New medical technologies

DAMAGE CONTROL SURGICAL APPROACH IN CIVILIAN AND MILITARY SETTINGS

A. Koltovich, R. Pfeifer, D. Ivchenko, Kh. Almahmoud, H.-C. Pape

A. Koltovich, R. Pfeifer, D. Ivchenko, Kh. Almahmoud, H.-C. Pape

Department of Coloproctology, Main Military Clinical Hospital,

Moscow, Russia,

Department of Orthopedics and Trauma Surgery, Aachen University Medical Center,

Aachen, Germany,

Department of Surgery, University of Pittsburgh,

Pittsburgh, USA

The objective of the study was comparison of damage control technique in civilian and military settings.

Results. It was shown that most civilian accidents were associated with blunt mechanism. Patients are distributed into several medical facilities with surgery departments.

Military injury is caused by explosive factor, which conditions long term treatment in highly equipped facilities. In field conditions the actuality of damage control technique consists in massive and rapid transport of patients to a single medical center.      

In both cases it is appropriate to use damage control. Treatment is realized at several levels. The differences between military and civilian injuries involve necessity of administration of different management strategies.

Conclusion. During surgical procedures military surgeons use the same techniques of short term operation as civilian ones. This is the main similarity. The differences are in characteristics of wounds, specific states, isolated localization, limited resources and necessity for obligatory evacuation to a rear hospital.

Key words: damage control; trauma; civilian and military conditions.        

Information about authors:

Koltovich A., MD, Department of Coloproctology, Main Military Clinical Hospital, Moscow, Russia.

Pfeifer R., MD, Department of Orthopedics and Trauma Surgery, Aachen University Medical Center, Aachen, Germany.

Ivchenko D., MD, Department of Coloproctology, Main Military Clinical Hospital, Moscow, Russia.

 Almahmoud Kh., MD, Prof., Department of Orthopedics and Trauma Surgery, Aachen University Medical Center, Aachen, Germany, Department of Surgery, University of Pittsburgh, Pittsburgh, USA.

Pape H.-C., MD, FACS, Department of Orthopedics and Trauma Surgery, Aachen University Medical Center, Aachen, Germany.

Address for correspondence:

Dr. Roman Pfeifer, Department of Orthopedic Trauma, Aachen University Medical Center, Pauwelsstrasse 30, 52074 Aachen, Germany

Phone: +49-241-80-37041

Fax: +49-241-80-82415

E-mail: rpfeifer@ukaachen.de

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Anesthesiology and critical care medicine

COMPARATIVE ASSESSMENT OF CENTRAL HEMODYNAMICS FUNCTIONAL STATE IN PATIENTS WITH SEVERE CONCOMITANT AND SEVERE BURN INJURIES DURING FIBROTRACHEOBRONCHOSCOPY AND PREVENTION OF PROCEDURE COMPLICATIONS

Komarov G.A., Korotkevich A.G., Churlyaev Y.A., Sitnikov P.G.

Komarov G.A., Korotkevich A.G., Churlyaev Y.A., Sitnikov P.G.

City Clinical Hospital #1,

Novokuznetsk State Institute of Postgraduate Medicine,

Novokuznetsk, Russia

The need for sanation and diagnostic fibertracheobronchoscopy (FTBS) in patients with severe concomitant injuries (SCI) and severe burn injuries (SBI) remains at high level. There are contradictory opinions regarding execution of the procedure (number, quality, timing, safety).

Objective ‒ to perform comparative evaluation of systemic hemodynamics in ventilated patients with SCI and SBI for clarification of indications and contraindications for FTBS.

Materials and methods. Cardiac index (CI) , systemic vascular resistance index (SVRI) , global end diastolic volume index (GEDVI), heart rate (HR) , systolic, diastolic, mean blood pressure (SBP, DBP, mean BP),  extravascular lung water index (EVLWI) and gas exchange (PaO₂/FiO₂) were investigated in 41 patients with SCI and SBI under conditions of artificial lung ventilation before and after FTBS.

Results. In both groups CI, GEDVI, SBP, DBP, mean BP and HR were increased. SVRI increased in the group I and decreased in the group II. In the group I EVLWI was 7.3 ± 0.16 before and 7.4 ± 0.17 ml/kg after FTBS; in the group II it was 9.7 ± 0.26 and 9.8 ± 0.29 ml/kg respectively. PaO₂/FiO₂ increased in the group I and increased in group II only in 54.5% of the patients with thermal inhalational injury. FTBS identified endobronchitis of degrees 1-2 in 80.7 % of the patients in the group I and in 80 % of the patients in the group II.

Conclusion. Development of acute respiratory distress syndrome in patients with thermal inhalational injury correlates with the degree of bronchial mucosa swelling. Increased EVLWI is a contraindication for FTBS. There are differences in the response of system hemodynamics to FTBS depending on a type of an injury. СI increase is a favorable factor during FTBS. Reduced CI indicates the need for procedure termination.

Key words: polytrauma; burn injury; bronchoscopy; hemodynamics; complications.

Information about authors:

Komarov G.A., endoscopist, endoscopy department, City Clinical Hospital #1, Novokuznetsk, Russia.

Korotkevich A.G., MD, PhD, professor, Novokuznetsk State Institute of Postgraduate Medicine, Novokuznetsk, Russia.

Churlyaev Yu.A., MD, PhD, professor, head of chair of anesthesiology and critical care medicine, Novokuznetsk State Institute of Postgraduate Medicine, Novokuznetsk, Russia.

Sitnikov P.G., candidate of medical science, head of department of resuscitation and intensive care, City Clinical Hospital #1, Novokuznetsk, Russia.

Address for correspondence:

Komarov G.A., Chernysheva St., 20A-197, Novokuznetsk, Russia, 654000

Tel: +7 (950) 270-17-34, +7 (3843) 79-66-95

E-mail: 82komarov@mail.ru

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Clinical aspects of surgery

SURGICAL TREATMENT AND MORTALITY IN PATIENTS WITH ABDOMINAL INJURIES IN POLYTRAUMA

 Agalaryan A. Kh.

Agalaryan A. Kh.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Objective ‒ to identify features and factors having significant influence on surgical outcomes and mortality in patients with abdominal injuries in polytrauma.

Materials and methods. The analysis included the results of treatment of 361 patients (the mean age of 37.5 ± 5.90) with abdominal injuries in polytrauma treated in Clinical Center of Miners’ Health Protection in 2003-2013. On admission 2 hours after trauma all patients had diagnosis of traumatic shock of degrees II-III (APACHE-III > 80), severe concomitant abdominal injuries according to Abbreviated Injury Scale (AIS), ISS > 30, blood loss volume > 20 % of total circulation blood.

All patients received emergent procedures according to their vital signs in the first 24 hours after admission. The standard surgical tactics included surgery (laparoscopy, laparotomy, and, if required, damage control laparotomy), bone fracture stabilization in locomotor injuries, drilling holes and trepanation in traumatic brain injuries.

The analysis was performed for demographic (age, gender, injury mechanism and characteristics according to AIS) and clinical data (ISS, Glasgow Coma Scale [GCS], heart rate [HR], systolic pressure [SP], number of abdominal operations, ALV duration, intensive care unit [ICU] and hospital stay, complications, mortality).

The statistical analysis was carried out with IBM SPSS Statistics 20. The quantitative variables are presented as M ± m (arithmetic mean ± error in mean), M (SD) (mean (squared deviation)). The qualitative variables are presented as absolute and relative (%) values. Fisher’s exact test and χ²-test were used for comparison of qualitative values. Student’s test was used for evaluation of statistical significance of quantitative differences. The critical level of significance was p < 0.05.

Results. The mean number of abdominal and retroperitoneal (liver, spleen, kidneys, mesentery and vessels) injuries was 1.62 ± 0.03 per patient. For 190 (69.1 %) patients laparotomy was finished with laparotomy wound sealing (final laparotomy). Laparotomy was performed with damage control technique in 85 (31.9 %) patients. Damage control technique was predominantly used in injuries to intestine, the mesentery and abdominal vessels. One patient had 3.63 ± 0.6 laparotomy procedures. Postsurgical complications were found in 21 % of the patients (acute respiratory distress syndrome and multiple organ failure). The total mortality was 19.9 % (72 patients).

The comparative analysis of the survived (n = 289) and deceased patients (n = 72) showed significant intergroup differences including age, injury severity according to ISS, injury characteristics according to AIS, GCS values, HR and SP on admission (p < 0.05). The group of the survived patients required less laparotomy operations (2 [1] vs. 4 [2], p = 0.002), and abdominal closure was performed after 3 (1) compared to 15 days (4) (p = 0.001). In the survived patients the ALV duration decreased (6 [7] days vs. 11 [6], p = 0.034) as well as ICU (12 [8] vs. 20 [8], p = 0.001) and hospital stay (25 [14] vs. 57 [31], p = 0.001).

Conclusion. Such values as age, HR and SP on admission, GCS, ISS and AIS injury mechanism reflect expressiveness of severe disorders and make significant influence on results of treatment and mortality in patients with abdominal injuries in polytrauma. The staged surgical approach (damage control laparotomy) decreases mortality in patients with abdominal injuries in polytrauma.

Key words: abdominal injuries; laparotomy; damage control; mortality. 

Information about author:

Agalaryan A.K., candidate of medical science, head of surgery department, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Agalaryan A.K., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Federal Scientific Clinical Center of Miners’ Health Protection

Tel: + 7 (384-56) 9-55-05

E-mail: irmaust@gnkc.kuzbass.net

References:

1. Agadzhanyan VV, Pronskikh AA, Ustyantseva IM, Agalaryan AKh, Kravtsov SA, Krylov YuM, et al. Polytrauma. Novosibirsk : Nauka Publ., 2003. 494 p. Russian

2. Agadzhanyan VV, Ustyantseva IM, Pronskikh AA, Kravtsov SA, Novokshonov AV, Agalaryan AKh, et al. Polytrauma. Emergency Aid and Transportation. Novosibirsk : Nauka Publ., 2008. 320 p. Russian

3. Gorshkov SZ. Closed injuries to abdominal organs and retroperitoneal space. Moscow : Meditsina Publ., 2005. 224 p. Russian

4. Amoroso TA. Evaluation of the patient with blunt abdominal trauma: an evidence based approach. Emerg. Med. Clin. North Am. 1999; 17 (1): 63-75.

5. Alishikhov AM, Bogdanov DYu, Matveev NL. The experience of administration of endovideosurgical technologies in diagnostics and treatment of thoracoabdominal injury. Endoscopic Surgery. 2010; (5): 7-14. Russian

6. Abakumov MM, Lebedev MV, Malyarchuk VI. Abdominal injuries in concomitant trauma. Moscow : Meditsina Publ., 2005. 175 p. Russian

7. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR, Fruchterman TM, Kauder DR, et al. ‘Damage control’: an approach for improved survival in exsanguinating abdominal injury. J. Trauma. 1993; 35: 375-382.

8. Johnson JW, Gracias VH, Schwab W, Reilly PM, Kauder DR, Shapiro MB, et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J. Trauma. 2001; 51: 261-269.

9. DuBose JJ, Scalea TM, Holcomb JB, Shrestha B, Okoye O, Inaba K, et al. Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter study. J. Trauma Acute Care Surg. 2013; 74: 113-122.

10. Brenner M, Bochicchio G, Bochicchio K, Ilahi O, Rodriguez E, Henry S, et al. Long-term impact of damage control laparotomy. Arch Surg. 2011; 146 (4): 395-399.

Clinical aspects of traumatology and orthopedics 

TACTICS OF SURGICAL TREATMENT OF PATIENT WITH SPINE AND SPINAL CORD INJURIES IN POLYTRAUMA

Yakushin O.A., Novokshonov A.V., Fedorov M.Yu., Vaneev A.V.

Yakushin O.A., Novokshonov A.V., Fedorov M.Yu., Vaneev A.V.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Objective – to optimize surgical treatment tactics for patients with spine and spinal cord injuries in polytrauma.

Materials and methods. The information is based on the results of treatment of 63 patients with spine and spinal cord injuries in polytrauma. After realized complex examination the following combinations of injuries were found: spinal cord injury (SCI) and traumatic brain injury (TBI) – 13 (20.6 %); SCI and thoracic injury – 13 (20.6 %); SCI, TBI and skeletal injury – 7 (11.2 %); SCI and abdominal injury – 1 (1.6 %); SCI, TBI, skeletal, thoracic and abdominal injury – 29 (46 %). According to the conception for rendering assistance in our clinic, we performed treatment for 61 patients with polytrauma. The indications included 150 surgical procedures in different anatomic regions depending on identified combinations of injuries.

Results. The offered tactics of programmed multistaged surgical treatment for patients with spinal cord injuries with polytrauma allowed two-fold reducing mean period of hospital treatment in comparison with the medical economic standards. During acute period of trauma the administration of microsurgical reconstructive technologies for spinal cord and its mater resulted in improving disordered functions of spinal cord. The satisfactory and favorable outcomes were achieved in 65.3 %.

Key words: polytrauma; spinal injury; spinal cord injury; surgical tactics; microsurgical technologies

Information about authors:

Yakushin O.A., candidate of medical science, traumatologist-orthopedist, neurosurgery department #2, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Novokshonov A.V., MD, PhD, head of neurosurgery center, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Fedorov M.Yu., candidate of medical science, head of neurosurgery department #1, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Vaneev V.A., neurosurgeon, neurosurgery department #1, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Yakushin O.A., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Tel: +7 (384-56) 2-40-16

E-mail: avn1952@rambler.ru

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3. Shchedrenok VV, Yakovenko IV, Moguchaya OV. Clinical organizational aspects of concomitant traumatic brain injury. Saint-Petersburg: Publishing office of Polenov Russian Neurosurgery Institute, 2010. 435 p. Russian

4. Zobnin AV, Pronskikh AA, Bogdanov SV, Yakushin OA. The clinical case of treatment of a patient with polytrauma. Polytrauma. 2011; (4): 94-99. Russian

5. Agadzhanyan VV, Pronskikh AA, Ustyantseva IM, Agalaryan AKh, Kravtsov SA, Krylov YuM, et al. Polytrauma. Novosibirsk : Nauka Publ., 2003. 494 p. Russian

6. Samokhvalov IM, Badalov IV, Petrov AN, Rud AA, Grebnev DG, Petrov YuN. The causes of complications and unfavorable outcomes of severe concomitant spinal injuries in level I trauma center. Infection in Surgery. 2012; 10 (3): 12-16. Russian

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8. Stepanov GA. New techniques in reconstructive microsurgery of spinal cord in severe injury. Moscow : SCIENCE-PRESS Publ., 2011. 120 p. Russian

9. Traumatology and orthopedics : the manual for doctors of 4 volumes. Kornilov NV, editor. Vol. 4, Injuries and diseases of pelvis, chest, spine and head. Administration of DTC in traumatology and orthopedics. The principles for experimental studies in traumatology and orthopedics. Saint-petersburg : Hippocrates Publ., 2006. 624 p. Russian

10. Yakushin OA, Milyukov AYu, Fedorov MYu, Stafeeva NV, Shatalin AV. Successful treatment of patients with severe concomitant injury to pelvis and spine in conditions of a specialized clinical center. Polytrauma. 2011; (3): 89-93. Russian

11. Tsvetkov AA. Optimization of restorative measures for spinal cord injury in late period. Cand. med. sci. abstracts diss. Tula, 2006. 25 p. Russian

12. Butcher N, Balogh ZJ. The definition of polytrauma: the need international consensus. Injury. 2009; 40 (4): 12-22.

13. Spine trauma. Surgical techniques. Patel VV, Burger E, Brown CW, editors. Berlin ; Heidelberg : Springer, 2010. [xiv], 413 p.

Functional, instrumental and laboratory diagnostics

DIFFUSE LUNG INJURY IN COMBINED CLOSED CHEST TRAUMA

Makhambetchin M.M., Kuraeva L.G.

Makhambetchin M.M., Kuraeva L.G.

Scientific Research Traumatology and Orthopedics Institute,

Astana, Kazakhstan,

Central Medical Unit #141,

Udomlya, Russia

The article proves  necessity for developing an algorithm for interpreting radiographs (for doctors with clinical specialties) with diffuse lung injury on supine X-ray visualization in patients with polytrauma. The analysis of typical radiographs with extensive lung field blackouts is presented. On the basis of the analysis the scheme-algorithm for reading similar radiographs was created.

Objective ‒ to develop the algorithm for interpretation of supine radiographs with extensive blackouts of lung fields.

Methods.  The analysis included 6 typical anterior posterior radiographs in the patients with isolated and combined injuries to the chest, with diffuse lung injury. All radiographs were performed in the supine position.

Results. The analysis of the radiographs showed 5 main criteria for determining the probability of certain pathology: quality of radiographs, bilateral lesions, symmetry, homogeneity, and stowage position of the mediastinum. On the basis of criteria we have made  the scheme-algorithm for interpretation of radiographs with diffuse lung injury in patients with trauma.

Conclusion. Different types of pulmonary edema are almost identical on X-ray images. It is important to distinguish pulmonary edema from pleural complications requiring surgery or drainage, and from atelectasis requiring bronchoscopy. Four separated main criteria optimize the quality of image interpretation.

Key words: concomitant thoracic injury; diffuse lung injury.

Information about authors:

Makhambetchin M.M., candidate of medical science, docent, senior researcher, Scientific Research Traumatology and Orthopedics Institute, Astana, Kazakhstan.

Kuraeva L.G., radiologist, X-ray department, Central Medical Unit #141, Udomlya, Russia.

Address for correspondence:

Makhambetchin M.M., Ablay Khana prospect, 17, Astana, Kazakhstan, 010000

Tel: +7 (717) 254-77-84

E-mail: mahambet777@mail.ru

References:

1.      Lichtenstein DA, Mezière GA. Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure. The BLUE Protocol. Chest. 2008; 134: 117-125.

2.      Lichtenstein DA. Lung ultrasound in the critically ill. Annals of Intensive Care. 2014; 4: 2.

3.      Khosla R. Bedside Lung Ultrasound in Emergency (BLUE) Protocol: A Suggestion to Modify. Chest. 2010; 137 (6): 1487.

4.      Rezaie S. RUSH protocol: Rapid Ultrasound for Shock and Hypotension. Available at: http://academiclifeinem.com/rush-protocol-rapid-ultrasound-for-shock-and-hypotension/

5.      Phillips P, Mailhot T, Riley D, Mandavia D. The RUSH Exam: Rapid Ultrasound in SHock in the Evaluation of the Critically III. Emerg. Med. Clin. N. Am. 2010;  28: 29-56. Available at: http://www.tairawhitidhb.health.nz/assets/ED/Misc/Abstracts-and-Articles/RUSH-exam-in-evaluation-of-shock.pdf

Researches of young scientists

INFLUENCE OF ULCEROUS BLEEDING ENDOSCOPIC MONITORING ON CLINICAL LABORATORY PRESENTATION OF RECURRENT BLEEDING

Pervov E.A., Agalaryan A.Kh., Zaikin S.A., Frolov P.A.

Pervov E.A., Agalaryan A.Kh., Zaikin S.A., Frolov P.A.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Chronic ulcer in upper departments of the digestive tract is complicated by bleeding in 15 % of patients. As of today, the mortality from ulcer bleeding is 13-15 %, and postsurgical one varies within the range of 12-21 % without tendency to decrease.

Objective ‒ to assess the influence of endoscopic monitoring on clinical and laboratory presentation of recurrent bleedings from gastroduodenal ulcer.

Methods. The retrospective analysis included 105 patients (the comparison group) with ulcerous gastroduodenal bleeding. On the basis of the analysis the endoscopic monitoring was developed. Endoscopic monitoring was used for 100 (the main group) patients. Its influence on the clinical laboratory presentation of recurrent bleeding was estimated.

Results. In the main group 23 % of recurrent bleedings (p = 0.013) were identified compared to 15.2 % in the comparison group. The greatest amount of recurrent bleedings was identified in the group with Forrest-IA and IIA bleeding activity (72.7 % and 73.7 %). In the main group the typical clinical picture of recurrent bleeding was diagnosed in 3 (8.4 %) patients (p < 0.05) including 1 case (2.8 %) with F-IA bleeding activity and 2 cases with F-IIa (5.6 %). In the comparison group the recurrent bleedings were diagnosed only on the basis of clinical picture with endoscopic confirmation. Red blood values responded only after 24 hours: Er (p = 0.004), Hb (p = 0.041) and Ht (p = 0.046) in the examined groups, with worsening tendency in the comparison group.

Conclusion. Ulcerous bleeding endoscopic monitoring allows identifying recurrent bleedings at early preclinical stages. The red blood values are not informative for a surgeon contrary to endoscopic monitoring data at the moment of recurrent bleeding. They become apparent after 24 hours only. Administration of endoscopic monitoring allows controlling patient’s state and providing adequate and timely treatment.

Key words: ulcerous bleedings; recurrent bleeding; endoscopic monitoring.

Information about authors:

Pervov E.A., endoscopist, endoscopic department, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Agalaryan A.Kh., candidate of medical science, head of surgery department, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Zaikin S.I., candidate of medical science, head of endoscopy department, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Frolov P.I., endoscopist, endoscopic department, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Pervov E.A., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Federal Scientific Clinical Center of Miners’ Health Protection, endoscopy department

Tel: (384-56) 9-54-29

E-mail: evgenpervov@mail.ru

References:

1. Zatevakhin II, Samsonova MV, Shchegolev AA, Al-Sabunchi OA, Mizianov SA, Titkov BE, et al. Ulcerous gastroduodenal bleedings: the modern state of the problem and real perspectives. Russian Medical Journal. 1998; (2): 3-8. Russian
2. Surma AS. Recurrent ulcerous gastroduodenal bleedings. Cand. med. sci. abstracts diss. Moscow, 1996. 35 p. Russian
3. Grigoryev SV, Koryttsev VK. Surgical tactics in ulcerous duodenal bleedings. Surgery. 1999; (6): 20-22. Russian
4. Shchegolev AA, Titkov BE, Shaginyan AK. The new approaches to improving outcomes of surgical treatment of gastric and duodenal in Hp-infected patients. Annals of Surgery. 1999; (4): 15-20. Russian
5. Pervov EA, Agadzhanyan VV, Zaikin SI, Krylov YuM, Frolov PA. Endoscopic monitoring in surgical treatment of bleeding gastric ulcer and duodenum. Endoscopic Surgery. 2007; (6): 25-30. Russian
6. Gostishchev VK, Evseev MA. Acute gastroduodenal bleedings: from strategic conceptions to management tactics. Moscow, 2005. 333 p. Russian
7. Zatevakhin II, Shchegolev AA, Titkov BE. New technologies in treatment of ulcerous gastroduodenal bleedings. Moscow : Kursiv Publ., 2002. p. 166. Russian
8. Kuzeev RE. Optimization of treatment of gastric and duodenal ulcer complicated by gastroduodenal bleeding. Dr. med. sci. abstracts diss. Moscow, 2000. Russian
9. Lebedev NV, Klimov AE, Barkhudarova TV, Malkarov MA. Tactics of management for patients with ulcerous gastroduodenal bleedings. Bulletin of Surgery by the name of I.I. Grekov. 2007; 166 (4): 76-79. Russian
10. Lebedev NV, Klimov AE, Barkhudarova AA. Gastroduodenal ulcerous bleedings. Surgery. 2014; (8): 23-27. Russian
11. Balalykin AS, Alimov AN, Gvozdik VV. Endoscopic classification and principles of treatment of gastroduodenal bleedings. In: 4^th Moscow International Congress of Endoscopic Surgery, Moscow, 26-28 of April, 2000. Moscow, 2000. p. 23-25. Russian
12. Briskin B, Martines Garsia Kh. The opportunities of quamatel in treatment of bleeding gastroduodenal ulcer. Physician. 1998; (2): 15-16. Russian
13. Bratus VB, Fomin PD, Lissov IL, Gudim-Levkovich NV, Fedorov EA, Pishchalenko NT. The opportunities for improving outcomes of treatment of patients with acute ulcerous bleedings. Surgery. 1992; (9-10): 65-67. Russian
14. Potashov LV, Morozov VP, Savransky VM, Kudrevatykh IP, Did-Zurabova ES, Kimkov AV. Prediction of development of bleedings from duodenal ulcer. Surgery. 1998: (7): 4-6. Russian
15. Timen LYa, Khait BA, Cherepanin AI, Sidorenko TP, Stonogin SV. Blood loss. The opportunities of endoscopic hemostasis and significance of endoscopy in choice of management tactics for gastroduodenal bleedings. Medical Consultation. 1995; (3): 8-15. Russian
16. Papikyan GA, Khachatryan GS, Bagdasaryan EG, Grigoryan GA. Computer estimation of some signs of duodenal ulcer. Clinical Medicine. 1992; (11-12): 46-48. Russian
17. Ermolov AS, Pinchuk TP, Volkov SV, Sordiya DG. Efficiency of urgent endoscopic examinations in patients with acute gastrointestinal bleeding and experience of work of consultative endoscopic service. Endoscopic Surgery. 1997; (4): 28-32. Russian
18. Imhof M., Schroders C, Ohmann С, Röher H. Impact of early operation on mortality from bleeding peptic ulcer - ten years experience. Dig. Surg. 1998; 15 (4): 308-314.
19. Sanders DS, Carter MJ, Goodchap RJ, Cross SS, Gleeson DC, Lobo AJ. Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers. Am. J. Gastroentero.l 2002; 97: 630-635.
20. Bleau BL, Gostout CJ, Shaw MJ, Keate RF, Harford WV, Bracy Jr W, et al. Final results: rebleeding from peptic ulcers associated with adherent clots: a prospective randomized controlled study comparing endoscopy therapy with medical therapy. Gastroint. Endoscopy. 1997; 45: AB87.
21. Zimmerman J, Meroz Y, Arnon R, Tsvang E, Siguencia J. Predictors of mortality in hospitalized patients with secondary upper gastrointestinal hemorrhage . J. Int. Med. 1995; 237: 331-337.
22. Zimmerman J, Siguencia J, Tsvang E, Beeri R, Arnon R. Predictors of mortality in patients admitted to hospital for acute upper gastrointestinal hemorrhage. Scand. J. Gastroenterol. 1995; 30: 327-331.

Rehabilitation

PROSPECTS OF DEVELOPMENT OF REHABILITATION SYSTEM IN KEMEROVO REGION

Korbanova T.N.

Korbanova T.N.

 Kemerovo Institute of Social Economic Problems in Healthcare,

Kemerovo, Russia

During the recent years the demand for measures and methods of rehabilitation has been increasing in connection with decrease in mortality of the population, increase in life expectancy and, respectively, population ageing and increasing rates of children with congenital pathology.

Objective ‒ to develop the effective technologies of medical rehabilitation.

The created technique allows assessing demand for technologies of remedial treatment. The analysis of health state in the population of Kemerovo region was carried out, and the demand for remedial techniques on the basis of the general incidence was assessed.

Conclusion. Considering the current state of the rehabilitation system in Russia and in Kemerovo region, the systematic development of this direction of medicine is necessary. Taking into account the planned actions in Kuzbass, it is supposed to provide  decrease in mortality rate from 14.6 to 13.0 for 1,000 of the population in 2020, to reach positive value of natural increase of the population from -2.8 to +0.4 (units), to increase life expectancy from 66 to 75 years, to decrease level of primary disability of adult working age population by 10 %, at child's age ‒ by 15 %, to increase coverage with rehabilitation assistance for adult population by 25  %, for disabled children ‒ by 85 %, and to increase satisfaction of the population with medical care from 34.5 % to 60 %.

Key words: medical rehabilitation; remedial treatment; prospects of development of health care.

Information about author:

Korbanova T.N., leading specialist, Department of Population Health Protection of Kemerovo region, Kemerovo, Russia.

Address for correspondence:

Korbanova T.N., Serebryanny Bor St., 15a – 188, Kemerovo, Russia, 650070

Tel: +7 (923) 601-89-99

E-mail: hott811@hotmail.ru

REFERENCES:

1.       Demographic Yearbook of Russia. 2010 : stat. sat : [Electronic resource] / Rosstat. Moscow, 2010. 525 p. URL: www.gks.ru/doc_2010/demo.pdf/ (accessed on 09.02.2014). Russian

2.      Izmerov NF. The concept of long-term social and economic development of the Russian Federation for the period till 2020 ("Strategy 2020") and preservation of health of the working population of Russia. Occupational Medicine and Industrial Ecology. 2012; (3): 1-9. Russian

3.      Panov AV, Vorobyev TM. How to open the private medical center. Legal Questions in Health Care. 2012; (4): 12-19. Russian

4.      Policy of health protection in "Strategy-2020". Manager of Health Care. 2012; (5): 6-16. Russian

5.      Health protection prevention in "Strategy – 2020". Manager of Health Care. 2012; (6): 6-18. Russian

6.      DeCoster C, Peterson S, Carriere KC. Assessing the extent to which hospitals are used for acute care purposes. Medical Care. 1999; 37(6 Suppl.): 151-166.

7.      Britten N. Qualitative research: qualitative interviews in medical research. BMJ. 1995; 311: 251-253.

8.      Campbell J. Inappropriate admissions: thoughts of patients and referring doctors. J. R. Soc. Med. 2001; 94: 628-631.

9.    Elwyn GJ, Stott NCH. Avoidable referrals? Analysis of 170 consecutive referrals to secondary care. BMJ. 1994; 309: 576-578.

10.              Hicks NR. Some observations on attempts to measure appropriateness of care. BMJ. 1994; 309: 730-733.

Case history

ULTRASOUND DIAGNOSTICS OF PERIPHERAL ARTERIAL INJURIES IN CLOSED TRAUMA. THE CLINICAL CASES

Vlasova I.V.

Vlasova I.V.

Federal Scientific Clinical Center of Miners’ Health Protection,

Leninsk-Kuznetsky, Russia

Limb injuries are often accompanied by magistral arterial injuries, which are characterized with variability of localization and extension. Duplex scanning is widely used in diagnostics of vascular complications in closed trauma both in acute and remote period of an injury.  Diagnostic difficulties of injured arteries can be conditioned by severity of patient’s general state, unclear clinical picture and other factors.

Objective – to analyze the possible difficulties in diagnostics of arterial injuries in closed injury on the basis of the clinical cases.

Results. The review included four clinical cases with different problems in identification of vascular complications in patients with polytrauma. The significance of duplex scanning is shown according to diagnostics of different types of arterial injuries.

Conclusion. Almost twenty year experience with duplex scanning for diagnostics of vascular complications in patients with polytrauma allows recommending this technique as obligatory examination in closed limb injuries.

Key words: arterial injury; duplex scanning; arterial thrombosis; arteriostenosis.

Information about author:

Vlasova I.V., candidate of medical science, head of department of functional diagnostics, Federal Scientific Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia.

Address for correspondence:

Vlasova I.V., 7^th district, 9, Leninsk-Kuznetsky, Kemerovo region, Russia, 652509

Tel: +7(384-56) 9-54-20, 9-54-25

E-mail: info@gnkc.kuzbass.net

REFERENCES:

1.         Sokolov VA. Multiple and concomitant injuries. Moscow : GEOTAR Media Publ., 2006. 512 p. Russian

2.         Yetkin U, Bayrak S, Tetik O, Lafç? B, Özbek , Ye?il M, et al. Surgical Approach To The Pseudoaneurysms Of Lower Extremity Arteries Developed After Gunshot Injuries. The Internet Journal of Thoracic and Cardiovascular Surgery. 2007; 10 (2):  1524-1574.

3.         Coimbra R, Hoyt DB. Epidemiology of vascular trauma. Vascular surgery. Rutherford RB, eds. 2005. Vol. 2. 1001 p.

4.         Chernukha LM, Nikulnikov PI, Kashirova EV, Vlaykov GG, Altman IV, Guch AA, et al. The modern approaches to diagnostics and surgical treatment of patients with syndrome of posttraumatic arterial venous discharge. Bulletin of Emergency and Restorative Medicine. 2010; 11 (3): 330-335. Russian

5.         Nemytin YuV, Kokhan EP. Management of wounded persons according to the experience of local wars. In: Rendering Specialized Surgical Aid in Vascular Injuries. Krasnogorsk, 2002. P. 8-12. Russian

6.         Bocharov SM, Belozerov GE, Chernaya NR, Klimov AB. Angiographic semiotics injuries and damage arteries. Diagnostic and Interventional Radiology. 2007; 1 (1): 88–92. Russian

7.         Prokubovsky VI, Cherkasov VA, Dubovik SG. Transosseous catheter embolization in treatment of arterial injuries and their consequences. Angiology and Vascular Surgery. 1997; (1): 39-43. Russian

8.         Korotkov DA, Mikhaylov DV. X-ray endovascular occlusion of pulsating hematoma and false aneurism. Angiology and Vascular Surgery. 1998; 4 (1): 134-136. Russian

9.         Trauma. Mattox KL, Moor EE, Feliciano DV, editors. 7th. ed. McGraw-Hill Companies, 2013. xx, 1224 p.

10.     Agadzhanyan VV, Pronskikh AA,Ustyantseva IM, Agalaryan AK, Kravtsov SA, Krylov YM et al. Polytrauma. Novosibirsk : Nauka Publ., 2003. 494 p. Russian

A CASE OF SUCCESSFUL TREATMENT OF THE PATIENT WITH SEVERE TRAUMATIC SHOCK

Yudakova T.N., Girsh A.O., Shchetina A.V.

Yudakova T.N., Girsh A.O., Shchetina A.V.

 Kabanov City Clinical Hospital #1,

Omsk State Medical Academy,

Omsk, Russia

Objective – complex treatment of severe traumatic shock complicated by acute respiratory distress syndrome.

Materials and methods. The case included the patient K-n of 50 years, with traumatic shock of II-III degree, and complicated acute respiratory distress syndrome. In the comprehensive program of treatment not only antibacterial, infusion-transfusion, respiratory and symptomatic therapies were used, but also enteral nutritive support with balanced polysubstrate mix with food fibers.

Results. In the course of treatment use of enteral polysubstrate isocaloric mix corrected hypermetabolism syndrome, water and electrolytic composition of blood plasma, as well as had positive influence on regress of organ dysfunctions, especially pulmonary one.

Conclusion. Use of modern technologies of infusion and nutritive support in combination with other methods of intensive therapy at the background of haemodynamic and metabolic monitoring favors effective correction of volemic, haemodynamic disorders and hypermetabolism syndrome.

Key words: traumatic shock; infusion therapy; nutritive support.

Information about authors:

Yudakova T.N., candidate of medical science, head of resuscitation and intensive care department, Kabanov City Clinical Hospital #1, Omsk, Russia.

Girsh A.O., MD, PhD, professor, chair of anesthesiology and critical care medicine, Omsk State Medical Academy, Omsk, Russia.

Shchetina A.V., physician, department of resuscitation and intensive care #1, Kabanov City Clinical Hospital #1, Omsk, Russia.

Address for correspondence:

Girsh A.O., 24^th Severnaya St., 204, building 1, 143, Omsk, Russia, 644052

Tel: +7 (3812) 66-69-95; +7 (923) 681-40- 60

E-mail: agirsh@mail.ru

REFERENCES:

1. Intensive therapy : national guidelines. Gelfand BR, editors. Moscow : Medicine Publ., 2009. 954 р. Russian

2. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, et all. ESPEN Guidelines on Enteral Nutrition: Intensive Care. Clin. Nutr. 2006; 25(2): 210-223.

3. Singer P. The tight calorie control study: a pilot PRST of nutritional support in critical ill. Intensive Care Med. 2011; 28: 601-602.

4. Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, et al. ESPEN guidelines on parenteral nutrition: Intensive Care. Clinical Nutr. 2009; 28: 387-400.

5. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H et al. Sepsis in European intensive care units: result of the SOAP study. Critical Care Med. 2006; 34: 344-353.

THE RESULTS OF SUCCESSFUL TREATMENT OF A CHILD WITH POLYTRAUMA INCLUDING MULTIPLE PELVIC, FEMORAL AND HUMERAL FRACTURES

Shatohin V.D., Shuvaev S.O., Baranov F.A.

Shatohin V.D., Shuvaev S.O., Baranov F.A.

Samara Regional Clinical Hospital by the name of M.I. Kalinin,

Samara, Russia

Objective – to demonstrate a clinical case of successful treatment of a child with polytrauma including pelvis fracture with disarrangement of integrity of the pelvic ring, and fractures of the femur and humerus.

Materials and methods. The patient S., 10 years old (born in 2003), with a clinical diagnosis of polytrauma was examined. There were a closed fracture of the pelvis with disarrangement of integrity of the pelvic ring; fracture of the right wing of the ilium with displacement; displaced fracture of the right pubic and ischial bones; fracture of the left iliac wing without displacement; closed fracture of the left femur in the middle-lower third part; closed displaced fracture of the left humerus; posttraumatic neuritis of the median and radial nerves to the left; abrasions in the occipital region, the shoulder and lower leg to the left; traumatic shock of degree I.

The patient S., 10 years old, was admitted to the pediatric emergency department of Samara Regional Clinical Hospital 45 minutes after the traffic accident. On admission the state was severe. The patient was in the ICU during 24 hours. On day 6, after stabilization of hemodynamics and general state, the external fixation for the pelvis and the left femur, and low invasive metal osteosynthesis of the left humerus were performed.

Results. The patient was in the ICU on the first day after admission and one day after surgery. The total period of stay in the traumatology department was 28 bed-days. On the 20^th day after the operation remounting of the external fixation device for release of the left hip joint was performed. On the day 21 the patient started to move with crutches with the right lower limb support. After 4 months the external fixation device was dismounted from the pelvis and the left femur. The metal fixators in the left humerus were removed. The load on the left lower extremity and walking without crutches were allowed after 6 months from the date of the surgery.

Conclusions. Adequate stabilization of damaged segments in optimal time, and intensive care of polytrauma allow reaching the favorable anatomic and functional outcomes.

Key words: pelvic fracture; osteosynthesis; polytrauma; children.

Information about authors:

Shatokhin V.D., MD, PhD, professor, traumatologist-orthopedist, traumatology department, Samara Regional Clinical Hospital by the name of M.I. Kalinin, Samara, Russia.

 Shuvaev S.O., head of pediatric traumatology department, Samara Regional Clinical Hospital by the name of M.I. Kalinin, Samara, Russia.

Baranov F.A., candidate of medical science, traumatologist-orthopedist, pediatric traumatology department, Samara Regional Clinical Hospital by the name of M.I. Kalinin, Samara, Russia.

Address for correspondence:

Baranov F.A., Demokraticheskaya St., 30-172, Samara, Russia, 443031

Tel: +7 (927) 732-22-77

E-mail: f.orto@yandex.ru

REFERENCES:

1.      Leonov SA, Ogryzko YeV, Andreeva TM. Dynamics of main rates of road traffic injuries in Russian Federation. Bulletin of Traumatology and Orthopedics by the name of N.N. Priorov. 2009; (3): 86-91. Russian

2.      Nikitin GD. Modern problems of polytraumatology. Polytrauma problems. In: Treatment of multiple and concomitant injuries and fractures : the abstracts of the anniversary scientific practical conference. Smolensk, 1998. p. 9-20. Russian

3.      Bondarenko AV, Peleganchuk VA, Gerasimova OA. Hospital mortality in concomitant injury and possibilities for treatment for its decrease. Bulletin of Traumatology and Orthopedics by the name of N.N. Priorov. 2004; (3): 49-52. Russian

4.      Gisak SN, Tishchenko AV, Myakushev VL. Mortality in children with severe traumatic injuries. In: Polytrauma in children : the abstracts of reports from All-Russian symposium of pediatric surgeons. Samara, 2001. p. 15-16. Russian

5.      Timofeev VV, Bondarenko AV. Structure and characteristics of polytrauma in Barnaul city. Traumatology and Orthopedics of Russia. 2013; (2): 94-98. Russian

6.      Krasnoyarov GA, Vaulina AV, Kozlov OO. The analysis of polytrauma management in children and adolescents. Bulletin of Eastern-Siberian Scientific Center of Siberian Department of Russian Academy of Medical Science. 2009; (2): 55-60. Russian

7.      Sokolov VA. “Damage control” – the modern concept for treatment of patients with critical polytrauma. Bulletin of Traumatology and Orthopedics by the  name of N.N. Priorov. 2005; (1): 81-84. Russian

Reviews

The history of traumatologic and orthopedic methods in thoracic surgery (literature review)

Benyan A.S.

Benyan A.S.

Kalinin Samara Regional Clinical Hospital,

Samara, Russia

Objective ‒ to present the historical review of traumatology and orthopedics techniques in thoracic surgery.

The points of application of these methods are multiple rib fractures and flail chest. The history of chest stabilization began in 1924, when the first publication about sternal traction at flail chest with positive outcome was presented. Severity of these traumatic lesions and location of problem in the border of different specialties determined many approaches and opinions.

There are 3 principles in the basis of main methods of stabilization: external traction, external fixation and internal operative fixation of fractures.

The evolution of each method was described, also the advantages and disadvantages were noted, and the analysis of their role and place in modern surgery was carried out.

Conclusion. At the present time the optimal method is fixation of fractures with anatomic rib plates. The methods for external traction and external stabilization can be used for temporal stability of the chest.  The explanation for limited utilization of operative stabilization methods was done, and possible ways of development were defined. The conclusion was made about demand for synergism in work of traumatologists and orthopedists during rendering assistance for patients with multiple and floating rib fractures.

Key words: rib fractures; skeletal traction; stabilization; fixation.

Information about author:

Benyan A.S., candidate of medical science, head of department of thoracic surgery, Kalinin Samara Regional Clinical Hospital, Samara, Russia.

Address for correspondence:

Benyan A.S., Tashkentskaya St., 159, Samara, Russia, 443095

Kalinin Samara Regional Clinical Hospital, department of thoracic surgery

Tel: +7(846) 372-51-80; +7 (927) 692-21-89

E-mail: armenbenyan@yandex.ru

References  

1.      Vagner YeA. Surgery of chest injuries. Moscow : Meditsina Publ., 1981. 288 p. Russian

2.      Vishnevsky AA, Rudakov SS, Milanov NO. Surgery of chest wall : the manual. Moscow : Vidar-М Publ., 2005. 312 p. Russian

3.      Zhestkov KG, Barsky BV, Voskresensky OV. Thoracoscopic fixation of bone fragments in floating rib fractures. Endoscopic Surgery. 2006; (4): 59-64. Russian

4.      Klyuchevsky VV. Skeletal traction. Leningrad : Meditsina Publ., 1991. 160 p. Russian

5.      Kolkin YaG, Pershin YeS, Vegner DV. Panel fixation of fragments of sternocostal frame in severe closed injury to the chest. Surgery of Ukraine. 2009; (3): 62-65. Russian

6.      Kuzmichev AP, Sokolov VA. Surgical restoration of rib frame in closed chest injury. Surgery. 1983; (4): 26-30. Russian

7.      Maslov VI, Takhtamysh MA. Suture fixation of floating rib valves in closed chest injury. Surgery. Journal by the name of N.I. Pirogov. 2007; (3): 39-43. Russian

8.      Ushakov NG. The algorithm for diagnostics and treatment of patients with multiple valve rib fractures in closed chest injury. Postgraduate Bulletin of Volga region. 2010; (3-4): 116-119. Russian

9.      Shapot YuB, Besaev GM, Kashansky YuB, Zaytsev YeN. Osteosynthesis technique in fractures of ribs, sternum and clavicle. Bulletin of Surgery by the name of I.I. Grekov. 1985; (11): 83-87. Russian

10.  Actis Dato GM, Aidala E, Ruffini E. Surgical management of flail chest. Ann. Thorac. Surg. 1999; 67: 1826–1827.

11.  Ahmed Z, Mohyuddin Z. Management of flail chest injury: internal fixation versus endotracheal intubation and ventilation. J. Thorac. Cardiovasc. Surg. 1995; 110: 1676–1680.

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SURGICAL TACTICS IN POLYTRAUMA WITH MUSCULOSKELETAL SYSTEM INJURIES

Shapkin Yu.G., Seliverstov P.A., Efimov E.V.

Shapkin Yu.G., Seliverstov P.A., Efimov E.V.

 Saratov State Medical University named after V.I. Razumovsky,

Saratov, Russia

Objective – to consider the main modern medical and tactical concepts and principles that define the timing and extent of surgical procedures in polytrauma with musculoskeletal system injuries.

This review describes the concepts of "early total care", "damage control orthopedics", "surgical" resuscitation and traumatic disease. The features of choosing the methods and sequence of osteosynthesis in treatment of skeletal lesions in patients with multiple injuries were reviewed.

Conclusion. Early fixation of long bones and fixation of unstable pelvic injuries and spine in polytrauma can reduce mortality, the incidence of complications and improve functional outcomes. Timing and extent of surgical interventions for skeletal injuries in polytrauma are chosen based on the severity of injury, the patient's condition and period of traumatic disease. Operation should not present additional aggression worsening the condition of patient. The promising areas for optimization of surgical tactics in polytrauma with lesions of the musculoskeletal system are improvement of objective assessment of the severity of the victims, further development and implementation of staged treatment of skeletal injuries in critically ill patients and minimally invasive surgery.

Key words: polytrauma; fractures; osteosynthesis.

Information about authors:

Shapkin Yu.G., MD, PhD, professor, head of chair of general surgery, Saratov State Medical University named after V.I. Razumovsky, Saratov, Russia.

Seliverstov P.A., candidate of medical science, assistant of chair of general surgery, Saratov State Medical University named after V.I. Razumovsky, Saratov, Russia.

Efimov E.V., candidate of medical science, docent of chair of general surgery, Saratov State Medical University named after V.I. Razumovsky, Saratov, Russia.

Address for correspondence:

Seliverstov P.A., Lermontova St., 9-38, Saratov, Russia, 410002

Tel: +7 (960) 340-73-84

E-mail: seliwerstov.pl@yandex.ru

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