Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

In Russia the prehospital and hospital mortality after polytrauma exceeds the rates in other foreign countries. According to All-Russian data only 40 % of patients with polytrauma are admitted to day and night clinics, 30 % die at accident site and about 30 % - during transportation. Because of extreme severity of state, victims are admitted to from accident site to nearest medical prophylactic institutions, mostly non-specialized. Treatment and examination of such patients in full volume are difficult because of known limitations of possibilities in non-specialized medical prophylactic institutions. In this regard after realization of primary anti-shock measures and controlling external and internal bleeding the maximally earliest transfer of these patients to specialized multi-profile facilities is performed [1, 3, 10].

Without proper immobilization transport of patients, especially with fractures, is inadmissible even for short distances, because it can result in increase of displacement of bone fragments, nerve and vascular injuries near mobile bone fragments, fat embolia and additional bleeding. Transport immobilization allows to prevent such complications, to significantly reduce pain for a patient. As a result, it is included into the list of main measures for prevention of such dangerous complications of severe injuries including traumatic shock. There are many different standard transportation splints for realization of temporary immobilization for bones of upper extremities. However, standard splints do not provide proper immobilization of bone fragments (especially for bones of lower extremities and pelvis) that result in additional discomfort, pain feelings and worsening degree of state severity during transportation [3].

Since 1992 Russia has experience of using Kashtan anti-shock suit (ASS) which was developed in Sklifosovsky Scientific Research Institute of Emergency Medical Aid in association with Zvezda Research and Production Enterprise. The clinical trials were performed in conditions of military actions in Transdniestria and Tadzhikistan. The results showed its high reliability [9]. The principle of action of Kashtan ASS is external pneumatic compression of the lower half of the body that results in blood flow redistribution in favor of vital organs [4]. Anti-shock effect is realized through inflation of two leg sections and one pelvic section of Kashtan ASS, with reaching the pressure of 60-80 mm Hg. During 8-10 minutes blood redistribution takes place from the lower extremities and pelvis into the upper half of the body. It corresponds to transfusion of 1.5-2 L of autoblood [8] accompanied by increase in system arterial pressure by means of increase in peripheral resistance of vessels of the lower extremities. Decrease in vascular capacity allows to cover blood flow requirements for patients by means of lesser blood volume. The literature includes the data about heart rate increase after rising venous return of the blood to the heart before carrying out of full volemic support [7], mechanic centralization of blood circulation, improvement of coronary and brain blood flow [13]. But during shock of degree I the peripheral resistance (PR) is already increased in relation with compensatory reactions of the body (circulation centralization), and use of Kashtan ASS with maximal compression of 60-80 mm Hg can result in higher worsening microcirculation by means of additional mechanic compression [3, 13]. It challenges the appropriateness of its use. During shock of degree II the compensatory reaction of the body runs down and shifts to decompensation phase, and at this moment PR decrease is noted. Use of Kashtan ASS with recommended mode of pneumatic compression is rational. However, use of Kashtan ASS with compression in leg and pelvic sections with 60-80 mm Hg, in abdomen one – up to 60 mm Hg is associated not only with positive anti-shock effect, but also with some limitations: during abdominal wall compression > 60 mm Hg decrease in systolic output (SO) is observed; it is associated with inferior vena cava compression and it limits possibility of using Kashtan ASS during respiratory disorders associated with severe thoracic injury. Besides, long term use of Kashtan ASS can result in trophic changes in tissues development of compartment syndrome and, in further, in severe reperfusion syndrome [3, 4]. Therefore, it is necessary to revise the compression values for their optimization.

During interhospital transportation it is necessary to consider negative influence of additional stress factors. Vibration has the most significant influence: increase in muscular activity, metabolism and redistribution of blood flow with peripheral vasoconstriction [11]. As a rule, this factor is without attention because of short duration of transportation, but it can significantly provoke worsening state of patients. With creation of additional amortization Kashtan ASS allows significant reduction of negative effect of this factor.

High complexity of transportation of patients with polytrauma (because of high severity of their state) testifies necessity of improvement of methods of transport immobilization during interhospital transportation of this category of patients.

Objective – to optimize the modes of pneumatic compression of Kashtan ASS for carrying out transport immobilization of patients with polytrauma during their interhospital transport.

MATERIALS AND METHODS

The study included 35 patients with polytrauma. There were 24 men and 11 women. All patients were transported from the non-specialized medical facilities of Kuzbass region to Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky. The indication for transfer was absence of medical and diagnostic opportunities for rendering specialized assistance for patients with polytrauma. The mean time of interhospital transport was 152 ± 17 min. Transfer was realized in the early period of traumatic disease (days 4-5 after trauma).

The inclusion criteria to the study program were age 20-60 (mean age 37 ± 2.1), clear consciousness, presence of fractures of pelvis and/or lower extremities, ISS ≥ 14 [10], compensated state according to the scale for assessment of severity of state in polytrauma by H. Pape [2].

The exclusion criteria from the study program were ongoing bleeding, traumatic shock, additional injuries (TBI, thoracic injury, abdominal trauma), concurrent pathology in decompensation stage.

All patients were divided into 3 groups. The first group included 5 patients, the second and third groups – 15 patients. In the first group pneumatic compression was 30 mm Hg, in the second one – 400 mm Hg, in the third one – 50 mm Hg.

Circulating blood volume compensation in the groups was performed during previous 4-5 days with arresting stress shock reactions [6]. During interhospital transportation all patients had infusion of crystalloid solutions (0.9 % NaCl, Ringer's solution) with volume of 440.0 ± 112.0 ml and compensation of compensation physiological needs.

During transportation Kashtan ASS was used not for anti-shock purpose, but for immobilization of the lower extremities and pelvis. With this aim Kashtan-1D ASS was used. It includes distraction splint for proper immobilization of lower extremity fractures and reposition of bone fragments by means of axial traction up to 10 kg. Also different modes of low pneumatic compression for effective lateral stabilization were used (30, 40 and 50 mm Hg).

Before placement into Kashtan ASS all patients received anesthesia with narcotic analgetics (promedol 2 % - 1 ml i.m., morphine 1 % - 1 ml i.m.). During transportation according to indications the additional analgesia with narcotic analgetics was performed.

For evaluation of reliability of immobilization during interhospital transportation X-ray methods were used. After application of Kashtan ASS for all patients radiography of locations with fractures of the lower extremities and pelvis was performed. The same study was performed in a specialized traumatology center after interhospital transportation.

During interhospital transportation for assessment of pain syndrome strength the 5-point verbal rating scale (VRS) was used [12]. This scale allows to evaluate intensity of pain expression through qualitative verbal assessment. Pain intensity was evaluated with the point system which was preliminarily accommodated with a patient within the range 0-4 points: 0 – no pain, 1 – slight pain, 2 – pain of middle intensity, 3 – strong pain, 4 – very strong pain.   

During transportation AP and HR monitoring was performed for all patients.

The statistical analysis was performed with Microsoft Excel and Statistica 6 (StatSoft Inc., USA). For quantitative variables the test for normalcy of distribution using Shapiro-Wilk test was performed. Variables were described with mean (M) and standard error of mean (m). Student’s test was used for evaluation of the obtained results. The critical level of significance for p was 0.05. In the case of p > 0.05 null hypothesis was accepted.

RESULTS

At the primary stage of the study after transportation of 5 patients with pneumatic compression of 300 mm Hg the X-ray study showed additional lateral displacement of bone fragments in 4 patients. During interhospital transportation all patients demonstrated evident pain syndrome (VRS = 2.8) that required additional use of narcotic analgetics. Considering the obtained data the further study for the first group of the patients was stopped.

During examination of pneumatic compression of 40 and 50 mm Hg after completion of interhospital transportation X-ray investigation did not show additional displacement of bone fragments that testified the reliability of performed transport immobilization.

However, during examination of pain syndrome expressiveness the higher intensity was noted with 50 mm Hg compression compared to 40 mm Hg compression (Table 1).

Table 1
Dynamics of pain estimation in patients with polytrauma during interhospital transport (M ± m)

Note: * P < 0.05 compared to a previous index. 

During the study it was noted that in the end of interhospital transportation these compression modes (40 and 50 mm Hg) created additional discomfort for a patient in the view of paresthesia, pain senses, absence of possibility for changing defense attitude of a limb, sense of respiratory difficulty (in case of abdominal section compression). Decrease of compression above uninjured limbs and in the abdominal section up to 15-20 mm Hg allowed to neutralize such discomfort. At the same time the air pillow in the view of Kashtan anti-shock suit allowed reducing vibration effect during movement of a reanimobile, and the patients had an opportunity to consider it as additional comfort during transportation.

During the primary examination in the non-specialized medical facilities the patients of both groups demonstrated AP values within the normal range, with moderate tachycardia (Table 2).

Table 2

Hemodynamics indices in patients with polytrauma during interhospital transportation

Note: 2, 3 – group number; * P < 0.05 compared to the group 3.

During interhospital transportation AP values were stable, however, after its completion they were higher (with statistical significance) in the third group with 50 mm Hg compression that gave evidence of more frank pain syndrome. During interhospital transportation and after its completion the patients of both groups had moderate tachycardia without statistically significant differences (Table 2).

There was no worsening state and lethal outcomes in the patients with polytrauma during interhospital transportation.

CONCLUSION

During interhospital transportation of patients in compensated state it is necessary to reconsider the pneumatic compression modes of Kashtan anti-shock suit. The optimal mode of compression above uninjured body parts is the pressure of 40 mm Hg, in other sections – not more than 15-20 mm Hg. These pneumatic compression modes allow providing proper immobilization for fractures of the lower limbs and pelvis, preventing possible disorders of microcirculation in tissues, risk of compartment syndrome and reducing negative influence of vibration.