PROBLEMS OF STAGED TREATMENT OF PATIENTS WITH SEVERE CONCOMITANT INJURIES IN A REGIONAL TRAUMA SYSTEM
Chair (clinic) of military field surgery, Kirov Military Medical Academy, Saint Petersburg, Russia
The issues of treatment of severe concomitant injuries are important for development of modern health care. The common feature of the last decades is the changes in structure of injuries by means of increasing severity of trauma and higher proportion of concomitant and multiple injuries (their rate is 55-80 %) that determine the high mortality and disability in young persons of working age [1-3].
Most developed countries have the regional trauma systems. Such systems imply the transfer from the accident site to the specialized trauma centers (TC) of different levels. The type of a sanitary vehicle and the level of TC are conditioned by severity of an injury and the patient’s condition. Rapid transportation of patients with polytrauma to level 1 TC can be achieved with available number, appropriate territorial coverage and transport accessibility of TC. So, Germany had 108 level 1 TCs, 209 level 2 TCs and 431 level 3-4 TCs in 2006 [4].
The regional trauma centers appear in the Russian federation from beginning of 2000s. There were more than 1,500 TCs in 2015 [1]. However their availability (that also depends on the geographic features) does not provide the rapid transfer of all patients with polytrauma to the level 1 TC from the accident site. Most patients are initially transferred to level 2-3 TCs, where they receive the emergent surgical interventions. After stabilizing their condition, the patients who require for the specialized (including high-tech) medical care, which cannot be conducted in such trauma centers, are transferred to level 1 TC [5, 6].
The objective of the study – to conduct the analysis of the structure of injuries and the features of surgical treatment of patients in conditions of the regional trauma system.
MATERIALS AND METHODS
The retrospective analysis included 336 patients who were transferred to the military field surgery clinic of Kirov Military Medical Academy in 2010-2015 from the hospitals, which were included into the regional trauma systems as level 2-3 TCs.
The severity of the injuries was assessed with Military Field Surgery-Injury score [7].
The statistical analysis was conducted with the applied software Statistica-6 (StatSoft, 2010) and Microsoft Office Excel 2010 with obligatory estimation of statistical significance of the identified relationship (p < 0.05).
RESULTS AND DISCUSSION
The figure 1 shows the time course of admission of the patients according to the years. It notes the gradual decrease in the amount of transferred patients: from 72 patients in 2010 to 36 ones in 2015. It reflects the improving activity of the regional trauma center. However the number of patients with polytrauma changes in a less degree and varies from 10 to 19 patients per year. The proportion of the patients with polytrauma varied from 16.9 % in 2013 to 33.3 % in 2015.
The analysis of time of transfer of the patients (Fig. 2) shows that 140 patients (41.6 %) were transported to the clinic within 3 days after trauma, 116 patients (34.5 %) – from 4th to 10th day, and only 80 patients (23.8 %) – after 10 days.
The general severity of the injuries was 5.9 ± 1.3, the severity of the injuries in the patients with polytrauma – 14.6 ± 3.4 according to Military Field Surgery-Injury (MFS-I) score. The severe and extremely severe injuries were in 81.4 % of the patients.
The most common locations of the injuries in the transferred patients were the injuries to the extremities (34.8 %), the spine (17.0 %) and the head (16.7 %), whereas the patients with polytrauma had the injuries to the head (30.7 %), the pelvis (22.7 %) and the abdomen (18.2 %) (the table 1).
For estimating the characteristics of the injuries, the efficiency of the treatment in the trauma centers of different levels, and for identification of the most important problems in carrying out the surgical care, the general groups were divided into the subgroups according to locations of the injuries.
The head injuries were in 197 transferred patients (58.8 %), including 56 patients (16.6 %) with the head injuries as the main location of the concomitant injury. According to MFS-I, the general severity of the injuries was 2.4 ± 0.8, whereas in the patients with the head injury as the main trauma – 11.9 ± 1.4.
The patients received 231 surgical interventions. Most interventions were the head wound suturing in different locations. Among 9 patients who required for decompressive interventions for the cranium and the brain in level 2-3 TCs, 4 (44.4 %) patients needed for urgent retrepanation in the day of admission according to the results of the examinations. It was determined by either insufficient volume of a primary intervention (the untreated compression fracture of the left temporal and parietal bones (Fig. 3) or recurrent intracranial hematoma (3 patients).
Patients with injuries to the middle and lower regions of the face presented the special problem for the surgeons in level 2-3TCs. During treating such patients, the surgical activity was low and was presented by anterior and posterior nasal tamponage and fixation of mandibular fractures with the wire splints. Surgical interventions were not conducted for most patients with the verified fractures of facial bones. It is conditioned by complexity of this pathology, uncertainty of the applied approaches and the lack of specialists and appropriate equipment. It was especially evident during primary surgical preparation of the gunshot wounds of the maxillo-facial area. The common errors are insufficient volume of removed necrotic tissues, inadequate draining of the intermuscular regions of the face and the neck, underestimation of injuries severity, the drive to suture the facial gunshot wound at all costs (Fig. 4a), unstable fixation of fractures with internal metal constructs, refusal from external fixing devices (Fig. 4b) or their absence in a trauma center.
Spinal injuries took the place in 91 patients (27 %), including 57 patients (16.9 %) with such injuries as the main ones. The general severity of the injuries was 2.3 ± 0.6, in the group with the spinal injury as the main damage – 3.1 ± 1.4.
The analysis of the conducted surgical interventions identified two problems (the table 2). Firstly, the urgent surgical interventions (laminectomy) for spinal injuries were carried out only for 43.8 % of the patients. In some cases, the spinal injuries could be identified only in the examination in the clinic. It was determined by the severity of the concomitant injuries in the patients with polytrauma, when the urgent interventions for other regions of the body were carried out in level 2-3 TCs. Such patients received the surgical interventions within 24 hours after admission to the clinic (Fig. 5).
Secondly, the absence of conditions and equipment in level 2-3 TCs did not allow the spinal fixation, although surgical interventions were performed by the qualified neurosurgeons. One patient had the migration of the autograft that resulted in urgent recurrent surgery in the clinic (Fig. 6).
Thoracic injury was in 123 patients (36.5 %). Such damage was the main injury in 33 patients (9.8 %). The general severity of the injury was 2.3 ± 0.6, in the group with the thoracic injury as the main trauma – 3.1 ± 1.0.
The table 3 shows that the most common surgical interventions in all trauma centers were thoracocentesis and pleural cavity draining. Single mistakes were usually associated with choice of the diameter of the draining tube or the place of thoracocentesis. Inadequate pleural cavity draining caused the necessity for recurrent thoracocentesis or development of clotted hemothorax. Only a single urgent thoracotomy for a penetrating chest injury with heart damage was conducted in level 2 TC. In the clinic, 5 patients received the diagnostic and curative thoracoscopy for big hemothorax (1 patient), 3 cases – for recurrent tension hemothorax, 1 patient – for clotted hemothorax.
An unexpected problem was preparation and realization of medical evacuation to the clinic. Some patients were admitted with the pleural drains, which were ligated or connected with the drain camera (Redon system). The keys for successful treatment of patients with chest trauma in level 1 TC are:
1) obligatory chest computer tomography after transfer of patients with chest injury and polytrauma;
2) use of low invasive methods for diagnostics and treatment;
3) appropriate intensive therapy for lung and heart contusion in the specialized ICU.
Abdominal injuries were diagnosed in 70 patients (20.8 %). 32 patients had the abdominal injury as the main location of injuries. The injury severity was 4.2 ± 0.4 according to MFS-I. The general injury severity was 2.3 ± 0.4, in the group with abdomen as the main region of trauma – 3.1 ± 1.1.
The analysis of surgical activity (the table 4) showed that only 11 patients were operated in the clinic, but they received 33 surgical interventions. In most cases, the multi-staged surgical treatment was conducted.
Only one patient with the gunshot abdominal wound with the injuries to the duodenum, caput pancreatic, ductus choledochus and the inferior vena cava received the relaparotomy as the third stage of damage control in the day of admission. The timely breakaway of the duodenum, jejunostomy, sanitation and draining of the abdominal cavity were carried out. The subsequent posttraumatic pancreatitis with purulent-fibrous peritonitis required for another three programmed relaparotomy procedures.
For other 10 patients, laparotomy was conducted for programmed treatment of peritonitis. The causes were the injuries, which were not diagnosed or were missed during urgent laparotomy, for example, a full rupture of the small intestine identified in the clinic on 9th day after the road traffic injury (Fig. 7).
The multi-staged treatment included the systems with controlled negative pressure.
75 patients (22.3 %) had the pelvic injuries. The general severity of the injury was 4.4 ± 2.2, in the group with the pelvis as the main injured region – 3.1 ± 1.6. The pelvic injury as the main trauma was in 39 (11.6 %) patients.
The table 5 shows a fairly high proportion of the patients with extrafocal fixation of unstable pelvic fractures in level 2-3 TCs. It was associated with improvement in the system of medical care for injuries, development of well-equipped traumatology units. However 10 patients were admitted to the clinic with non-fixed fractures. Moreover, some patients received the interventions, but the goal was not achieved. The figure 8 shows the CT images of the patient with the applied rod device, but the vertical displacement of the right half of the pelvis and the dislocation of the left hip were not corrected.
The separate problem was the recurrent interventions for the patients with injuries to the pelvic organs. Among 5 patients, 4 ones needed for recurrent surgery due to disadvantages in primary surgical interventions and inadequate draining of paravesical fat (Fig. 9), resulting in inconsistency of urinary bladder sutures and formation of pelvic urohematoma.
The injuries to the extremities were identified in 212 patients (63.1 %). The general severity of trauma was 2.1 ± 0.5, in the group with the extremities as the main injured regions – 3.1 ± 1.2. Such injuries were main ones in 177 (34.8 %) patients.
The treatment of this category of the patients was associated with three main problems. The first problem was the disadvantages in transport immobilization of extremities fractures during transfer to the clinic. As the table 6 shows, 25 patients received the extrafocal osteosynthesis in level 2-3 TCs, whereas other 40 patients also needed for this procedure. The attempts to perform immobilization with the plaster bars or dressings were usually non-efficient. The result of inadequate immobilization of a leg fracture in one patient was popliteal artery thrombosis with development of non-compensated ischemia in the leg and the foot, with requirement for urgent vascular reconstruction.
The second problem was inadequate awareness among the physicians of level 2-3 TCs in relation to the treatment techniques for extensive circular detachments of the skin. The attempts to suture the detached skin flaps caused their necrosis (Fig. 10), and the absence of immobilization of an injured extremity was the cause of inappropriate survival of the autograft.
The surgical treatment of extensive injuries to the soft tissues of the extremities was the third problem in this group of the patients (Fig. 11). The attempt to complete the surgery with application of the primary suture by any costs was the frequent error on primary surgical preparation. The edema of the injured tissues caused their secondary necrosis (Fig. 12), development of purulent-septic complications and recurrent surgical interventions.
The analysis of the treatment outcomes of all patients showed the mortality of 9.8 % among the transferred patients (22.7 % in the patients with polytrauma) (the table 7). There were not any reliable differences in the general mortality in the patients who were initially admitted to the clinic. However the calculation of these values in the patients who survived within the first 24 hours after primary admission to the clinic identified the lower values of the general mortality in polytrauma.
CONCLUSION
1. The variant of the course of traumatic disease is determined by both the severity of trauma and the volume and adequacy of the treatment.
2. The optimal level of surgical and intensive care for polytrauma is fully realized only in conditions of the specialized hospital (level 1 trauma center).
3. The task of level 2-3 trauma centers at the moment of admission of patients with polytrauma is life-saving with use of multi-staged treatment, the patient’s condition stabilization and fast transfer to the specialized centers (level 1 trauma centers). Any delay in evacuation of such patients is accompanied by risk of development of unfavorable consequences of untimely or inadequate surgical and intensive care, and increasing mortality.
4. The multi-staged surgical treatment for life salvage in level 2-3 trauma centers can be realized according to the vital (refusal from full volume of a surgical intervention owing to severity of condition) and tactical (absence of a technical possibility for realization of full volume of surgical intervention) indications.
5. For full realization of the required level and volume of medical care in the trauma centers of the level 2-3, it is necessary to give the special attention to material and technical resources and to staff education concerning the actual problems of polytrauma.
6. The system of medical care realization for patients with polytrauma should consist in maximal reduction of the stages and time of all types of surgical care.
Information about conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.