RU2497443C1 - Method of determining tactics of treating patients with closed abdominal trauma - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to abdominal surgery, and can be used in case if it is necessary to determine tactics of treatment of said category of patients. For this purpose anamnestic and clinical-instrumental criteria are determined: a) time from the moment of trauma; b) possibility of contact with patient; c) state of hemodynamics; d) presence of free gas in abdominal cavity, e) growth of volume of appearance of free liquid in abdominal cavity within an hour; f) US or CT-signs of injury of parenchymatous organs; g) increase of small intestine diameter. Assessment of obtained data is carried out in points in the following way: tome from the moment of trauma: 0 points - less than 2 hours, 1 point - 2-6 hours, 2 points - 7-12 hours, 3 points - 13-24 hours, 4 points - more than 24 hours; possibility of contact with patient: 0 points - possibility of communication, 1 point - confused speech, 2 points - inadequate speech, 3 points - inarticulate sounds, 4 points - no contact; state of hemodynamics: 0 points - stable, 4 points - unstable; presence of free gas in abdominal cavity: 0 points - absent, 1 point - present; separation of peritoneum layers: 0 points - absent, 1 point - less than 1 cm, 2 points - 1-2 cm, 3 points - 2.1-3 cm, 4 points - 3.1-4 cm; growth of volume or appearance of free liquid in abdominal cavity within an hour: 0 points - absent, 1 point - to 200 ml, 2 points - 200-500 ml, 3 points - more than 500 ml; US or CT - signs of injury of parenchymatous organs: 0 points - no; 1 point - isolated tear of capsule, 2 points - rupture of capsule and parenchyma, 3 points - fragmentation of organ; increase of small intestine diameter: 0 points - no, 1 point - to 3 cm, 2 points - 3-4 cm, 3 points - 4.1-6 cm, 4 points - more than 6 cm. Obtained points are summed up. If the sum of points is from 0 to 6 including, conservative treatment with dynamic clinical and instrumental control is carried out. If the total quantity of points is from 7 to 14 including, laparoscopic operation is performed. If the total quantity of points is from 15 to 27, laparotomy is carried out.EFFECT: method makes it possible to ensure optimisation of selection of medical assistance type due to consideration of individual changes of diagnostically significant totality of indices.1 tbl, 1 ex

Description

The invention relates to medicine, namely to abdominal surgery.

Damage to abdominal organs with closed abdominal trauma is from 1.5 to 36.5% of the number of peacetime injuries, and their frequency and severity continue to progressively increase [1, 2, 3]. However, during the examination and treatment of victims, high numbers of diagnostic errors, postoperative complications and deaths remain, which dictates the need to improve their diagnostic and therapeutic tactics [3, 4, 5, 6].

Difficulties in diagnosing abdominal injuries with a closed abdominal injury are determined not only by the severity of the condition of the victims, but also by the presence of drug or alcohol intoxication, which significantly affects the quality and duration of the preoperative period [1, 4, 6, 7, 8]. Hyperdiagnosis leads to an increase in the number of exploratory laparotomies, the frequency of which varies from 7 to 68%, which significantly aggravates the condition of the victims, especially with combined trauma [3, 9, 10]. Thus, improving the diagnostic algorithm for closed abdominal trauma will reduce both the examination time of patients and the number of exploratory laparotomies.

To improve the results of examination and treatment of patients with closed abdominal trauma, we developed a scale, the interpretation of the parameters of which allows us to determine the type of treatment aid: conservative management, video laparoscopy or laparotomy.

The problem to be solved when using the proposed method is to determine the type of medical aid.

Achievable technical result is the optimization of the choice of the type of medical aid by taking into account individual changes in a diagnostically significant set of indicators.

The proposed method is as follows.

Upon admission of a patient with an abdominal injury to the hospital, a comprehensive examination is carried out, including the collection of medical history data, a clinical and instrumental examination. When collecting an anamnesis, the prescription and nature of the damage are clarified. In the absence of contact with the patient, they immediately begin clinical and instrumental examination. During a physical examination, conventional methods of palpation, percussion and auscultation are used. Non-invasive instrumental diagnostic methods used in this algorithm are ultrasound, X-ray examination and computed tomography of the abdominal cavity.

The purpose of ultrasound is to detect free fluid in the abdominal cavity, assess prevalence by region, and determine its amount. In addition, the state of parenchymal organs, the presence of their injuries, as well as the presence, localization, and size of intraorgan and retroperitoneal hematomas are assessed.

Depending on the severity of the patients, an X-ray examination is performed both in a standing position and polypositionally. The aim of the study is to determine the free gas in the abdominal cavity with damage to the hollow organ.

If it is impossible to exclude damage to internal organs or traumatic pancreatitis according to clinical and instrumental examination, CT is performed.

To determine the type of medical aid, the following anamnestic and clinical-instrumental criteria were used, evaluated according to a point system:

- time from the moment of injury (prescription): 0 points - less than 2 hours, 1 point - 2-6 hours, 2 points - 7-12 hours, 3 points - 13-24 hours, 4 points - more than 24 hours;

- the possibility of contact with the patient: 0 points - the ability to communicate, 1 point - confused speech, 2 points - inadequate speech, 3 points - inarticulate sounds, 4 points - no contact;

- hemodynamic status: 0 points - stable, 4 points - unstable;

- the presence of free gas in the abdominal cavity (according to x-ray examination): 0 points - none, 1 point - present;

- separation of the sheets of the peritoneum (the ratio of the amount of free fluid in the abdominal cavity is presented in table 1): 0 points - none, 1 point - less than 1 cm, 2 points - 1-2 cm, 3 points - 2.1-3 cm, 4 points - 3.1-4 cm;

Table 1 The ratio of the amount of free fluid in the abdominal cavity and ultrasound data on the separation of the peritoneum The number of abdominal areas Dissection of the leaves of the peritoneum > 0 <1 cm 1-2 cm 2.1-3 cm 3.1-4 cm 1 area 100-120 ml 200-220 ml 400-450 ml 460-530 ml 2 areas 540-590 ml 600-1000 ml 1100-1250 ml 1260-1350 ml 3 or more areas 500-530 ml 1000-1400 ml 1800-2200 ml 3000-3600 ml

- an increase in volume or the appearance of free fluid in the abdominal cavity with a control ultrasound for an hour: 0 points - absent, 1 point - up to 200 ml, 2 points - 200-500 ml, 3 points - more than 500 ml;

- Ultrasound or CT - signs of damage to the parenchymal organs: 0 points - no, 1 point - isolated capsule tear, 2 points - capsule and parenchyma rupture, 3 points - organ fragmentation;

- an increase in the diameter of the small intestine (by ultrasound and / or Rg): 0 points - no, 1 point - up to 3 cm, 2 points - 3-4 cm, 3 points - 4-6 cm, 4 points - more than 6 cm.

The maximum number of points on the scale presented is 27. The minimum is 0 points.

With a total number of points from 0 to 6 inclusive, the patient is shown conservative treatment with dynamic clinical and instrumental control.

With a total number of points from 7 to 14 inclusive, the patient is shown to perform laparoscopic surgery.

With a total number of points from 15 to 27, a patient with abdominal trauma is shown to perform laparotomy.

Clinical example

Patient K., 46 years old, was admitted on an emergency basis after 3.5 hours from the moment of injury [1 point] with a preliminary diagnosis: closed abdominal injury, damage to the spleen? At admission: the patient is in a clear mind, oriented in space and time, answers questions [0 points]. The skin and visible mucous membranes of normal color, warm, dry. Respiratory auscultation is carried out in all departments, vesicular. NPV 19 / min. Hemodynamics is stable [0 points], blood pressure - 130/90 mm RT. Art., the rhythmic pulse, heart rate of 90 beats per minute. The tongue is wet. The abdomen of the correct form, symmetrical, does not swell, participates in the act of breathing, with palpation, tension, pain, fuzzy peritoneal symptoms in the left hypochondrium are noted. Percussion determined tympanitis over all sections of the abdomen. During auscultation, normal peristaltic intestinal murmurs are heard. When survey radiography of the abdominal organs there are no signs of free gas in the abdominal cavity [0 points]. Ultrasound examination of the spleen is 10.6 × 3.7 cm, the echostructure is heterogeneous - in the lower pole there is a hyperechoic area with hypoechoic zones up to 2-4 mm, with color Doppler mapping (CDC) in this area blood flow is not recorded from the gate, determined " isolated capsule tear ”[1 point]. Dissociation of the peritoneum along the diaphragmatic surface of the spleen to 1.1 cm [2 points]. No expansion of the loops of the small intestine [0 points].

Thus, the total number of points in this patient was 4, which was an indication for conservative treatment. The patient was discharged in satisfactory condition on the 5th day.

Literature

1. Integral systems for assessing the severity of patients with polytrauma. / Gelfand B.R., Yaroshetsky A.I., Protsenko D.N., Romanovsky Yu.Ya. // Bulletin of intensive care. - 2004. - No. 1. - S. 58-65.

2. The global burden of disease: 2004 update URL: www.who.int/.../global_burden_disease/GBD_report_2004update_full.pdf.

3. Abdominal and pelvic injuries caused by road traffic accidents / Cheynel N, Gentil G, Freitz M, et al. // World J Surgery. - 2011 .-- Vol.35. - No. 7. - P.1621-1625.

4. Abakumov, M.M. Features of the diagnosis of abdominal injuries in patients with combined trauma / Abakumov M.M., Malyarchuk V.I., Lebedev N.V. // Emergency. - 2004. - Volume 5. - No. 3. - S. 140.

5. Video laparoscopy in case of abdominal injury / Ermolov AS, Pakhomova GV, Gulyaev AA et al. // Collection of theses dokl. 10th anniversary international congress on endoscopic surgery, Moscow, April 19-21, 2006. - M., 2006. - P.89-90.

6. Nast-Kolb, D. Current diagnostics for intra-abdominal trauma / Nast-Kolb D, Bail HJ, Taeger G. // Chirurg. - 2005 .-- Vol.76. - No. 10. - P.919-926.

7. Abdullaev, E.G. Video laparoscopy in the diagnosis and treatment of abdominal injuries / Abdullaev E.G., Babyshin V.V., Khodos G.V. // Endoscopic surgery. - 2007. - No. 1. - C.6.

8. Video laparoscopic technique in the treatment of damage to abdominal organs / Sakharov A.V., Rozanov V.E., Bolotnikov A.I., Krivtsov A.V. // Endoscopic surgery. - 2007. - No. 1. - S.83-84.

9. Ultrasound diagnosis of injuries of the abdominal cavity and retroperitoneal space in case of combined injuries / Maskin SS, Ermolaeva NK, Shvartsman IM, Parovatkin MI // Emergency. - 2004. - Volume 5. - No. 3. - S. 177-178.

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Claims (1)

A method for determining treatment tactics with closed abdominal trauma, which consists in determining the medical history and clinical and instrumental criteria:
a) the time from the moment of injury,
b) the possibility of contact with the patient,
c) the state of hemodynamics,
g) the presence of free gas in the abdominal cavity,
d) the separation of the leaves of the peritoneum,
e) an increase in volume or the appearance of free fluid in the abdominal cavity within an hour,
g) ultrasound or CT - signs of damage to the parenchymal organs,
h) an increase in the diameter of the small intestine,
criteria are scored:
- time from the moment of injury: 0 points - less than 2 hours, 1 point - 2-6 hours, 2 points - 7-12 hours, 3 points - 13-24 hours, 4 points - more than 24 hours;
- the possibility of contact with the patient: 0 points - the ability to communicate, 1 point - confused speech, 2 points - inadequate speech, 3 points - inarticulate sounds, 4 points - no contact;
- hemodynamic status: 0 points - stable, 4 points - unstable;
- the presence of free gas in the abdominal cavity: 0 points - absent, 1 point - present;
- separation of the peritoneum leaves: 0 points - absent, 1 point - less than 1 cm, 2 points - 1-2 cm, 3 points - 2.1-3 cm, 4 points - 3.1-4 cm;
- an increase in volume or the appearance of free fluid in the abdominal cavity within an hour: 0 points - absent, 1 point - up to 200 ml, 2 points - 200-500 ml, 3 points - more than 500 ml;
- Ultrasound or CT - signs of damage to the parenchymal organs: 0 points - no, 1 point - isolated capsule tear, 2 points - capsule and parenchyma rupture, 3 points - organ fragmentation;
- an increase in the diameter of the small intestine: 0 points - no, 1 point - up to 3 cm, 2 points - 3-4 cm, 3 points - 4.1-6 cm, 4 points - more than 6 cm;
the obtained points are summarized and, with a total number of points from 0 to 6 inclusive, conservative treatment is carried out with dynamic clinical and instrumental control; with a total number of points from 7 to 14 inclusive, laparoscopic intervention is performed; with a total score of 15 to 27, a laparotomy is performed.