Polytrauma

Polytrauma in the English-language literature - multiple trauma, polytrauma.

Combined trauma is a collective concept that includes the following types of injuries:

• multiple - damage more than two internal organs in one cavity or more than two anatomo-functional formations (segments) of the musculoskeletal system (for example, damage to the liver and intestine, fracture of the femur and forearm bones),
• combined - simultaneous damage of two or more anatomical areas of two cavities or damage to internal organs and supporting motor apparatus (for example, spleen and bladder, chest cavity organs and fracture of limb bones, craniocerebral trauma and damage to pelvic bones),
• combined - damage by traumatic factors of various nature (mechanical, thermal, radiation), and their number is unlimited (for example, a fracture of the femur and a burn of any area of the body).

ICD-10 code

The principle of multiple coding of injuries should be used as widely as possible Combined headings for multiple injuries are used in case of insufficient detailing of the nature of individual injuries or in the case of primary statistical developments, when it is more convenient to register a single code, in other cases all trauma components should be coded separately

T00 Superficial injuries that seize multiple areas of the body

• T01 Open wounds that seize several areas of the body
• T02 Fractures that capture several areas of the body
• T03 Dislocations, sprains and injuries of the capsular-ligamentous apparatus of the joints, which seize several areas of the body
• T04 Crushing injury, multiple areas of the body
• T05 Traumatic amputations that involve several areas of the body
• T06 Other injuries involving several areas of the body, not elsewhere classified
• T07 Multiple injuries, unspecified

With a combined injury, it may be necessary to encode damage caused by other factors:

• Т20-Т32 Thermal and chemical burns
• T33-T35 Frostbites

Sometimes, some complications of polytrauma

• T79 Some early complications of injuries, not elsewhere classified

Epidemiology of polytrauma

According to the WHO, up to 3.5 million people die every year from injury. In economically developed countries, injuries rank third in the list of causes of death, in Russia - the second. In Russia, men under 45 and women under 35 years of age have traumatic injuries, the main cause of death, and 70% of cases - severe co-traumatic injuries. Victims with polytrauma account for 15-20% of the total number of patients with mechanical injuries. The prevalence of polytrauma is subject to significant fluctuations and depends on the specific conditions of a given locality (demographic indicators, production characteristics, prevalence of rural or urban population, etc.). However, in general, the world has noted a tendency to increase the number of victims with multiple injuries. The frequency of polytrauma over the past decade has increased by 15%. The lethality with it is 16-60%, and in severe cases - 80-90%. According to the American researchers, in 1998, 148 thousand Americans died from various traumatic injuries, and the death rate was 95 cases per 100 thousand of the population. In the UK in 1996, there were 3,740 deaths as a result of serious traumatic injuries, which amounted to 90 cases per 100 thousand of the population. In the Russian Federation, large-scale epidemiological studies have not been carried out, however, according to a number of authors, the number of deaths of polytrauma per 100 thousand of population is 124-200 (the last figure is for large cities). The approximate cost of treating the acute phase of traumatic injuries in the US is $ 16 billion per year (the second most expensive medical unit in the medical unit). The total economic damage from injuries (considering the death and disability of the victims, lost income and taxes, the cost of medical care) in the US is $ 160 billion per year. Approximately 60% of victims do not survive to qualified medical care, and die as soon as possible after injury (on the spot). Among hospitalized patients, the greatest mortality is noted in the first 48 hours, which is associated with the development of massive blood loss, shock, damage to vital organs and severe head injury. Further, the leading causes of death are infectious complications, sepsis and PON. Despite the achievements of modern medicine, mortality from polytrauma in intensive care units over the past 10-15 years has not decreased. 40% of survivors remain disabled. In most cases, the able-bodied population at the age of 20-50 years suffers, and the number of men is approximately twice that of women. Injuries in children are recorded in 1-5% of cases. Newborns and infants are more likely to suffer as passengers in road accidents, at older ages - as cyclists and pedestrians. Estimating the damage from polytrauma, it should be noted that the number of unextended years, it significantly exceeds that of cardiovascular, oncological and infectious diseases combined.

[1], [2], [3], [4], [5]

Causes of polytrauma

The most common cause of combined trauma is auto- and railway accidents, falling from height, violent damage (including gunshot and mine-explosive injuries, etc.). According to German researchers, in 55% of cases, polytrauma is the result of an accident, in 24% - industrial injuries and active rest, in 14% - falls from height. The most complex combinations of injuries are noted after an accident (57%), with chest injuries occurring in 45% of cases, TBC in 39%, and injuries in 69%. Important for the prediction of CCT, chest and abdominal trauma (in particular with a bleeding in the pre-hospital stage). Damage to the organs of the stomach and pelvic bones as a component of polytrauma is met in 25-35% of all cases (and in 97% they are closed). Due to the high incidence of soft tissue damage and bleeding, the lethality in pelvic injuries is 55% of cases. Damage to the spine as a component of polytrauma is met in 15-30% of all cases, in connection with which every patient is unconsciously suspected of spinal trauma.

The mechanism of trauma has a significant effect on the prognosis of treatment. In a collision with a car:

• in pedestrians 47% of cases are met with CCT, in 48% - injuries of the lower extremities, in 44% - trauma of the chest,
• in cyclists in 50-90% of cases - limb injuries and in 45% - CCT (with the use of protective helmets significantly reduces the amount of severe injuries), chest trauma is a rarity.

In case of car accidents, the use of belts and other safety elements determines the types of injuries:

• Persons who are not wearing seat belts are dominated by severe TBI (75% of cases), while those who use them are more likely to suffer from abdominal trauma (83%) and spine.
• At lateral impacts often there are injuries of the chest (80%), abdomen (60%), pelvic bones (50%).
• At impacts behind the cervical spine suffers more often.

The use of modern security systems significantly reduces the number of cases of severe injuries to the abdominal cavity, chest and spine.

Falls from a height can be either a consequence of chance or an attempt at suicide. At unexpected falls more often heavy TBT are noted, and at suicides - traumas of the lower extremities.

[6], [7], [8]

How does polytrauma develop?

The mechanism of development of a combined trauma depends on the nature and type of injuries received. The main components of pathogenesis are acute blood loss, shock, traumatic illness:

• the simultaneous occurrence of several foci of nociceptive pathological impulses leads to the disintegration of compensatory mechanisms and the disruption of adaptation reactions,
• the simultaneous existence of several sources of external and internal bleeding makes it difficult to adequately estimate the volume of blood loss and its correction,
• early posttraumatic endotoxicosis, observed with extensive soft tissue damage.

One of the most important features of the development of polytrauma is the mutual burdens caused by the multiplicity of mechanical damages and the multifactor effect. At the same time, each injury aggravates the severity of the general pathological situation, proceeds more severely and with a greater risk of complications, including infections, than with isolated trauma.

Damage to the central nervous system leads to a violation of the regulation and coordination of neurohumoral processes, dramatically reduces the effectiveness of compensatory mechanisms and significantly increases the likelihood of purulent-septic complications. Trauma to the breast inevitably leads to aggravation of ventilatory and circulatory hypoxia. Damage to the abdominal cavity and retroperitoneal space is accompanied by pronounced endotoxicosis and a significant increase in the risk of infectious complications, which is due to the structural and functional characteristics of the organs of the anatomical region, their participation in metabolism, functional conjugation with the vital activity of the intestinal microflora. Injury of the musculoskeletal system increases the risk of secondary damage to soft tissues (the occurrence of bleeding, necrosis), enhances pathological impulses from each affected area. Immobilization of damaged segments of the body is associated with prolonged hypodynamia of the patient, aggravating the manifestations of hypoxia, which, in turn, increases the risk of infectious, thrombembolic, trophic and neurological complications. Thus, the pathogenesis of mutual burdening is represented by a multitude of non-planar mechanisms, but for most of them the universal and most important link is hypoxia.

Symptoms of polytrauma

The clinical picture of combined trauma depends on the nature, combination and severity of its components, an important element is mutual burdening. In the initial (acute) period, there may be a discrepancy between visible lesions and the severity of the condition (degree of hemodynamic disorders, resistance to therapy), which requires the doctor to pay special attention to the timely recognition of all components of the polytrauma. In the early post-shock period (after stopping bleeding and stabilizing systemic hemodynamics), the victims are likely to have ARDS, acute systemic metabolism disorders, coagulopathy complications, fat embolism, hepatic and renal insufficiency. Thus, the distinctive feature of the first week is the development of MES.

The next stage of traumatic illness is characterized by an increased risk of infectious complications. There is a possible localization of wound infection, pneumonia, abscesses in the abdominal cavity and retroperitoneal space. In the role of pathogens can act as endogenous, and nosocomial microorganisms. There is a high probability of generalization of the infectious process - the development of sepsis. The high risk of infectious complications in polytrauma is due to secondary immunodeficiency.

In the period of convalescence (usually prolonged), asthenia predominates, and gradual correction of systemic disorders and functional disorders occurs in the work of internal organs.

There are the following features of the combined injury:

• objective difficulties in diagnosing damage,
• mutual burdening,
• a combination of injuries that exclude or impede the conduct of diagnostic and therapeutic measures,
• high frequency of severe complications (shock, ODN, arthritis, coma, coagulopathy, fat and thromboembolism, etc.)

There are early and late complications of trauma.

Complications of the early period (first 48 hours):

• blood loss, hemodynamic disorders, shock,
• fat embolism,
• coagulopathy,
• impaired consciousness,
• OPN,
• respiratory distress,
• thrombosis of deep veins and PE,
• hypothermia.

Complications of the late period:

• infectious (including nosocomial) and sepsis,
• neurological and trophic disorders,
• PON.

Domestic researchers combine the early and late manifestations of poly-trauma with the concept of "traumatic illness." Traumatic illness is a pathological process caused by severe mechanical trauma, and the change of the leading pathogenesis factors causes a regular sequence of periods of the clinical course.

Periods of traumatic illness (Bryusov PG, Nechaev EA, 1996):

• shock and other acute disorders - 12-48 h,
• PON - 3-7 days,
• infectious complications or a special risk of their occurrence - 2 weeks - 1 month or more,
• delayed convalescence (neurological and trophic disorders) - from several weeks to several months.

Classification of polytrauma

On the spread of traumatic injuries:

• isolated trauma - the emergence of an isolated traumatic focus in one anatomical region (segment),
• multiple - more than two traumatic foci in one anatomical region (segment) or within one system,
• combined - the emergence of more than two traumatic foci (isolated or multiple) in different anatomical regions (segments) or damage more than two systems or cavities, or cavities and system,
• combined - the result of more than two physical factors.

On severity of traumatic injuries (Rozhinsky MM, 1982):

• trauma is not life-threatening - all variants of mechanical damage without pronounced violations of the body's activity and immediate danger to the life of the victim,
• life-threatening - anatomical damage to vital organs and regulatory systems, surgical removable with timely provision of qualified or specialized care,
• deadly - destruction of vital organs and regulatory systems, not surgically removable, even with timely qualified care.

On the localization of traumatic injuries the head, neck, chest, abdomen, pelvis, spine, upper and lower limbs, retroperitoneal space.

[9], [10], [11], [12], [13]

Diagnosis of polytrauma

Questioning the patient allows you to clarify complaints and the mechanism of injury, which greatly facilitates the diagnostic search and examination. Often, the history of the anamnesis is difficult due to a violation of consciousness in the victim. Before examination, the victim should be completely undressed. Pay attention to the general appearance of the patient, the coloring of the skin and mucous membranes, the state of the pulse, the localization of wounds, abrasions, hematomas, the position of the injured (forced, passive, active), which allows tentatively identify the damage. Percussion and auscultation methods examine the thorax, palpate the abdomen. Inspect the oral cavity, remove mucus, blood, vomit, removable dentures, fix the sinking tongue. When examining the chest, pay attention to the amount of her excursion, determine whether there is any deviation or swelling of parts, sucking air into the wound, swelling of the cervical veins. The increase in the deafness of cardiac tones, revealed during auscultation, may be a sign of damage and tamponade of the heart.

For an objective assessment of the condition of the victim, severity of damage and prognosis, coma scales Glasgow, APACHE I, ISS, TRISS are used.

Most of the events shown in the figure are carried out simultaneously.

In patients in stable condition, CT of the skull and brain is performed before the examination of the abdominal cavity.

If patients in an unstable state (there is focal neurological symptomatology, according to ultrasound and peritoneal lavage - free fluid in the abdominal cavity), infusion therapy can maintain a safe index of blood pressure, then the CT of the head is performed before laparotomy.

Prior to assessing the neurological status, the victims try not to prescribe sedatives. If the patient has breathing disorders and / or impaired consciousness, then it is necessary to ensure reliable airway patency and constant monitoring of oxygenation of the blood.

To choose the right therapeutic tactics and the sequence of surgical interventions, it is necessary to determine as quickly as possible the dominant lesions (determining the severity of the condition of the victim at the moment). It should be noted that over time, the leading place can go to different injuries. Treatment of polytrauma is conditionally divided into three periods of resuscitation, treatment, rehabilitation.

[14], [15], [16], [17], [18]

Instrumental Explorations

Urgent studies

• peritoneal lavage,
• CT of the skull and brain,
• radiography (chest, pelvis), if necessary - CT,
• Ultrasound of the pleural and pleural cavities, kidneys

Depending on the severity of the condition and the list of necessary diagnostic procedures, all victims are conditionally divided into three classes:

1. The first - severe, life-threatening damage, there are pronounced neurological, respiratory and hemodynamic disorders. Diagnostic procedures: chest radiography, ultrasound of the abdominal cavity, echocardiography (if necessary). In parallel, intensive and urgent medical interventions are performed for intubation of the trachea and IVL (with severe TBI, respiratory dysfunction), puncture and drainage of the pleural cavity (with massive pleural effusion), surgical stopping of bleeding.
2. The second is severe damage, but against a background of massive infusion therapy, the condition of the victims is relatively stable. The examination of patients is aimed at finding and eliminating potentially life-threatening complications of ultrasound of the abdominal organs, chest radiography in four positions, angiography (with further embolization of the source of bleeding), CT of the brain.
3. The third - victims in a stable condition. To quickly and accurately diagnose damage and determine further tactics, such patients are recommended to conduct CT of the entire body.

Laboratory research

All the necessary laboratory tests are divided into several groups:

Available within 24 hours, the result is ready in an hour

• determination of hematocrit and hemoglobin concentration, differential count of leukocyte count,
• the determination in the blood of the concentration of glucose, Na +, K \ chlorides, urea nitrogen and creatinine,
• definition of indicators of hemostasis and coagulogram - PTI, prothrombin time or INR, APTT, fibrinogen concentration and platelet count,
• general urine analysis.

Available within 24 hours, the result is ready in 30 minutes, and in patients with severe disturbances of oxygenation and ventilation they are performed immediately:

• gas analysis of arterial and venous blood (paO2, SaO2, pvO2, Sv02, paO2 / FiO2), acid-base balance

Available daily:

• microbiological determination of the pathogen and its sensitivity to antibiotics,
• determination of biochemical parameters (CK, LDH with fractions, serum a-amylase, ALT, ACT, bilirubin concentration and fractions, alkaline phosphatase activity, y-glutamyltranspeptidase, etc.)
• control of the concentration of drugs (cardiac glycosides, antibiotics, etc.) in body fluids (preferably).

When a patient enters a hospital, he is required to determine the blood group and Rh-factor, carry out tests for blood-borne infections (HIV, hepatitis, syphilis).

At certain stages of diagnosis and treatment of the victims, it may be useful to study the concentration of myoglobin, free hemoglobin and procalcitonin.

Monitoring

Constant observations

• control of heart rate and heart rate,
• pulse oximetry (S 02),
• concentration of CO2 in the exhaled gas mixture (for patients on IVL),
• invasive measurement of arterial and central venous pressure (with unstable condition of the victim),
• measurement of central temperature,
• invasive measurement of central hemodynamics by various methods (thermodilution, transpulmonary thermodilution - with unstable hemodynamics, shock, ARDS).

Regularly observed observations

• measurement of blood pressure by a cuff,
• measurement of CB,
• determination of body weight,
• ECG (for patients older than 21 years).

Invasive methods (catheterization of peripheral arteries, right heart) are shown to victims with unstable hemodynamics (resistant to treatment), pulmonary edema (against the background of infusion therapy), as well as patients who need to monitor arterial oxygenation. Right heart catheterization is also recommended for those with OPL / ARDS who need respiratory support.

It is necessary to equip the intensive care unit

• Equipment for respiratory support.
• Sets for resuscitation (including the Ambo bag and facial masks of various sizes and shapes) - for transferring patients to mechanical ventilation.
• Endotracheal and tracheostomy tubes of different sizes with cuffs of low pressure and non-manicure (for children).
• Equipment for aspiration of contents of the oral cavity and respiratory tract with a set of disposable sanitation catheters.
• Catheters and equipment for permanent venous access (central and peripheral).
• Kits for carrying out thoracocentesis, drainage of pleural cavities, tracheostomy.
• Special beds.
• The driver of a rhythm of heart (the equipment for EKS).
• Equipment for warming up the victim and controlling the temperature in the room.
• If necessary - apparatus for replacement renal therapy and extracorporeal detoxification.

Indications for hospitalization

All victims with suspicion of polytrauma for examination and treatment are hospitalized in a hospital with the possibility of providing specialized care. It is necessary to adhere to the logical strategy of hospitalization, which allows ultimately to get the most rapid recovery of the victim with the least number of complications, and not trivial to deliver the patient to the nearest medical institution. In the majority of victims with a combined trauma, the condition is initially assessed as severe or extremely difficult, so they are hospitalized in the ICU. When surgical intervention is required, intensive therapy is used as preoperative preparation, its purpose is to maintain vital functions and minimal sufficient preparation of the patient for surgery. Depending on the nature of the damage, patients need to be hospitalized or transferred to specialized hospitals - spinal cord injuries, burns, microsurgery, poisonings, psychiatric.

Indications for consultation of other specialists

Treatment of victims with severe combined trauma requires the involvement of specialists of different profiles. Only if the efforts of intensive care doctors, surgeons of various specializations, traumatologists, radiologists, neurologists and other specialists combine, one can hope for a favorable outcome. Successful treatment of such patients requires consistency and continuity in the actions of medical personnel at all stages of care. The necessary condition for obtaining the best results of treatment for polytrauma is the trained medical and paramedical personnel, both at the hospital and prehospital stages of care, and the effective coordination of hospitalization of the victim to a medical institution, where immediate specialized assistance will be provided. Most patients with polytrauma after the main course need a long recovery and rehabilitation treatment with the involvement of doctors of relevant specialties.

Treatment of polytrauma

The goals of the treatment are intensive therapy of victims with a combined trauma - a system of medical measures aimed at preventing and correcting violations of life-critical functions, ensuring normal responses of the body to damage and achieving sustainable compensation.

Principles of first aid:

• ensuring airway patency and tightness of the chest (with its penetrating wounds, open pneumothorax),
• temporary stopping of external bleeding, priority evacuation of victims with signs of continuing internal bleeding,
• ensuring adequate vascular access and early initiation of infusion therapy,
• anesthesia,
• immobilization of fractures and extensive damage by transport tires,
• careful transportation of the victim for the provision of specialized medical care.

General principles of treatment of victims with polytrauma

• the fastest recovery and maintenance of adequate tissue perfusion and gas exchange,
• if general resuscitation measures are required, then they are carried out in accordance with the ABC algorithm (Airways, Breath, Circulation - airway patency, artificial respiration and indirect heart massage),
• adequate anesthesia,
• maintenance of hemostasis (including surgical and pharmacological methods), correction of coagulopathies,
• adequate provision of energy and plastic needs of the body,
• monitoring the patient's condition and heightened alertness regarding the possible development of complications.

Therapy of circulatory disorders

• It is necessary to constantly monitor the condition of the victim.
• Victims often come with hypothermia and vasoconstriction, which can mask and impede the timely recognition of hypovolemia and peripheral circulation disorders.
• The first stage of hemodynamic support is the introduction of infusion solutions for the rapid restoration of adequate perfusion. Isotonic crystalloid and isoncotic colloidal solutions have the same clinical efficacy. To maintain hemodynamics (after the restoration of the volemic status), sometimes the introduction of vasoactive and / or cardiotonic drugs is indicated.
• Monitoring of oxygen transport makes it possible to detect the development of multiple organ dysfunction earlier than its clinical manifestations (they are observed 3-7 days after trauma).
• With the growth of metabolic acidosis, it is necessary to check the adequacy of the intensive therapy being conducted, to exclude latent bleeding or necrosis of soft tissues, OCH and myocardial damage, arthritis.

Correction of respiratory disorders

All victims are shown immobilization of the neck until the fractures and instability of the cervical vertebrae are excluded. First of all, they exclude neck trauma in patients without consciousness. For this purpose, an X-ray examination is performed, the victim is examined by a neurologist or neurosurgeon.

If the patient is being given ventilation, then before stopping it, you need to make sure of the stability of the hemodynamics, the satisfactory state of the gas exchange parameters, the elimination of metabolic acidosis, adequate warming of the victim. If the patient's condition is unstable, then the transfer to independent breathing should be postponed.

If the patient breathes independently, then oxygen must be supplied to maintain adequate arterial oxygenation. With the help of non-oppressive but effective anesthesia, a sufficient depth of breathing is achieved, which prevents atelectasis of the lungs and the development of a secondary infection.

When predicting long-term mechanical ventilation, the early formation of a tracheostomy is shown.

[19], [20], [21], [22], [23]

Transfusion therapy

Adequate transport of oxygen is possible at a hemoglobin concentration of more than 70-90 g / l. However, in patients with chronic diseases of the cardiovascular system, pronounced metabolic acidosis, low CB and partial pressure of oxygen in mixed venous blood, it is necessary to maintain a higher value - 90-100 g / l.

In case of recurrence of bleeding or development of coagulopathy, a stock of erythrocyte mass is required, compared with group and rhesus-affiliation.

Indication for the appointment of FFP - massive blood loss (loss of bcc for a day or half of it for 3 hours) and coagulopathy (thrombin time or APTT more than 1.5 times longer than normal). The recommended initial dose of FFP is 10-15 ml / kg of body weight of the patient.

It is necessary to maintain a platelet count of more than 50x10 ⁹ / l, and in those with massive bleeding or severe TBT, more than 100x10 ⁹ / L. The initial volume of donor platelets is 4-8 doses or 1 dose of thromboconcentrate.

Indication for the use of coagulation factor VIII (cryoprecipitate) - a decrease in the concentration of fibrinogen less than 1 g / l. Its initial dose is 50 mg / kg.

In intensive care for severe bleeding with closed injuries, the use of the VII factor of blood coagulation is recommended. The initial dose of the drug is 200 μg / kg and then after 1 and 3 hours - 100 μg / kg.

Anesthesia

Adequate anesthesia is necessary to prevent the development of hemodynamic instability, increase respiratory chest excursion (especially in patients with chest, abdominal and spinal injury).

Local anesthesia (in the absence of contraindications in the form of local infection and coagulopathy), as well as the methods of analgesia controlled by the patient, contribute to better relief of the pain syndrome.

Opioids are used in an acute period of trauma NSAIDs are more effective for arresting pain syndrome with bone damage. However, they can cause coagulopathy, stress ulcers of the mucous membrane of the stomach and intestines, and impaired renal function.

In determining the indications for anesthesia, it must be remembered that anxiety, agitation of the victim can be caused by other causes (brain damage, infection, etc.) than pain.

[24], [25], [26], [27], [28], [29], [30]

Food

Early administration of nutritional support (immediately after the normalization of central hemodynamics and tissue perfusion) leads to a significant reduction in the number of postoperative complications.

You can use full parenteral or enteral nutrition, as well as their combinations. While the victim is in a serious condition, the daily energy value of food is at least 25-30 kcal / kg. On a full enteral diet, the patient should be transferred as soon as possible.

[31], [32], [33], [34]

Infectious complications

The development of infectious complications largely depends on the location of the injury and the nature of the injury (open or closed, whether there is contamination of the wound). Surgical treatment, tetanus prophylaxis, antibiotic therapy (from a single appointment to treatment for several weeks) may be required.

Intravenous catheters installed during urgent and resuscitative measures (sometimes without observing aseptic conditions) must be replaced.

Patients with polytrauma have an increased risk of developing secondary infections (in particular, respiratory tract infections and wound surfaces associated with catheterization of large vessels, abdominal cavity and retroperitoneal space). For their timely diagnosis, it is necessary to conduct regular (once every 3 days) bacteriological studies of the body's media (blood, urine, tracheobronchial aspirate, separated from drains), and also to monitor possible foci of infection.

Peripheral injuries and complications

When injuries of limbs often damage the nerves and muscles, thrombosis of blood vessels, violation of blood supply, which ultimately can lead to the development of compression syndrome and rhabdomyolysis. With regard to the development of these complications, increased alertness is needed to perform corrective surgery as soon as possible.

To prevent neurological and trophic disorders (pressure ulcers, trophic ulcers) use special techniques and equipment (in particular, special anti-decubitus mattresses and beds that allow full kinetic therapy).

Prevention of major complications

To prevent the development of deep venous thrombosis appoint drugs heparin. Their use is especially important after orthopedic operations on the lower extremities, the pelvis, and also with prolonged immobilization. It should be noted that the administration of small doses of low molecular weight heparins is associated with fewer hemorrhagic complications than treatment with unfractionated drugs.

For the prevention of stress ulcers of the gastrointestinal tract, the most effective are the inhibitors of the proton pump.

Prevention of nosocomial infection

Regular monitoring of patients' condition is necessary for timely detection and correction of possible late complications (pancreatitis, noncalculous cholecystitis, PON), which may require repeated laparotomy, ultrasound, CT.

Medicamentous treatment of polytrauma

Stage of resuscitation

If the intubation of the trachea is performed prior to catheterization of the central vein, then adrenaline, lidocaine and atropine can be administered endotracheally, increasing the dose by 2-2.5 times compared with that required for intravenous administration.

It is most expedient to use saline solutions to replenish bcc. The use of glucose solutions without monitoring of glycemia is undesirable because of the adverse effects of hyperglycemia on the central nervous system.

Adrenaline for resuscitation is administered starting with a standard dose of 1 mg every 3-5 minutes, if it is ineffective, the doses are increased.

Sodium bicarbonate is administered with hyperkalemia, metabolic acidosis, prolonged circulatory arrest. However, in the latter case, the use of the drug is possible only with intubation of the trachea.

Dobutamine is indicated in patients with low CB and / or low saturation of mixed venous blood, but with an adequate change in blood pressure in response to the infusion load. The drug can cause a decrease in blood pressure, tachyarrhythmias. In patients with signs of impairment of organ blood flow, the appointment of dobutamine can improve the perfusion performance by increasing CB. However, the routine use of the drug to maintain central hemodynamics at the supranormal level [cardiac index greater than 4.5 l / (min. ² )] is not accompanied by a significant improvement in clinical outcomes.

Dopamine (dopamine) and norepinephrine effectively increase blood pressure. Before using them, it is necessary to ensure adequate replenishment of the BCC. Dopamine increases CB, but its use is limited in some cases because of the development of tachycardia. Norepinephrine is used as an effective vasopressor drug.

Do not recommend the use of low doses of dopamine to maintain kidney function.

Phenylephrine (mezaton) is an alternative drug for increasing blood pressure, especially in patients prone to tachyarrhythmias.

The use of epinephrine is justified in patients with refractory hypotension. However, when it is used, side effects are often noted (for example, it is able to reduce mesenteric blood flow, provoke the development of persistent hyperglycemia).

To maintain an adequate value for mean BP and CB, simultaneous separate administration of vasopressor (noradrenaline, phenylephrine) and inotropic drugs (dobutamine) is possible.

Non-pharmacological treatment of polytrauma

Indications for immediate intubation of the trachea:

• Obstruction of the respiratory tract, including at moderate severity and severe damage to the soft tissues of the face, bones of the facial skull, burns of the respiratory tract.
• Hypoventilation.
• Severe hypoxemia with O2 inhalation.
• Oppression of consciousness (Glasgow Coma Scale is less than 8 points).
• Heart failure.
• Severe hemorrhagic shock.

Recommendations for an urgent intubation of the trachea

• The main method is orotracheal intubation by a direct laryngoscope.
  • If the patient retains muscle tone (you can not take the lower jaw), then use pharmacological drugs to achieve the following goals:
    • neuromuscular blockade,
    • sedation (if necessary),
    • maintaining a safe level of hemodynamics,
    • prevention of intracranial hypertension,
    • warning of vomiting.

Increasing the safety and effectiveness of the procedure depends on:

• from the experience of a doctor,
• pulse oximetry monitoring,
• maintaining the cervical spine in a neutral (horizontal) position,
• pressure on the thyroid cartilage (Selik's reception),
• monitoring of CO2 level.

Conicotomy is indicated if the vocal cords are not visible when laryngoscopy or the oropharynx is filled with large amounts of blood or vomit.

Laryngeal mask - an alternative to conicotomy with insufficient experience of its implementation.

Surgical treatment of polytrauma

The main problem with polytrauma is the choice of the optimal time and volume of surgical interventions.

In patients who need a surgical stop of bleeding, the interval between the moment of injury and the operation should be as short as possible. Victims in a state of hemorrhagic shock with an established source of bleeding (despite the successful initial resuscitation) are operated immediately for the final surgical stop. Victims in a state of hemorrhagic shock with an unidentified source of bleeding are immediately examined additionally (including ultrasound, CT and laboratory methods).

Operations performed with polytrauma are divided into:

• urgent first line - urgent, aimed at eliminating the direct threat to life,
• urgent second line - designed to eliminate the threat of development of life-threatening complications,
• urgent third stage - ensure the prevention of complications at all stages of traumatic illness and increase the likelihood of a good functional outcome.

In more remote terms, perform reconstructive and restorative surgery and interventions for developing complications.

When treating patients in an extremely difficult condition, it is recommended to adhere to the tactics of "damage control". The main postulate of this approach is the implementation of surgical interventions in a minimal amount (short time and least traumatism) and only to eliminate the immediate threat to the life of the patient (eg, stop bleeding). In such situations, the operation can be suspended for resuscitation, and after correction of gross violations of homeostasis is resumed. The most frequent indications for the use of "damage control" tactics are:

• the need to accelerate the end of the operation in patients with massive blood loss, coagulopathy and hypothermia,
• sources of bleeding that are not subject to one-stage elimination (for example, multiple ruptures of the liver, pancreas with blood flow into the abdominal cavity),
• lack of the opportunity to sew an operating wound in the traditional way.

Indication for urgent operations - ongoing external or internal bleeding, external mechanical breathing disorders, damage to vital internal organs, those conditions requiring anti-shock measures. After their completion, they continue complex intensive therapy to relative stabilization of the basic vital parameters.

The period of a relatively stable condition of the victim after exiting the shock is used to perform urgent surgical interventions of the second stage. The operations are aimed at eliminating the syndrome of mutual burdens (its development directly depends on the timing of a full surgical manual). Early elimination of major blood flow disorders in the limbs, stabilization of injuries to the musculoskeletal system, elimination of the threat of complications in case of damage are especially important (if performed during the operations of the first stage). Internal organs.

Fracture of pelvic bones with a violation of the integrity of the pelvic ring should be immobilized. For hemostasis, angiographic embolization, surgical arrest, including tamponation, is used.

Hypodinamy is one of the important pathogenetic mechanisms of the syndrome of mutual burdening. For its early elimination, surgical immobilization of multiple fractures of limb bones using lightweight rod fixation devices of extra-focus fixation is used. If the patient's condition allows (there are no complications, for example, hemorrhagic shock), the use of early (in the first 48 hours) surgical reposition and fixation of bone injuries leads to a significant reduction in the number of complications and reduces the risk of death.

Forecast of polytrauma

Among the more than 50 classifications proposed for quantifying the severity of traumatic injuries and the prognosis of the disease, only a few have become widespread. The main requirements for scoring systems are high predictive value and convenience in application:

• TRISS (Trauma Injury Severity Score), ISS (Injury Severity Score), RTS (Revised Trauma Score) are specifically designed to assess the severity of injury and the prognosis for life.
• APACHE II (Acute Physiology And Chronic Health Evaluation), SAPS (SimpliFied Acute Physiology Score) is used for an objective assessment of the severity of the condition and the prognosis of the outcome of the disease of the majority of patients in the ICU (APACHE II Do not use to assess the condition of victims with burns).
• SOFA (Sequential Organ Failure Assessmen), MODS (Multiple Organ Dysfunction Score) allow a dynamic assessment of the severity of organ dysfunction, evaluate and predict the results of treatment.
• GCS (Glasgow Coma Score - Glasgow Coma Score) is used to assess the severity of impaired consciousness and the prognosis of the disease in patients with brain damage.

Currently, the international standard for assessing the state of victims with polytrauma is the TRISS system, taking into account the age of the patient and the mechanism of the resulting trauma (it consists of the ISS and RTS scales).

[35], [36], [37], [38], [39], [40], [41]