necessary only to make antiseptic wound treatment, removal of debrides, the clamp is applied in damage of the main vessels and sheltering the wounds by bandage with antiseptics. At the same time the intensive syndromic resuscitation is performed. Treatment of open wounds of limbs and amputation are expedient to carry out after 24-36 hours, and in this case it is necessary to wait 3-4 hour break after the preceding operations on organs of chest and abdomen. Performing operations on the skeleton and thoracic and abdominal cavities simultaneously are not allowed. In some cases, with adequate restoration of vital functions in these patients after 6-8 days minimally invasive methods of osteosynthesis may be performed.
In our study, the severity of trauma of patients of the main group receiving treatment during 2011- 2012 and the comparative group treated in 2009-2010 were evaluated on the AIS scale (Abbreviated Injury Scale) and ISS (Injury Severity Scale), and damage coding was conducted in all patients (Sokolov V.A., 2006; Malinin D.A., Bosko J.Y., 2008).
To assess the severity of the damage on the AIS scale 6 anatomical regions (head, spine, chest, abdomen, pelvis and limbs) are used. Any damage is estimated from 1 (light damage) to 5 (critical for the life damage) points. The result is determined by the highest score, not summing up other points.
On the ISS scale an assessment of severity of the injury is carried out by determining the damage in each of the six anatomical regions according to AIS. Three of the most severe damages are squared, obtained figure characterizes the degree of injury severity on ISS scale, the maximum number of points may be equal to 75. This scale reflects in details the extent of damage in each anatomical
Table 1.
Assessment of the severity of the injury on the ISS scale
region and therefore is more attractive in practice in many countries. On this scale with the number of points equal to 25 severity is assessed as moderate, from 26-41 - severe, 41- 50 - extremely severe, up to 75 points - critical damage.
As an example, the following table provides an assessment of the severity of damage in the patient on the ISS scale adopted with diagnose of a moderate brain contusion, hepatorrhexis, fracture of the femur (Table. 1).
Anatomical regions Kind (type) of damage Points on the AIS scale Points on the ISS scale
Head brain contusion 3 9
Thorax - - -
Abdominal cavity hepatorrhexis 4 16
Limbs
Fracture of the left femur 3 9
Fracture of the right femur 3 9
Total on the ISS scale - 34 points
As seen from Table 1, in patient received the above diagnosis, severity of damage is assessed with 34 points on the ISS scale. On the AIS scale brain contusion is estimated at 3 points, hepatorrhexis - at 4 points, fracture of each of the femurs - at 3 points. On the ISS scale a square value of the greatest number of points in this case is 34 indicating severe damage.
Such patient parallel to resuscitation measures as emergency surgery, were performed suturing the hepatorrhexis by surgeon, temporary immobilization of femoral fractures by traumatologist, ie, assisted in strict compliance with the principles of "damage control". CT examination was diagnosed with brain contusion, which was taken into account in carrying out the measures of intensive care unit.
Patients with SCI and PT, admitted to the clinic, were examined by a team of doctors, which includes a surgeon, a traumatologist, a neurosurgeon, a resuscitator, a radiologist. This team is led by the most experienced of these doctors (usually a surgeon) and depending on the condition of patients in different variants there were examined and treated according to the following scheme.
1. If there is no danger to the life of the patient from his/her injuries, for intended of sergoen, neurosurgeon and traumatologist in order to clarify the diagnosis, radiological examinations were carried out and there was assisted on the basis of "damage control".
On the ISS scale severity of damage in these patients was equal to 17-25 points (moderate). In our study, these patients were 140 (28.6%).
2. In 204 (41.6%) patients on the ISS scale 2641 points (serious injury) are noted. In these patients there is a probability of occurrence or deepening traumatic-hemorrhagic shock. Therefore, against the background of resuscitative measures they are carried out a survey and assisted on the basis of "damage control".
3. In 119 (23.4%) patients, the severity of the damage on the ISS scale was estimated at 41-49 points (very severe). In this case, the patient's condition requires bypassing the emergency
department, all examinations and treatment activities to carry out in the intensive care unit or operating room.
4. 27 (5.5%) patients had critical and agonal states (75 points on the ISS). These patients died within 30 minutes, regardless of the treatment.
In 140 (28.6%) patients, whose severity of injuries are rated on the AIS and ISS scale as moderate, despite some complications in treatment (in these patients 27.5% in the comparative and 18.3 % in the main group early complications were observed) there were no cases of death.
Thus, in the provision of care to patients of the main group, whose status has been assessed as moderate, thanks to a new algorithm of diagnosis and treatment and strict observance of the principles of "damage control", there were no deaths and in the main group early complications decreaded from 27.5 to 18.3%.
For 204 (41.6%) patients whose condition is estimated as heavy (on the ISS scale between 2641 points) resuscitative measures were initiated in the emergency department and in parallel medical diagnostic measures on the principles of "damage control" were carried out.
To patients admitted to the hospital with severe injuries, first of all, the measures were applied in the direction of correction of vital functions:
1. For the restoration of patency of the upper airway and provision of the body with a sufficient amount of oxygen intubation was carried out for 132 (26.9%) patients.
2. Correction of hemodynamic in the compression of the brain and spinal cord, causing life-threatening.
3. The transfusion of red cel, plasma, albumin, restoration of blood circulation, antishock therapy, correction of a water-salt and acid-base balance were carried out.
We have identified conditions such as when damaged skull - an open fracture, with neck injury - damage to the larynx, trachea, blood vessels, chest trauma - an open injury, and subcutaneous
emphysema, with abdominal injuries - massive blood loss, hematuria, open fractures of the limbs.
In 98 (77.8%) patients of the comparative group, and in 128 (44.9%) patients of the main group with SCI and PT at ultrasound examination there were revealed such changes in the thorax as a hemothorax and hemopericardium, changes in the structure and size of spleen, liver and kidneys. In 27 (5.5%) patients urethrographic examination and emergency operation (riptures of kidneys and bladder) were conducted. In 117 (23.9%) patients after survey of the neurosurgeon it was conducted computer-tomographic examination. As a result of clinical and instrumental examinations, it was found
the incidence of damage to the anatomical regions, as shown in Table 2.
As noted above, 27 (5.5%) of 490 patients were admitted to the hospital in the agonal state. These patients due to the very short lifetime in the hospital are failed in instrumental diagnostics. The diagnosis in these patients was set as clinically and updated at postmortem examination at autopsy.
The remaining 463 (94.5%) patients were conducted various clinical and instrumental investigations for the above schemes. Based on these studies, the frequency of damage was determined in anatomical regions that were presented in Table 2.
Damaged anatomical region Main group Comparative group The total number of patients
Patients discharged home after treatment Patients whose treatment ended lethally Total Patients discharged to home after treatment Patients whose treatment ended lethally Total
Brain contusion 61 (47,3%) 68 (52.7%) 129 (45.3%) 42 (46,7%) 48 (53.3%) 90 (43,9%) 219 (44,7%)
Thorax 71 (56,3%) 55 (43.7%) 126 (44,2%) 42 (53,2%) 37 (46,8%) 79 (38.5%) 205 (41,8%)
Abdominal cavity 18 (40%) 27 (60%) 45 (15.8%) 20 (44,4%) 25 (55,6%) 45 (21,9%) 90 (18,4%)
Musculoskeletal system (fractures) 163 (68,5%) 75 (31,5%) 238 (83.5%) 116 (71,6%) 46 (28,4%) 162 (79%) 400 (81,6%)
Table 2.
The frequency of injuries of different anatomical regions of the main group and the comparative group
As seen from Table. 2, in 400 (81.6%) of 490 patients damage to the musculoskeletal system was observed, 219 (44.7) patients
had brain contusion, 205 (41.8%) patients had thorax injuries and 90 (18.4%) patients had damage to abdominal organs. In the main group 83.5% of patients had injuries of the musculoskeletal system, whereas 79% of patients in the comparative group. Brain contusions in the main group were revealed at 45.3% of patients, in the comparative - at 43.9%. Damage of thorax in the main group - at 44.2%, and in the comparative group - at 38.5% of patients, abdominal injury - at 15.8% in the main group, and at 21.9% - in a comparative group, ie patients in the main group had a slight increase in skeletal, head and chest injuries. Abdominal damages, on the contrary, are somewhat lower than in the comparative group. However, the number of patients who died from head and chestinjuries, was slightly less than the deaths from abdominal injuries and musculoskeletal system. What we should pay attention is to the formation of therapeutic and diagnostic aspects.
Status of 140 (28.6%) of 490 patients was evaluated as moderate, 204 (41.6%) patients with severe, 119 (24.3%) patients with very severe degrees of severity. 27 (5.5%) patients were admitted to the clinic in preagonal and agonal states, and they had dead in the first 30 minutes.
For 119 (24.3%) patients whose conditions were evaluated as extremely difficult (on the ISS scale above 41 points) resuscitative measures were initiated in the emergency department. In urgent intubation was performed, beam diagnostic examination was conducted in parallel, 72 (14.7%) patients were conducted a laparotomy, 17 (3.5%) patients - thoracotomy, 8 (1.6%) patients was carried out craniotomy, in 17 (3.5%) patients stop bleeding was conducted as emergency operation after the amputation and open fractures.
In 30 patients (14.7%) out of 204 (41.6%) with severe trauma treatment has been fatal. 174 (85.3%) patients after treatment were discharged home. Treatment of 107 (89.9%) of the 119 patients (24.3%), the states of whose were rated as extremely difficult, was fatal, lives of only 12 (10.1%) patients were saved.
Table 3.
Distribution of patients by groups and the severity of injuries.
Groups Patients discharged home after treatment Patients discharged to home after treatment The total number of patients
Moderate Severe Extremely severe Total Moderate Extremely severe agonal stage Total
The main group 72 (25,3%) 103 (36%) 7 (2,3%) 182 (63,9%) 16 (5,6%) 69 (24,2%) 18 6,3%) 103 (36,1%) 285 (58,2%)
The comparative group 68 (33,2%) 71 (34,6%) 5 (2,4%) 144 (70,2%) 14 (6,8%) 38 (18,5%) 9 (4,4%) 61 (29,8%) 205 (41,8%)
140 (28,6%) 174 (35,5%) 12 (2,4%) 326 (66,5%) 30 (6,1%) 107 (21,8%) 27 (5,5%) 164 (33,5%) 490
As can be seen from Table 3, among patients in 2009-2010, ie, in the comparative group, patients with injuries of moderate severity reached 33.2%, whereas in the main group in 2011- 2012 the figure was 25.3%. In the comparative group, patients with severe injuries were accounted for 41.5%, and with extremely severe - 21%, whereas in the main group, these figures were 41.8% and 26.7% respectively. In the comparative group patients brought to the hospital in the agonal state were amount of 4.4%, and in the main group the figure was in excess of 6.3%. These parameters once again prove that among patients with SCI and PT extent of damage each year continues to grow. For this reason, it is necessary to carry out research on the formation of more advanced concepts of diagnostic and therapeutic measures.
As seen from Table 3, patients with severe injuries and those whose treatment ended lethally in the comparative group were accounted for 6.8%, and 5.6% in the main group. Mortality in patients with very severe injuries in the comparative group was 18.5%, whereas in the main group, the figure was 24.2%.
Thus, the mortality rate among patients with severe injuries was decreased. However, among patients with extremely severe injuries despite the strict observance of the principles of "damage control", mortality was increased. For this reason, among these patients, the principles of assessing the severity of the damage should be reviewed, and algorithms for treatment and diagnosis should be improved.
Patients whose conditions were estimated as severe (204-41,6% of patients) and extremely severe 119 (24.3%) (total 323-65,9% of patients) at admission to the clinic only in 12% (39 patients) the number of hemoglobin was below specified standards. After 1 day, 72% of patients (232- 47.3% of patients) had hemoglobin levels below normal (Hb 90-100 g / l), and in some patients (52-16% of patients), a serious decline in the level of hemoglobin was observed only in 5 -7 days.
When planning an intensive therapy to properly assess the degree of severity of the injury all these factors should be taken into account. In addition, initiated at the scene emergency - pre-clinical and internal clinical assistances should make a certain sequence. Fast and accurate carrying out of diagnostic
and therapeutic measures, as well as the quality and quantity of injected fluids to regulate traumatic disease (TD) and acute respiratory distress syndrome (ARDS) should be under strict control.
Almost in all patients with multiple organ failure acute respiratory distress syndrome (ARDS) is developed [5]. On the other hand, 50% of patients with ARDS have dysfunction of two or more organs [7,9,11]. Despite the decline in mortality in patients with ARDS, the figure still remains high at 22-74%, a third of these patients (1624%) die due to the inability to correct hypoxemia. All this is due to the impossibility of a full examination of the complex mechanisms of the pathogenesis of this process and an incorrect diagnosis at an early stage [10].
Thus, an early correct diagnosis of ARDS is difficult clinical problem. All the above mentioned parameters must be taken into account for the diagnosis and treatment of these patients. The severity of damage to the patient must be properly assessed, time and duration of the urgent, immediate and deferred operations should be properly selected. If, after the emergency surgery patient has complications, there are difficulties in planning treatment strategy, and during the process gets out of control. As a result, disability and mortality are increased. Here is an example: S.R. patient, male, 26 years old. Date of admition: 05.10.2011-09.01.2012. The diagnosis: a closed craniocerebral injury, brain contusion, laceration of the liver, a closed fracture and displacement in both thighs. Since entering the clinic in parallel with resuscitation measures laparotomy and suturing of liver wounds were conducted. A few hours later a second operation was performed - relaparotomy, cholecystectomy, removal of ileostomy. After 10 days, the patient was carried rerelaparotomy - opening and drainage of interloop abscess. The patient was imposed tracheostomy, he was more than a month in a coma.
Despite the fact that in patient admitted to the clinic the severity of the injury on the ISS scale was rated as severe (26-41 points), as a result of early complications of emergency surgery performed at an early stage of traumatic disease, condition of the patient was transferred from the severe to extremely severe. Because of the patient's condition a planned operation in connection with fractured thighs could not be held.
S.R. patient.
Closed fracture and displacement in both thighs.
As can be seen from the X-rays in the femur the patient has a wrong coalescing fracture. Due to the severe state a minimally invasive osteosynthesis has been failed to carry out. A result of this is a potential disability.
We propose to use regardless of the type of traumatic injury the following algorithm.
1) Adequate anesthesia;
2) Full restoration of the airway, ensuring adequate ventilation, and a free lung spread, draining the pleural cavity;
3) Stop the bleeding and restore lost blood volume;
4) Immobilization of injured limbs;
5) Conduct a full infusion and antibiotic therapy.
Thus, in the completion of research we can
formulate the following conclusions:
1. Patients with severe combined injury and multiple injuries after admission to the hospital, for a correct choice of tactics and surgical intensive care measures there should be determined the severity of the injury. To do this in a short period there should be identified all damages and fully formulated a diagnosis.
2. In the treatment of patients with severe combined injuries and polytraumas there should be applied new therapeutic - diagnostic measures with widespread introduction of modern principles of "damage control».
3. In order to reduce disability and mortality for a more progressive treatment and diagnostic algorithm the research in this direction should continue.
References_
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