ARRANGEMENT OF MEDICAL ASSISTANCE FOR MULTIPLE AND ASSOCIATED INJURIES (POLYTRAUMA). THE CLINICAL RECOMMENDATIONS (THE TREATMENT PROTOCOL) (THE PROJECT)
The chair of integrative traumatology, Kemerovo State Medical Academy,
Kemerovo, Russia
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
The normative legal acts which were used for development of the clinical recommendations
- The order of Health Ministry of Russia, November, 12, 2012, #901n, “About confirmation of order of realizing medical assistance for the population according to the profile traumatology and orthopedics” (registered in Ministry of Justice of Russia, December, 25, 2012, # 26374);
- The order of Health Ministry of Russia, November, 15, 2012, #919n, “About confirmation of order of realizing medical assistance for adult population according to the profile anesthesiology and critical care medicine”;
- The order of Health Ministry of Russia, November, 15, 2012, #927n, “About confirmation of order of realizing medical assistance for patients with associated, multiple and single injuries with shock”;
- The order of Health Ministry of Russia, December, 24, 2012, #1394n, “About confirmation of the standard of emergency medical aid for associated injury” (registered in Ministry of Justice of Russia, March, 19, 2013, #27757);
- The order of Health Ministry of Russia, June, 20, 2013, #388n, “About confirmation of order of realizing emergency (including specialized) medical assistance”;
- The order of Health Ministry of Russia, December, 1, 2005, #752n, “About equipping for sanitary motor transport” (with the amendments from March, 31, 2008, #154n);
- The order of Health Ministry of Russia, December, 20, 2012, #1090n, “About confirmation of the standard of medical assistance for injuries to male urinogenital organs, foreign bodies in male urinogenital organs, excessive preputium, phimosis and paraphimosis” (registered in Ministry of Justice of Russia, March, 6, 2013, #27531);
- The order of Health Ministry of Russia, December, 20, 2012, #1123n, “About confirmation of the standard of emergency medical assistance for injuries to the abdomen and lower back” (registered in Ministry of Justice of Russia, March, 6, 2013, #27534);
- The order of Health Ministry of Russia, December, 12, 2012, #1384n, “About confirmation of the standard of emergency medical assistance for injuries to extremities and (or) pelvis” (registered in Ministry of Justice of Russia, February, 13, 2013, #27052);
- The order of Health Ministry of Russia, December, 24, 2012, #1389n, “About confirmation of the standard of emergency medical assistance for chest injuries” (registered in Ministry of Justice of Russia, February, 7, 2013, #26916);
- The order of Health Ministry of Russia, December, 24, 2012, #1390n, “About confirmation of the standard of emergency medical assistance for head injuries” (registered in Ministry of Justice of Russia, March, 14, 2013, #27693);
- The order of Health Ministry of Russia, December, 24, 2012, #1457n, “About confirmation of the standard of emergency medical assistance for spinal injury” (registered in Ministry of Justice of Russia, March, 14, 2013, #27683);
- The order of Health Ministry of Russia, July, 1, 2015, #407an, “About confirmation of the standard of specialized medical aid for injuries to lumbosacral spine and pelvic bones” (registered in Ministry of Justice of Russia, July, 17, 2015, #38073).
Development of the clinical recommendations was realized with the materials from the leading world institutions:
World Health Organization, Cochrane Reviews, World Federation of Societies of Anaesthesiologists, American College of Surgeons Committee on Trauma, International Association For the Surgery of Trauma and Surgical Intensive Care (IATSIC), International Society of Surgery, Societe International de Chirurgie, International Trauma Life Support (ITLS), The World Association for Disaster and Emergency Medicine (WAEDM).
INTRODUCTION
The structure of mechanical injuries in polytrauma is under great influence of increasing rates of road traffic and industrial injuries, and natural and technogenic disasters, local war conflicts and terrorist attacks. The dominating significance is related to severe multiple and associated traumatic injuries, for which it is impossible to separate treatment of locomotor injuries from treatment of injuries to internal organs [7, 9, 11].
Polytrauma and its consequences take one of the most important places in structure of morbidity and causes of mortality among population. Despite of close attention to the problem of polytrauma, the mortality from multiple and associated injuries is up to 40 %, and disability of 25-45 % in the world. In Russia the mortality from polytrauma takes the second place in the world: 65.5 per 100,000 persons. The main thing is the fact that 70 % of victims are working age and young persons who suffer from road traffic accidents (65 %) and fallings from height (25 %) [7-9, 11-13].
Therefore, the problem of diagnostics and treatment of polytrauma is one of the most important ones.
For development of efficient system of treatment of polytrauma it is necessary (besides expensive medical techniques) to consider the problem of succession during rendering medical assistance at prehospital stage and after admission to the hospital [9, 12]. In systemless approach to the patient with polytrauma one can meet with the situation with an unconscious patient with multiple injuries in the admission department, when the traumatologist begins skeletal injury, the surgeon treats chest trauma, but the patient dies as result of respiratory problems caused by severe traumatic brain injury [7, 8, 12].
Each year the volume of information about various aspects of polytrauma increases. It is conditioned by great variety of types and combinations of injuries in polytrauma, relatively low number of observations in each author, and, as result, by these factors: difficulties in making conclusions and recommendations for treating polytrauma, moreover, medical facilities of various levels (municipal, regional, federal facilities). It is reasonably to accentuate the interdisciplinary pattern of the problem.
All above mentioned moments require estimation and summarizing of all available data about arrangement of medical assistance for multiple and associated injuries to develop and accept the consistent Russian national guidelines for diagnostics and treatment of polytrauma. The presented project of the clinical recommendations is based on observation of more than 3,000 cases.
Terminology and classification of polytrauma
The given terminological adjustments demonstrate organizational and practical sense. At the present time, the conceptual approach to the issue of polytrauma is characterized by interchange of several static opinions about shock in severe injury and by the dynamic scientific practical concept of traumatic disease. Moreover, success in treatment of polytrauma may be conditioned by change of the existing system of arrangement of medical assistance, development of efficient methods of evaluation of state severity, diagnostics and treatment.
Trauma (from Greek trauma – a wound, a bodily damage; syn. an injury) is disarrangement of integrity and function of tissues (an organ) as result of external influence (The Encyclopedic Dictionary of Medical Terms Edited by B.V. Petrovsky, 1984).
Single injury is an injury to one anatomic functional element of locomotor system (isolated fracture of the femur, of humerus or the spine; joint injury etc.) or one internal organ within the limits of single anatomic field (cavity): splenic rupture – abdominal cavity, lung rupture – the chest; brain contusion or concussion, eye injuries etc.
Multiple injury is an injury to several anatomic structures (organs) within single anatomic region or cavity. For example, fracture of several segments of the extremities, liver or spleen injury, lung rupture and costal fracture etc.
Associated injury is presence of injuries in two or more anatomic regions regardless of their amount and functional direction. For example, a fracture of extremity segment and brain contusion or a fracture of extremity segment, brain contusion and splenic rupture etc.
Combined injury is an injury as result of single-moment or sequential influence of several adverse factors: mechanical, thermal, radioactive, chemical etc.
Polytrauma is a combined notion including multiple, associated and combined injuries, which are dangerous for life or health and require emergency medical aid.
Polytrauma is a combination of two or more injuries, one of which or their combination gives immediate threat for victim’s life and presents the direct cause of development of traumatic disease.
Polytrauma is a notion, which determines patient’s state as severe. Therefore, it is for no good reason to talk about severe or mild polytrauma [7-10]. Separation of polytrauma into the individual categories is important because of some characteristics of such injuries which should be considered during triage or realizing medical assistance. Polytrauma includes injuries to the extremities in 86 % of cases, head injuries – in 69 %, the chest – in 62 %, the abdomen – in 36 %, the pelvis – in 28 %, the spine – in 19 %. Among all number of injured patients, polytrauma is observed in 20-25 %, in case of disasters – 50-75 % [9, 12, 13].
Pathophysiology of polytrauma. Polytrauma is considered as a systemic traumatic disease developing after severe associated injuries and determining the main features of its pathogenesis and the principles of treatment tactics.
The systemic traumatic response produces systemic inflammatory response syndrome. The specific pathogenetic factors depend on a single-moment injury in several regions of the body and on characteristics of disorders relating to an injury in one or other anatomic region.
The feature of polytrauma is a syndrome of mutual burdening, when each injury worsens severity of general pathologic situation, and, at the same time, each individual injury takes more severe course in case of an associated injury, and with higher risk of infectious complications than for a single injury. Mutual burdening syndrome is a pathophysiologic statement of crisis of disorders of vital functions, which are manifested in view of shock state in case of injuries to two or more anatomic functional regions.
The term polytrauma is popular in scientific practical usage in domestic and foreign medicine (table 1). For medical personnel of emergency aid services, admissions departments and intensive care units this word (as well as the term shock) is a danger signal and a stimulus to initiation of emergency diagnostic and medical measures [7-10, 13, 14].
|
Table 1 |
||||
|
Terminology and classification of polytrauma |
||||
Clinical course. The clinical manifestations of polytrauma depend on severity of traumatic disease – a combination of general and local changes, pathologic and adaptive responses appearing in the body in the period from moment of the injury to its outcome.
Pathogenetic classification of periods of course of traumatic disease
I. The period of acute response to the injury (shock period). It corresponds to the period of traumatic shock and early postshock period; it should be considered as the period of inductive phase of multiple organ dysfunction syndrome (MODS). It lasts from several hours to two days from the injury.
II. The period of early manifestations and complications (postshock or intermediate period) is an initial phase of MODS. It is characterized by disorder or inconsistency of functions of some organs and systems. Its duration is from 3rd day to 7th day.
III. The period of late manifestations – is a spread phase of MODS. It begins after 7 days and is characterized by developing complications determining prognosis and outcomes of the disease.
IV. Rehabilitation period – in case of favorable outcome. It is characterized by complete or incomplete recovery.
The above mentioned concept appeals to consider traumatic shock, blood loss, posttraumatic toxicosis, thrombohemorrhagic disorders, posttraumatic fat embolia, MODS and sepsis not as complications of polytrauma, but pathogenetically associated links of the single process – traumatic disease [8, 16, 21].
The first period (traumatic shock) is the syndrome of perfusion deficit (acute hemodynamic disorders) in response to a severe mechanical injury with predominant influence of blood loss.
The second period of traumatic disease is characterized by extensive clinical symptoms of MODS: disorders or dysfunctions of individual organs and systems. Multiple organ insufficiency is the result of generalized systemic inflammatory response to the injury, if upon admission of the patient organ or multiple organ insufficiency can be the result of the direct injury, traumatic factor for an organ or several organs. Its intensity correlates with degree of injury severity. MODS should be considered as a severe degree of systemic inflammatory response syndrome (SIRS) [8, 16, 21].
The third period is the period of late manifestations of traumatic disease. In favorable course it is characterized by development of restorative and reparative processes in injured organs and tissues. This period is characterized by some individual cases of dystrophic and sclerotic changes in injured organs and secondary disorders of functions with development of various complications: abscess, phlegmon, osteomyelitis, wound dystrophy, thrombophlebitis, sepsis. This period lasts for several months and requires appropriate treatment. Restoration of basic (before trauma) values of hemoglobin is considered as one of the signs of completion of late period of manifestations of traumatic disease.
The fourth period of traumatic disease is rehabilitation. It is characterized by complete or incomplete recovery (disability) [9, 10, 12, 15, 17].
Arrangement of assistance
In Russian Federation the understanding of the problem of polytrauma at the federal level resulted in development of the specialized centers and departments for polytrauma management in most regional centers and in the big cities.
Decreasing mortality from injuries in the foreign countries is associated with foundation of trauma centers (USA, Great Britain) or Unfallchirurgie clinics (Germany, Switzerland, Austria), additional education with systematic trainings, and good equipping [13, 15, 17].
Russian and foreign trauma centers are based on three levels depending on volume of medical assistance, on the basis of regional, central municipal and regional hospitals and hospitals of emergency aid [1-6].
During the years of realization of the federal programs Health and Increasing Road Traffic Safety in 2006-2012 the modern system of arranging medical assistance for road traffic accidents has been implemented from 2008 till 2011in 64 constituent territories including the territories with 14 federal autoroads (14,261 km).
During realization of the programs 511 ambulance cars of C class were bought, 302 trauma centers were developed (69 trauma centers of level 1, 119 – of level 2, 114 – of level 3), more than 4,000 medical specialists completed their training, the scientific guidelines for various aspects of arrangement and realization of medical assistance were developed and implemented into practice.
In concordance with the order by Health Ministry of Russian Federation, November, 15, 2012, #927n “About confirmation of order of realizing medical assistance for patients with associated, multiple and single injuries accompanied by shock” medical assistance for patients with associated, multiple and single injuries with shock is realized as part of emergency medical aid (including specialized sanitary aviation), primary medical sanitary assistance, specialized aid including high tech medical aid [3].
Level 1 (the highest level) trauma center is intended for realizing qualified and specialized medical aid. It provides day and night realization of emergency medical aid in fields of general and thoracic surgery, traumatology, cardiosurgery, neurosurgery, hand surgery, ophthalmology, facial surgery, microsurgery, gynecology, urology and pediatrics. In case of admission of patients with severe injuries (according to vital signs) to other medical facilities the specialists of the center give medical and consulting aid. Level 1 trauma center is a regional center. Usually its services cover big cities and densely populated areas.
Level 2 trauma center gives emergency medical aid in fields of general and thoracic surgery, traumatology, neurosurgery, ophthalmology, gynecology, urology and pediatrics. Level 2 trauma center provides traumatological assistance in densely populated areas and/or supplements clinical activity and expertise of level 1 center.
In less populated areas the level 2 hospital presents the leading trauma center because of low possibility of availability of level 1 trauma center. Local regulations are used for arrangement of transfer to distant facilities of level 1 and 2.
Level 3 trauma center presents emergency medical assistance in view of general surgery, neurosurgery, traumatology and gynecology. Level 3 center has possibilities for arranging emergency aid for significant number of trauma patients. It is necessary to have the agreement about transporting patients to other trauma centers with more recourses. The group of intensivists is to be arranged for patients with severe injuries [2, 5].
The system of arrangement of emergency medical aid is separated into two stages – prehospital and hospital. Up to the present time the problematic moment is succession during transferring the patient from one stage to another. The solution for the problem is introduction of areas of responsibility in medical prophylactic institutions.
Polytrauma management. Management of polytrauma is realized in a staged manner.
Prehospital stage includes emergency aid: arresting bleeding, clearing the airways and artificial lung ventilation in respiratory disorders, indirect massage and medications for heart arrest, transport immobilization and analgesia.
Hospital stage includes correction of shock including hemodynamics stabilization, analgesia, proper immobilization, oxygen therapy and correction of all disordered functions.
Medical assistance for patients with polytrauma at all stages of treatment should be realized with velocity and volumes which are sufficient for overrunning the pathologic processes developing in the organs and tissues as result of progressing hypoperfusion and hypoxia, with preventing the irreversibility and decompensation of vital functions.
The concept of the golden hour is very popular in USA and some European countries. The essence of the concept is as indicated below: vital functions are restored within one hour after injury; otherwise, a lethal outcome is possible because severe complications associated with irreversible processes. This concept became the basis of emergency aid: the time of delivery of patients with polytrauma to the trauma center is 46 min in USA and 18 min in Germany [14, 15].
The principles of realizing the medical diagnostic process for patients with polytrauma
1. Timeliness – realization of fully-featured diagnostics within the first hour of hospital stay.
2. Safety for patient’s life: realization of diagnostic procedures should not threaten life according to direct danger and danger as result of delaying medical measures.
3. Synchrony of realization of medical and diagnostic procedures, i.e. integrity and simultaneity of emergency medical manipulations (which are firstly oriented to arresting bleeding and correcting shock) and diagnostic measures.
4. Optimal volume of diagnostics. The full value of diagnostics for polytrauma is determined with not maximally possible volume and number of diagnostic manipulations and examinations. Limitations of diagnostics are considered. It means that diagnostic process for patients with polytrauma should be realized in concordance with the principle of optimal diagnostic appropriateness.
PREHOSPITAL STAGE (the protocol of emergency medical aid for polytrauma)
1. Releasing the patient without additional injuring.
2. Upper airway management (the triple method by P. Safar).
3. Realization of expiratory methods of ALV.
4. Arresting external bleeding by means of tourniquet or pressing dressing.
5. Correct positioning for unconscious patient (physiologic position edgewise).
6. Correct positioning for patient with signs of shock (with lowered head of bed).
Medical assistance at accident site
1. To identify and immediately eliminate vital disorders.
2. To examine the patient, to identify causes of life threatening disorders and to make prehospital diagnosis.
3. To decide a point about necessity of admission or refusal from admission.
4. To determine the place of admission on the basis of patterns of injuries.
5. To determine sequence of admission of patients (in case of large scale accident).
6. To provide maximal prevention of injuries and maximal rate of transportation to the hospital.
Predoctor aid (ambulance attendant)
1. Vein puncture of ulnar vein, beginning of intravenous infusion in case of shock.
2. Introduction of cardiotonics and vasoconstrictors for critical decrease of arterial pressure.
3. Introduction of respiratory analeptics for respiratory difficulty.
4. Continuation of simple measures of cardiopulmonary resuscitation, adequate analgesia.
5. Conversion of closed tension pneumothorax to open type (by means of thick needles).
First medical assistance
1. Elimination of life threatening factors.
2. Supporting functions of vital organs.
3. Prevention of severe complications. Magistral vein catheter is obligatory. Catheter for subclavian or femoral vein or venesection are according to indications.
4. Adequate hemodilution.
5. Additional regionary local anesthesia – vagosympathetic and case blockades.
6. Final arrest of bleeding – application of tourniquet or ligature for a great vessel; if it fails, other techniques are used.
7. Bladder catheterization or puncture.
8. Tracheal intubation.
9. Tracheotomy – according to indications.
10. Removal of mucus and sanitation of bronchial tree, prevention of lung edema, correction of respiratory insufficiency.
11. Thoracic puncture for tension pneumothorax.
Primary targets of prehospital stage
1. The problem of normalizing breathing.
2. Correction of hypovolemia (crystalloids and colloids).
3. The problem of analgesia (tramadol, moradol, nalbuphine, low dosage of ketamine, 1-2 mg/kg, in combination with benzodiazines).
4. Application of aseptic dressings and transportation splints.
The prehospital protocol of resuscitation for patients with polytrauma
1. Temporary arrest of bleeding.
2. Point estimation of severity of patient’s state: HR, AP, Algover’s index (shock index, SI), pulse oximetry (SaO2).
3. Emergency intensive care is carried out in systolic AP < 80 mm Hg, pulse > 110 per min, SaO2 < 90 %, SI > 1.4.
4. Resuscitation measures include:
- If SaO2 < 94 % – oxygen inhalation with facial mask or nose catheter;
- If SaO2 < 90 % during oxygen therapy – tracheal intubation and initiation of assisted ventilation or ALV;
- Peripheral/central vein catheterization;
- Infusion of HES, 12-15 ml/kg/per hour (or adequate volume of crystalloids without 5 % glucose);
- Anesthesia: promedol, 10-20 mg or fentanyl, 2 mg/kg, droperidol, 2.5 mg, seduxen, 10 mg, local anesthesia in fracture regions with 1 % lidocaine;
- Prednisolone, 1-2 mg/kg;
- Transport immobilizing.
5. Transportation to the hospital at the background of ongoing intensive care.
The protocol of transportation of patients with polytrauma to the hospital
The first 60 minutes (the golden hour) are critical for life of the patient. Sometimes medical assistance is performed by paramedics or accidental persons. Emergency medical aid is realized at site of accident, at triage place, at first-aid post, in the ambulance car or in the reanimobile. Volume of assistance differs in dependence on multiple factors. However, the physician has to solve the following tasks:
1. Identification and removal of events, which are life-threatening at this time.
2. Identification of causes, which are associated with possible dangerous disorders; estimation of location and characteristics of injuries, confirmation of preliminary diagnosis.
3. Prevention of life-threatening complications.
4. Preparation for evacuation, estimation of profile of the hospital (if the unit for polytrauma management is absent) depending on the main injury of the way of evacuation [7, 9, 11, 12, 15, 17].
At prehospital stage emergency medical aid is conducted by emergency aid teams including anesthesiologist-intensivist and 2 paramedics (or 2 nurse anesthetists) [2, 3]. Transportation from accident site to institutions for specialized medical aid is realized with the ambulance car of C class, and if it is absent – by emergency aid teams with the ambulance car of B class (the distance is not more than 100 km) with equipment corresponding to the standards of equipping confirmed by the Order of Health Ministry of Russia, December, 12, 2005, #752, “About equipping for sanitary motor transport” (with the amendments from March, 31, 2008, #154n) [6] or with use of sanitary motor transport. Maneuver brigades of emergency aid are activated in emergency cases and receiving several calls.
Interhospital transport for patients with polytrauma is conducted only with participation of the special team with reanimobiles. Transport team includes 4 persons (intensivist, nurse anesthetist, driver, neurosurgeon, traumatologist or surgeon). If necessary, several specialists move out. The equipment of the reanimobile corresponds to the order by Ministry of Healthcare and Social Development of the Russian Federation, #752, December, 1, 2005 [6].
The important stage for preparing to transportation is evaluation of severity of state:
1. Estimation of respiratory system.
2. Estimation of blood circulation system.
3. Estimation of neurologic status.
4. Estimation of internal organs.
5. Estimation of skeletal muscular system.
The final decision about possibility of transportation is accepted by intensivists of medical transport team.
The absolute contraindications for transportation: agonal state.
The relative contraindications for transportation: ongoing internal or external bleeding. After arresting bleeding and stabilizing state the patient is transported to the multi-profile hospital.
HOSPITAL STAGE. The main causes of death from injuries in medical facilities are shock and blood loss. Therefore, it is necessary to implement timely diagnostics and treatment within the first hours of admission. Patients with polytrauma are admitted to the intensive care unit or to the well-equipped anti-shock room [2, 4].
Examination of the patient with polytrauma
The basis for making preliminary diagnosis is anamnesis. The data is collected with AMPLE system.
Case history according to AMPLE
Allergies;
Medications – consumption of medical drugs, narcotics or alcohol;
Previous illnesses;
Last meal;
Events surrounding injury.
The main things for diagnostics are identification of life-threatening injuries to the brain, the chest, the abdomen, the pelvis, vessels, the spinal cord and nerves. The targeted search of such injuries presents the important principle of diagnostics in case of acute injury.
The following diagnostic and treatment schedule is used upon admission to the hospital
1. Emergency examination:
- the patient is stable, unstable, decompensated or near death;
- simultaneous examination of breathing, AP and CNS;
- fast stripping.
2. Realization of measures for life support:
- provision of two approaches to great veins;
- airway management with intubation;
- Pleural cavity draining;
- Life-saving surgery.
3. Provision of oxygenation and perfusion:
- replacement of volume;
- breathing;
- hemodynamic and ventilation monitoring.
4. Emergency diagnostics.
Clinical diagnostics:
- head, chest, abdomen, pelvis, spine, extremities;
- neurologic prolapse, peripheral pulsation;
- urinary catheter, hourly measurement of diuresis.
Laboratory diagnostics:
- acid-base balance (pH, pO2, pCO2, ÍÑÎ3, ÂÅ, Na+ , Ê+, Ñl-, Ñà++, lactate, glucose);
- hemogram (Hb, Ht, PLT, recurrent control);
- blood clotting (PTT, PTI, INR, fibrinogen, APTT);
- blood type, cross matching;
- activity of liver enzymes, urea, creatinine;
- toxicological screening, urina + blood.
Ultrasonography: abdomen
X-ray examination – chest, abdomen and spine (lateral view).
Computer tomography – cranium, spine, pelvis, abdomen. It is conducted for suspicious cases and for making diagnosis.
Angiography – for absent pulse in extremities, ruptured extremity and its proximal injury.
Estimation of injury severity according to ISS, SCG.
5. Emergency care:
- treatment of shock;
- breathing stabilization;
- primary surgical interventions;
- intensive care.
The stages of diagnostics and treatment
Diagnostic and curative measures are conducted simultaneously within the first minutes in the anti-shock room or in the intensive care unit. However, the priority is given to removal of life-threatening symptoms.
The resuscitation measures are conducted according to the conventional scheme ABCD [15].
A (airway) — airways, cervical spine control.
 (breathing).
Ñ (circulation) — maintenance of blood circulation (indirect heart massage, bleeding arrest, infusion therapy).
D (disability) — neurologic status.
Å (environment) — stripping.
The following scale is used for hopeless situations.
Phase Alpha — life-saving operations — the measures within 1 minute.
Phase Bravo — emergency measures within 5 min.
Phase Charlie — obligatory emergency measures within one hour and 30 minutes.
Phase Delta — complex diagnostics and treatment.
Significant improvement of outcomes of treatment in patients with polytrauma is achieved by means of implementation of multi-staged programmed surgical interventions known as damage control. The idea consists in staged separation of surgical intervention:
1st – emergency surgical intervention at the background of decompensated state of the patient for salvation of his/her life; the intervention is timely reduced for life-saving measures (the remaining volume of surgery is transferred to 3rd stage);
2nd – intensive care restores vital functions to the level of subcompensation;
3rd – the full volume of the intervention is completed.
For injuries to the extremities with fractures of the long bones and severe associated component the first stage includes rigid fixation of fractures with fast low traumatic extrafocal techniques preventing development of severe complications. Commonly, the modules of Ilizarov device (or rod devices) are used. The second stage (intensive care) lasts from several days to several weeks. It corresponds to 3rd period of traumatic disease, when surgery is contraindicated. The third stage (4th period of traumatic disease) includes precise reposition and final fixation of fractures.
Damage control allows decreasing mortality from 66.5 % (without damage control) to 20.1 % (after its implementation) [7-9, 13, 18, 19, 23].
In most cases it is reasonable to perform point estimation of injury severity after completion of clinical, radiologic, ultrasonic and laboratory examination. Estimation of injury severity influences on the type and emergency of further surgical measures.
The common estimating tools for patients with polytrauma are Glasgow Coma Scale (GCS), which was developed in Glasgow University Clinic (England), Injury Severity Score (ISS) offered by Becker et al. (1974), and Polytraumaschlussel (Hannover code) developed by Í. Tscherne.
GCS is used for classification of degrees of neurologic disorders and consciousness disorders after brain injuries.
Injury Severity Score (ISS) by Becker et al. (1974) considers anatomic and topographic injuries. For estimation of injury severity the human body is separated into 5 regions: skin and soft tissues, head (with neck and face), chest, abdomen, extremities. The degree of severity of each region is estimated with five-point scale (from 0 to 5 points), where 0 corresponds to absence of injuries in this region, and 5 means the most severe injuries. After estimation of five regions three highest values are raised to the square. The sum of the squares presents estimation according to ISS.
PTS (Polytraumaschlussel) by Í. Tscherne is Hannover code for estimation of severity of polytrauma. It permits standardization and classification of injuries, planning necessary curative measures and predicting estimation. Estimation of the general degree of injury severity is possible by means of simple addition of points relating to GCS, individual injuries, age and biochemical parameters. After completion of primary diagnostics the early estimation of risk is possible (table 2) [9, 12, 13].
|
Table 2 |
||||||||
|
Early estimation of risk in polytrauma [Ankin L.N., 2004] [12] |
||||||||
|
| ||||||||
The scale for estimation of severity of state (Pape H-C, 2005) allows objective estimation of severity of state, degrees of injuries and functional state of patients with polytrauma (table 3) [22, 23].
|
Table 3 |
||||||||||||
|
Estimation of severity of state in polytrauma. The modification of the classification systems by Border JR 1995 and Pape H-C 2005 |
||||||||||||
The stages of treatment of polytrauma
The first stage is resuscitation.
This stages includes measures for life salvation, intubation, provision of sufficient volume of oxygen, breathing stabilization, blood circulation restoration, anti-shock therapy with transfusion of blood, plasma and albumin, correction of salt and alkaline exchange, analgesia and sedation. Simultaneously with the life-saving measures, this stage includes some clinical examinations for identification of disorders of blood circulation, respiratory disorders, symptoms of brain compression, spinal cord injuries. The manipulations of the first minutes include application of thoracic drain. The indications for this manipulation are tension pneumothorax, pneumo- or hemothorax. The relative indications are subcutaneous emphysema with unclear radiologic picture and rib fractures in patients with respiratory disorders. Diagnostic measures are not performed in presence of free fluid in abdominal cavity or unstable blood circulation, because in such cases emergency laparotomy is indicated.
The priority is given to the emergency surgical interventions for arresting massive bleeding in body cavities, decompressive trepanation, correction of pericardium tamponade, i.e. operations for life salvage.
All these measures are observed and guided with adequate monitoring. If possible, the upper part of the body is elevated, and forced position is initiated, if necessary. The important moments are adequate stabilization of fractures of the long bones, unstable injuries to the spine, the pelvic ring and great joints.
The second stage – emergency operations
The operation are conducted according to the vital signs: arrest of massive bleeding in liver or splenic rupture, in injuries to great thoracic or abdominal vessels, in open pelvic injuries, in injuries to magistral vessels, and in open bleeding from cavities and sinuses.
Intensive care of shock is conducted simultaneously with operations for vital signs. After confirmation of vital functions patients with polytrauma receive necessary volume of surgical assistance. In each case the sequence of operations and the volume of medical procedures are determined by the surgeon and the anesthesiologist. If technical conditions are adequate, operations are conducted simultaneously.
The operations include:
– cranial trepanation for correction of brain compression or for open brain injury;
– surgical interventions for internal bleeding or injuries to hollow organs;
– operations for injuries to magistral vessels;
– surgical preparation of wounds with intense bleeding, especially facial cranium;
– surgical preparation and osteosynthesis of open fractures, open joint injuries, wounds with loose-lying tendons, vessels and nerves;
– fasciotomy for compartment syndrome;
– external fixation for unstable injuries to the pelvic ring;
– extremity amputation;
– correction of rough skeletal instability in fractures of the femur, the spine, humeral shaft and leg bones.
Stabilization of pelvic ring with external fixation device is conducted for associated abdominal injuries and unstable pelvic injuries.
Open fractures of the third degree are treated with external fixation devices or locked nails (before restoration of magistral vessel). This stage includes the measures for supporting adequate breathing, correction of disorders of water electrolytic and acid-base balance with consideration of the results of analysis of blood and electrolytes.
At this stage diagnostics includes monitoring of pupils, body temperature, urination, arterial and central venous pressure, ECG, recurrent examinations of hemoglobin, hematocrit and blood gases.
The third stage – stabilizing state
After completion of operations for vital signs the patient receives infusion therapy (in the ICU) for normalizing respiratory function, cardiovascular system, blood clotting system and peripheral tissue exchange. Depending on severity of an injury the stabilization phase lasts from 6-12 hours to several days.
The objective of the phase – stabilization of vital organs and systems, and fast preparation to further operations. This phase includes cranial CT, X-ray examination of the chest, the abdomen, the pelvis and the extremities. Urogram is carried out if indicated. The strategy of polytrauma management is determined. Laboratory analyses are oriented to blood clotting system, arterial blood gases. The surgical manipulations include peritoneal lavage, reduction of dislocation (first of all, femoral dislocation), fracture immobilizing.
The fourth phase – late surgery
All identified fractures of the extremities are stabilized. After anti-shock therapy and stabilizing vital functions the priority regions are fractures of the long bones, unstable injuries to the pelvic ring, significant spinal instability. Stabilization of fractures gives the opportunity for pain and stress relief, prevention of further injuries to the tissues, arrest of bleeding, treatment of traumatic brain injury and chest injury by means of elevated position of the upper half of the body or free draining position.
In some cases of multiple fractures simultaneous operations are performed by two teams of surgeons. For traumatic brain injury, femoral fracture and leg fracture operations are conducted simultaneously or sequentially 1-2 hours after completion of the first operation.
The list of late operations which are conducted after evident stabilization of vital functions:
- unstable spinal injuries;
- fractures of humeral shaft and the leg;
- the injuries resulting in lost functions if not treated in proper time;
- early application of primary sutures;
- plastic closure of the wound;
- early change of fixation technique (nails instead of fixation device);
- reconstruction of joints;
- peripheral osteosynthesis;
- fractures of facial skeleton and mandibles.
The fifth stage – rehabilitation
Emergency operations and complex treatment of all injuries are conducted. The premise for final treatment is normal lung functioning, hemodynamics, water electrolyte and acid base balance, metabolism and blood clotting.
Operations of this stage are performed by facial surgeons, oculists, urologists and other specialists. The procedures include early application of primary sutures, plastic closure of the wound, early change of fixation technique (intramedullary nails or plates instead of fixation devices) and joint reconstruction [7-10]