THE ANALYSIS OF THE RESPONSES TO THE ARTICLE BY AGADZHANYAN V.V. "ARRANGEMENT OF MEDICAL ASSISTANCE FOR MULTIPLE AND ASSOCIATED INJURIES (POLYTRAUMA)" PUBLISHED IN THE JOURNAL POLYTRAUMA, NO.4, 2016
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Agadzhanyan Vagram Vaganovich, MD, PhD, professor (chief physician of Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky): the article presents the project of the uniform protocol for treatment of multiple and associated injury (polytrauma).
The main aim of development of the project is implementation of the main interdisciplinary approaches to arrangement of medical aid at the prehospital and hospital stages, as well as the principles of early effective diagnostics, treatment and prevention of complications in patients with polytrauma.
The project of the clinical recommendations is not only generalization of the common approaches to solving the problem of polytrauma, but also the attempt to adapt the accumulated international and personal twenty year experience towards the conditions of domestic healthcare.
All of this requires estimation and summing of all currently available findings about arrangement of medical aid for multiple and associated injury with the aim of development and acceptance of the consistent Russian national guidelines for diagnostics and treatment of patients with polytrauma.
Goncharov Sergey Fedorovich, MD, PhD, professor (director of All-Russian Disaster medicine Center “Zashchita”, chief free-lance specialist of disaster medicine of Russian Healthcare Ministry, chief of the main office of All-Russian service of disaster medicine, Moscow): the discussed project of the clinical guidelines contains the modern generalized organizational and clinical approaches to management of patients with polytrauma at the prehospital and hospital stages. It is worthy of note that the own experience of polytrauma management is considered (more than 3,000 cases). The priority tasks of the prehospital stage, the principles of medical aid at accident site, the range of medical and diagnostic procedures and management tactics in hospital conditions have been determined. The procedures for the period of medical evacuation to the medical facility have been systematized. According to our opinion, the presented protocol of treatment contains some update and substantiated medico-diagnostic measures and some arrangement approaches to management of patients. The confirmation of the clinical recommendations will favor the development of the uniform approaches to treatment of patients with polytrauma, will increase quality and availability of modern types of medical aid for such patients.
Ayvazyan Vachagan Petrosovich (director of the Scientific center of traumatology and orthopedics, chief traumatologist-orthopedist of Health Ministry of Armenia, chief of the chair of traumatology and orthopedics, Erevan State Medical University, Erevan, Russia): I have read the electronic version of the fourth issue of Polytrauma. I have taken a look at the project of the clinical recommendations for polytrauma (the treatment protocol). It is high time to use the written and confirmed projects for examination and treatment of various diseases. Unfortunately, despite its advantages, the Soviet medicine did not set such tasks. However in the current days when the laws dominate emotions and the huge amount of information exists, like in the foreign countries, we need to regularize and legalize some protocols for most cases. These protocols will help doctors to correctly select techniques and depth of examination and methods of optimal treatment, as well as will protect from complaints and trial.
Now let’s turn to polytrauma. Although the term polytrauma is translated as multiple injury and is interpreted so in most old books, currently we perceive the word polytrauma as significantly more severe condition than fractures of two bones. You have properly described the terminology, the classification, pathologic physiology of polytrauma and the clinical periods of traumatic disease course. The special importance relates to arrangement of necessary aid at different stages – from the accident site to the specialized hospital. It is important to describe the volume of necessary medical aid in dependence on the level of a medical facility. It is known that the level of the facility depends on availability of equipment and staff. There is a protocol for transferring the patient from the medical facility of high level.
The stages and diagnostics and treatment have been determined precisely.
There is one note: according to my opinion, the list of delayed surgical interventions is unnecessary. It can slightly limits the volume of interventions or, conversely, to force the doctor to accomplish such list. I think that description of delayed operations immediately under the title is enough (both paragraphs).
Your personnel headed by You have made the great work. Being the leading facility dealing with polytrauma, no other than you should generalize the experience of treatment of hundreds patients with polytrauma and develop the protocols.
Grigoryev Evgeny Valeryevich, MD, PhD, professor (chief of the chair of anesthesiology and critical care medicine, Kemerovo State Medical Academy, Kemerovo): one should adhere to the term multiple organ insufficiency instead of multiple organ dysfunction offered by the authors.
One should adhere to the term systemic inflammatory response (SIR) instead of addition of the word syndrome, because the combination of clinical manifestations of SIR is not the syndrome of critical states.
Ustyantseva Irina Markovna, doctor of biological sciences, professor (deputy chief physician of clinical laboratory diagnostics, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky): let us indicate some terminological specifications for substantiation of the terms systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS) in polytrauma. Systemic inflammatory response syndrome (SIRS) is a systemic non-specific response of the body to various stimuli or pathologic agents with manifestation in view of activation of all mediatory systems and pathologic biochemical cascades which are responsible for inflammation. This is a typical pathologic process, which is common for all life threatening conditions with maximal activation of the compensatory mechanisms of the body.
The concept of systemic inflammatory response syndrome was offered by R. Bone at al. in 1989. They tried to identify the patients with heterogeneity in the classical symptoms of sepsis and found the evidence of presence of the systemic response to the infection. Afterwards the concept was approved by the compromissary conference of the American Thoracic Society and the Critical Care Medicine Society (1992).
SIRS was defined as the clinical manifestations of systemic inflammation regardless of the cause. The hypothesis was accepted that SIRS was initiated by the local or generalized infection, trauma, thermic injury or the aseptic inflammatory process. The developed diagnostic criteria of the infection, sepsis, severe sepsis and septic shock were recommended for implementation into practical and researching activity. Despite of multiple revisions of the concept by Bone R.C., it did not acquire any essential changes. The improved (the third) edition of the clinical guidelines Surviving Sepsis Campaign (SSC12) was published on February 2013. Another revision of the definitions of sepsis added some new signs symptoms and laboratory indices (C-reactive protein, procalcitonin, glucose, lactate) indicating the possible presence of sepsis. Currently, most foreign and domestic researchers and practicing physicians use the criteria by Bone R.C. (1992) for SIRS diagnostics approved by the agreement conference of thoracic surgeons and specialists of critical care medicine (ACCP/SCCM) (2003, 2008).
The consensus conference ACCP/SCCM (2003, 2008) recommended using the term MODS for description of the examined process from two perspectives. Firstly, the MODS physiological disorders presented a complex of potentially reversible dysfunction. Secondly, the fact was considered that a certain syndrome is a sequence of activation of systemic inflammatory response. The factors favoring development of MODS are severe metabolic disorder after trauma; blood circulation disorders; the limited organ function; development of sepsis.
The pathogenesis of MODS in polytrauma is multifactorial and is determined by acute blood loss, pain, stress, hypoxia, hypovolemia, metabolic acidosis and shock. Primary multiple organ insufficiency is caused by blood circulation failure, respiratory and cerebral insufficiency and disseminated intravascular clotting (DIC). Primary MODS does not cause systemic inflammation, and organ and tissue dysfunction is associated with influence of a certain cause resulting in the stress response. It is a special type of adaptation with orientation to survival in critical conditions. The efferent response is realized through the activation of nervous and endocrine system with increasing activity of sympathetic nervous system, release of the pituitary hormones (adrenocorticotropic, somatotropic and antidiuretic hormones), glucocorticoids and increasing synthesis of the cytokines. The main role in the acute phase of stress is given to the nervous system as the rapid response system, when the cytokine response is timely delayed.
Multiple organ dysfunction syndrome (MODS) is one of the most severe complications of critical states in children. It determines the outcomes of the disease and the patient’s life quality in short term and long term periods. MODS appeared as result of development of intensive therapy and technical support favoring the survival of previously uncurable patients. Artificial lung ventilation, dialysis, nutritive support and other directions favor the increase in survivability, as well as increase development of MODS in most survived children.
Therefore, the clinical picture of posttraumatic states in polytrauma is many-sided and is determined by toxic affection of various organs and tissues. The signs include some circulatory disorders of blood coagulation, cardio- and nephropathy, development of toxic hepatitis, neurological disorders and acute respiratory insufficiency. The indicated disorders make the basis of multiple organ dysfunction syndrome and mainly rely on the data of the regular patterns of development of systemic inflammatory response syndrome. It is necessary to use early diagnostics and correction of organ disorders in clinical practice. It will timely eliminate appearance of multiple organ dysfunction.
Grigoryev E.V., MD, PhD, professor, the chief of chair of anesthesiology and critical care medicine, Kemerovo State Medical Academy: “The term traumatic disease should be avoided, so it is not supported in the modern concepts of critical states and in the foreign literature”.
Kravtsov Sergey Aleksandrovich, MD, PhD (the chief of the center of anesthesiology and intensive care, Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky): the concept of early targeted therapy is widely used for various critical conditions. It is based on use of the combination of available modern diagnostic methods, monitoring of the patient’s condition and complex treatment. It favors the increase in quality of rendering medical assistance, decreasing mortality and disability. Therefore, the presented project of arrangement of medical aid for patients with multiple and associated injuries (polytrauma) and the treatment protocol on the basis of this concept are topical and create some premises for wide discussion.
The author’s work dedicating to the analysis and the review of the available modern diagnostic and curative methods for multiple and associated injuries and the analysis of more than 3,000 cases of medical aid for the patients with various types of polytrauma allow proper reviewing of the features of arrangement and realization of medical aid at different stages. The attention is given to both the complex issues of diagnostics for such patients and necessity for succession, consistency and the interdisciplinary approach to organization of the curative process. For this purpose the issues of terminology, classification and pathophysiology are reviewed, which give the presented range of the recommendations on the basis of support of the standards including the fields of education, improving execution, arrangement of activity of traumatological (interdisciplinary) teams and the auditing measures in hospitals.
Along with the doubtless scientific practical value of the study, some moments are the matter of argument.
The analysis of the domestic and foreign publications about the problem of severe injury (for the last 35 years after 3rd All-Union convention of traumatologist-orthopedists) showed some disputable points (i.e. unsolved issues in Russia and abroad) about the terminology, definition of the terms, classification and objective estimation of severity of injuries and conditions, organization, diagnostics, treatment and rehabilitation of patients. Severe injury, shock and subsequent complications resulted in appearance of two similar directions, which allow the conceptual approach to solution of these two issues. The domestic and foreign literature reviews severe injuries and shock as the main causes of development of systemic inflammatory response syndrome, multiple organ dysfunction/insufficiency that determine the severity of state after trauma and outcomes. During all these years the foreign literature gave the main attention to identification of severity of injuries and condition at a definite time period, estimation of developing pathophysiological processes. On that ground the approach to terminological uniformity appeared. The terms of single, multiple, associated and concomitant injury were developed, and the uniform interpretation of the term polytrauma was accepted. Development of the complex programs for arrangement, dynamic observation and treatment is still proceeding along with development of the uniform systems for objective estimation of injury severity (AIS and ISS), severity of condition, degrees of intensity of multiple organ dysfunction (APACHE II, SOFA, MODS, GCS and so forth). The domestic literature reviews the posttraumatic and postshock processes as the uniform pathological process with the clear particularities and relationships between changes in different systems of the body. It allows not disarticulating this pathological process to individual links, but reviewing it as the uniform pathology with its own patterns. During 50s of the last century (the studies by Burdenko N.N., Davydovsky I.V., Robert Klark) this approach led to appearance of the term traumatic disease, which is used not only in the domestic literature. The studies, which were conducted during the last 30 years, allowed detalizing the incidental points of development of traumatic disease (Seleznev S.A. et al., 1984; Kreyner A.N. et al., 1991; Grinev M.V. et al., 1992; Agadzhanyan V.V. et al., 2003; Bagnenko S.F., 2004; Gumanenko K.E. et al., 1998, 2008; Kotelnikov G.P. et al., 2009; Baker S.P. et al, 1974; Sander E., 1983; Tscherne H. et al.,1983; Champion H.R. et al., 1981, 1983; Border J.R et al., 1987; Fischer R.P., Miles D.L., 1987; Vincent J.L. et al., 1998; Martin G.S. et al, 2003 and others; the list goes into infinity) that gave the significant incentive for development, which is still continuing. The pathogenetical classification of the periods of traumatic disease has been developed. The complexes of organizational, medico-diagnostic and rehabilitation measures for patients with severe injuries are being developed. The term traumatic disease is increasingly frequently used during international forums. I believe that its usage is absolutely substantiated and legal.
Grigoryev Evgeny Valeryevich, MD, PhD, professor: the description of the prehospital stage: the error is lateral positioning for the patient (danger of additional displacement of possibly injured cervical spine). The similar situation relates to the mistaken offer to lower down the head of the bed by a patient with shock (danger of aspiration and suppressed consciousness).
Kravtsov Sergey Aleksandrovich, MD, PhD: I agree with these comments and mistakes. Without changing the whole structure of the section of the prehospital stage, it is necessary to change or possibly combine the sections 5 and 6: “safe positioning – to put onto the board back or even surface, to provide the immobilization for the main regions of the injury. The transportation splints are applied to the injured extremities and the neck”.
Grigoryev Evgeny Valeryevich, MD, PhD, professor: the description of premedical assistance: the wrong offer is cardiotonic and vasopressor agents (in conditions of shock, the accepted concept is infusion-transfusion therapy and permissible hypotension). The similar situation is associated with adequate analgesia (at the background of unrestored circulating blood volume, it leads to collapse because of drug-induced vasodilatation). I am totally against introduction of respiratory analgetics.
Description of initial care: I am totally against regionary or local anesthesia (worsening hemodynamics at the background of resorption of local anesthetic drugs and non-corrected hypovolemia). The similar situation relates to elimination of lung edema (as the manifestation of ARDS – too early timeframes).
Kravtsov Sergey Aleksandrovich, MD, PhD: we think that combining these two notes is possible. They are correct and contradictory to the modern concept of treating critical states. It is unacceptable to use cardiotonic and vasopressory agents and regionary or local anesthesia in conditions of shock. The risk of irreversible complications (collapse, heart arrest) is extremely high after usage of the above-mentioned drugs. The items 2 and 3 of this section (Prehospital medical aid (paramedic)) are needed to be removed or replaced in the next edition:
“Realization of the complex of infusion therapy. Crystalloids. Colloid solutions. It is possible to use the infusion of hypertonic/hyperoncotic solutions (for example, influcol with 7.5 % hypertonic solution of natrium chloride or similar solutions)”.
The item 10 (the section “First medical aid”) contains the phrase “prevention of lung edema” instead of “control of lung edema”. Probably, this item is not clearly described, and it caused the question from honorable professor Grigoryev E.V. This item describes prevention of lung complications. Its basis is sanitation of the tracheobronchial tree. ARDS develops in later timeframes, as it was correctly noted. It is common knowledge that timely removal of mucus, blood and other substances from the tracheobronchial tree is an important link in prevention of pulmonary complications (including ARDS) in severe trauma. The project reviews that particular aspect of curative measures at that stage of first medical aid, but no treatment of ARDS. It is possible that the further working on the project “Sanitation of the tracheobronchial tree” it is necessary to put it onto the first place for prevention of dittology of the recommendations.
Grigoryev Evgeny Valeryevich, MD, PhD, professor: description of the protocol of intensive care measures at the prehospital stage: 1) realization of the complex of the measures should be initiated for any manifestations of shock (the supposed volume of blood loss according to the clinical data, cold skin, mental status + AP level and others), use of only AP and the fact of its decrease for diagnostics of shock means lengthening the timeframes of making the decision about initiation of therapy at the background of the stage of shock compensation, 2) I am totally against local anesthesia (please see above), 3) prednisolone and other forms of corticosteroids are not indicated because of absence of evidences, 4) one ought to include the possibility of infusion of hypertonic/hyperoncotic solutions into primary resuscitation.
Kravtsov Sergey Aleksandrovich, MD, PhD: as indicated in the project, the whole basic prehospital intensive therapy is based on the clinical data, which are previously accentuated in the sections “Prehospital medical aid (paramedic)”. “First medical aid”. In concordance with the concept of early targeted therapy it is recommended to initiate the complex intensive therapy of shock. Intensive care is necessary in absence of effects of therapy or worsening state. Therefore, for the prehospital stage it is offered to use simple and available methods of estimation of condition for quick estimation of patient’s condition and drawing the intensivist’s attention to realization of the complex of intensive care. I see no reasons for additional circumstantiation of this item of the prehospital resuscitation protocol.
The important component of anti-shock therapy is analgesia. Adequate analgesia is necessary for prevention of development of hemodynamic instability, increasing respiratory excursion of the chest (especially for patients with thoracic, abdominal and spinal injuries) etc. For total analgesia we use the drugs of resorption action. Intravenous introduction of opioids is preferential; according to indications – in combination with hypnotics, ataractic etc. Choice of the combination of the drugs depends on severity of the patient’s condition, characteristics of trauma, competence of the physician, equipping status of the team, which realizes medical aid and so forth. I see no need for detailed description of this item.
It is known that detailed analgesia (in absence of contraindications such as local infection and coagulopathy) and the analgesia methods controlled by the patient promote better elimination of pain syndrome in stable state of the patient (Barach P.J., 2001; Raj P.P., 2009; Ovechkin A.M., 2001; Svetlov V.A. et al., 2011). The well-known recommendations include local analgesia (novocaine, lidocaine) for fracture sites during reposition of bone fragments. But in this case I agree that these recommendations are to be excluded from the project”. Most blockades require from the patient his active participation in analgesia. Most victims with polytrauma are not available for productive contacting because of severity of their condition, traumatic brain injury, artificial lung ventilation and so forth. Use of electric stimulators for realization of nerve block anesthesia lengthens time of anesthesia that makes some troubles, for example, in injuries to nerve stems and plexus of big segments of the extremities and also in use of muscle relaxants. Moreover, the insufficiently researched moments include the influence of regionary anesthesia on central hemodynamics and state of neurohumoral response in acute development of critical states including severe associated injury and polytrauma (Jage J., Heid F., 2006, Schulz-Stubner S., 2010).
Currently, there are no evidence of efficiency of prednisolone and other glucocorticoids in traumatic and hemorrhagic shock. This point may be excluded from the recommendations.
The first stage of hemodynamic support is realization of the complex of infusion therapy, introduction of infusion solutions (crystalloids, colloids) for rapid recovery of adequate perfusion. Isotonic crystalloid and isooncotic colloid solutions provide the same clinical efficacy. Solutions with osmotic activity determine immediate increase in circulating blood volume by means of its volume, as well as promote additional flow of interstitial fluid to the vessels (by means of increase in colloid and osmotic gradient “vessels-tissues”. Such solutions include HES-based agents, which are noticed in the project, and crystalloid solutions such as 7.5 % natrium chloride or similar solutions. There are some indications for infusion of hypertonic/hyperoncotic solutions and their inclusion into the recommendations of the project.
Grigoryev Evgeny Valeryevich, MD, PhD, professor: the hospital stage: it is advisable to use the possibilities of FAST protocol for ultrasonic screening.
Kravtsov Sergey Aleksandrovich, MD, PhD: for reduction of time expenses the prehospital and primary hospital stages should include FAST (Focused assessment with sonography for trauma), which is oriented to rapid identification of intraabdominal bleeding and potentially dangerous organ injuries. The protocol is an obligatory part of ATLS (Advanced Trauma Life Support), an efficient educational concept, which has been accepted in more than 50 countries.
FAST includes ultrasonic scanning of the abdomen and the chest including 5 points, but actually 3 points are used, because flank points almost coincide and one passes to another. The English speaking countries use 6th point (echocardiographic). It is based on the subcostal position for rough estimation of heart activity and primarily for prevention of cardiac tamponade. Ultrasonic examination with FAST usually takes up to 2 minutes for abdominal trauma.
Currently, FAST is replacing diagnostic laparocentesis, because of its higher efficiency, safety, lower time consumption and reduced difficulty of realization. Moreover, the important part is a possibility for multiple use for dynamic control, decreasing radial load (CT) and prevention of excessive need for intrahospital transportation.
In the discussed project these recommendations are included into the algorithm of actions performed by the medical team in anti-shock room. “Sonography: abdomen”. Possibly, this item is to be extended a little – “Abdominal and thoracic sonography according to FAST protocol”.
Despite the fact that the presented protocol includes some equivocal recommendations, I would like to thank the author for his important work and to express my hopes for continuation and completion of the research.
Grigoryev Evgeny Valeryevich, MD, PhD, professor: It is desirable to translate English abbreviation into Russian for better understanding by common doctors.
Ustyantseva Irina Markovna, doctor of biological sciences, professor: from one side, most part of English abbreviations passed into the modern medical lexicon and became common in the Russian speaking society. From other side, sometimes direct transcription of foreign words does not allow getting out the author’s message after translation into foreign language (Russian).
The editorial board of Polytrauma journal expresses sincere appreciation for the mailed reviews and fast responses!
We invite all interested specialists for further productive cooperation and discussion in solution of the complex interdisciplinary medical problems for treatment of polytrauma.