RU2235545C1 - Method for treating high-degree frostbite of limbs at prereactive and early reactive periods - Google Patents

Abstract

FIELD: medicine, combustiology.

SUBSTANCE: one should daily detect blood content of antithrombin III and at its level being 61-75% it is necessary to introduce 300-400 ml cryoplasma, at its level being 51-61% one should introduce 400-500 ml cryoplasma, and at antithrombin level being 50%, or lower 500-800 ml cryoplasma should be introduced; cryoplasma heated up to 40 C should be introduced during the first 3 d since the moment of entering and 12 h later, then cryoplasma heated up to 37 C should be introduced once daily during the course of acute period. The present innovation enables to shorten therapy terms due to dosed application of cryoplasma compensating antithrombic blood potential that, in its turn, improves microcirculation in affected segments of patient's limbs, weakens spontaneous thrombocytic aggregation and decreases areas of necrosis.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, in particular to combustiology.

Pathogenetically substantiated methods of treating frostbite, in addition to general and local warming and other methods of conservative therapy, should be: normalization of the rheological properties of blood, prevention of secretively proceeding local disseminated intravascular coagulation (DIC). Most researchers are united in the fact that the destruction of tissues exposed to low temperatures is based on disorders in the microvasculature. Already in the pre-reactive period, a condition develops that is characterized by vascular thrombosis at the microcirculatory level, leading to malnutrition and tissue necrosis. In this regard, anticoagulant therapy with heparin is pathogenetically substantiated (Vikhriev BC, Kichemasov S.Kh., Skvortsov Yu.R. Local lesions with cold. - L .: Medicine, 1991. - 192 p .; Kotelnikov VP Frostbite. - M .: Medicine, 1988. - 256 p .; Murazyan R.I., Smirnov S.V. Frostbite of limbs.-M.: Medicine, 1984. - 112 p.). However, the assessment of the use of heparin in the treatment of frostbite is mixed. First, heparin therapy is carried out when platelet aggregation is completed and the microcirculatory pathways are already irreversibly blocked by blood clots. Secondly, heparin therapy is prescribed without taking into account the blood serum content of antithrombin III (AT III), which is a cofactor of heparin and progressively decreases during frostbite, spending on inactivation of coagulation factors during the development of DIC. (Barkagan ZS. Hemorrhagic diseases and syndromes. M .: Medicine, 1988. - 409 p.) Such a basic therapy using only heparin becomes insufficient. It is AT III deficiency that is the unfortunate obstacle that impedes the implementation of well-formed “therapeutic and tactical algorithms” in the treatment of frostbite, thereby dictating the need for the development of complex pathogenetically based programs of anticoagulant therapy for stealth local ICE in thawing tissues in patients with severe cold injury.

A known method of using cryoplasma during frostbite of the extremities proposed by R.I. Murazyan and S.V. Smirnov, through parenteral administration of thawed plasma reconvalescents in a dose of 50-100 ml with an interval of 1-2 days (frostbite of the extremities. - M .: Medicine, 1984, p. 62).

However, this method is absolutely unsuitable for the treatment of patients with frostbite of the extremities in the stage of hypercoagulation of the prereactive and early reactive periods, since the proposed dose and frequency of administration do not compensate for AT III deficiency and can only be used in case of an intense form of bacteremia and generalization of the infectious process of the late reactive period.

Closest to the proposed method for the treatment of patients with frostbite of the extremities in the pre-reactive and early reactive period is the method of using cryoplasma for the treatment of DIC blood, proposed by Z.S. Barkagan.

Its essence lies in the jet parenteral administration of a cryoplasm heated to 37 ° C in an initial dose of 600-800 ml, with repeated transfusions of 300-400 ml in 6-8 hours. In the following days, the dose is from 400 to 800 ml after 8-12 hours. In order to activate the plasma administered AT III, at the beginning of each infusion (hypercoagulation phase), 5000-7500 units of heparin are administered intravenously. (Barkagan Z.S. Hemorrhagic diseases and syndromes. - M .: Medicine, 1988, p. 409).

This method does not provide sufficient warming of the tissues from the inside, especially in the pre-reactive period, when frostbite is combined with general hypothermia, and the introduction of overestimated doses of cryoplasma without taking into account AT III deficiency makes the method prohibitively expensive.

The objective of the present invention is to increase the effectiveness of treatment of patients with general hypothermia and frostbite of the extremities in the pre-reactive and early reactive periods, reduce treatment time due to the dosed use of cryoplasma, which compensates for the antithrombotic potential of the blood, which improves microcirculation in the affected segments of the limbs, weakens spontaneous platelet aggregation, reduces necrosis zones.

The task is achieved by the fact that in the pre-reactive and early reactive periods of treatment of frostbite of the extremities of high degrees, cryoplasma heated to 40 ° C in combination with heparin is injected parenterally, focusing on the content of AT III in the blood, which is determined daily. At an AT III level of 61-75%, 300-400 ml of cryoplasma is administered, at an AT III level of 51-60%, 400-500 ml of cryoplasma is administered, at an AT III level of 50% or less, 500-800 ml of cryoplasma are administered. Heated to 40 ° C, the cryoplasma is administered in the first three days from the moment of receipt after 12 hours, in the subsequent once a day, heated to 37 ° C, during the acute period.

The novelty of the present invention lies in the fact that at a level of AT III in the blood of 61-75%, 300-400 ml of cryoplasma is administered to compensate for the antithrombotic potential of the blood, at a level of AT III 51-60%, 400-500 ml of cryoplasma is administered, at the level of AT III 50% or less is administered 500-800 ml of cryoplasm. The cryoplasm is administered the first three days from the moment of receipt after 12 hours, heated to 40 ° C, and subsequently once a day, heated to 37 ° C, throughout the acute period.

Such a temperature regime of cryoplasma is optimal and biophysically justified (regular) for uniform restoration of blood flow in frostbitten tissues. The introduction of cryoplasm heated to 40 ° C in addition to external warming provides internal tissue warming, thereby accelerating the restoration of microcirculation.

The method of using cryoplasma in the complex treatment of frostbite of the extremities is the basis for the therapy of secretively flowing DIC of blood, correcting hemostasis disorders by compensating components that support the antithrombotic potential of the blood, and restoring the antiprotease activity of the plasma. Timely and justified use of cryoplasma, which contains all the necessary components of the blood coagulation system, helps to eliminate hemodynamic disturbances, improves hemorheology, microcirculation in the affected limb segments, weakens spontaneous platelet aggregation, and reduces intoxication. It is known that for the effective action of heparin in the blood must contain at least 80% AT III. A decrease in its level below 60% corresponds to a state of hypercoagulation, and at an AT III concentration of 50% or lower, the risk of spontaneous thrombosis increases. In secondary (acquired during frostbite) AT III deficiency, a severe thrombotic condition develops, characterized by venous and arterial thrombosis and thromboembolism. With a decrease in AT III level below 30%, patients die from thromboembolism, and heparin does not have a significant anticoagulant effect. In addition, heparin therapy without taking into account the blood serum content of AT III poses a threat of secondary “ricocheting” thrombosis, which explains the inefficiency of heparin therapy in the early reactive period of severe cold injury. In particular, during the period when thrombosis of the vascular bed again occurs in tissues with seemingly restored blood flow on day 3-5. This problem is solved by the development of a method for stopping ICE by compensating for AT III deficiency.

The method is as follows. After the diagnosis has been established: Frostbite of the extremities of the III-IV degree, combined with or without hypothermia, in the pre-reactive or early reactive periods, against the background of general warming by the flow of warm air by the Veterok apparatus, one of the peripheral veins is catheterized. Pre-injured limb segments are insulated with heat-insulating covers. Infusion therapy is carried out according to known schemes in combination with a cryoplasm heated to 40 ° C. The determination of the content of AT III in the blood is carried out daily.

At an AT III content level of 61-75%, 300-400 ml of cryoplasma is administered, at an AT III content of 51-60%, 400-500 ml of cryoplasma is administered, at an AT III level of 50% or less, 500-800 ml of cryoplasma are administered. The cryoplasm is administered heated to 40 ° C in the first three days from the moment of receipt after 12 hours, then heated to 37 ° C once a day during the acute period.

A similar tactic was worked out in the experiment, and is currently being introduced into the clinical practice of the 333rd Military Clinical Hospital in Novosibirsk and Clinical Hospital No. 1 of Novokuznetsk. There were no complications. Long-term results are traced up to 1 year. Patients did not show complaints.

Example 1

Patient M., 38 years old, was taken to the trauma unit by an ambulance with signs of general hypothermia and frostbite of the upper and lower extremities. The day before, he fell into the hole and independently reached the village within 6 hours in wet clothes and shoes at an ambient temperature of minus 25 ° С.

Upon admission, the condition is serious, drowsy, inhibited, rectal temperature + 35 ° C. The hands and lower third of the forearms, just like the feet and lower third of the lower leg, cold to the touch, in a state of rigor, do not respond to pain stimuli. During the test of Billroth-Rudaev from the injection sites comes the sacred discharge, a “dry puncture” is obtained in the area of the fingers. The survey thermograms revealed the suppression of infrared radiation by the type of "amputation" from the level of the lower third of the forearms and lower third of the legs. On the coagulogram revealed a decrease in the level of AT III - 52%.

Diagnosed: General hypothermia. Adynamic stage. Frostbite of hands and feet III-IV degree. Prereactive period.

The patient was placed in the intensive care unit, where after isolation of the upper and lower extremities with heat-insulating covers and general warming with the Veterok apparatus, a comprehensive conservative frostbite therapy was started.

From the moment of admission and after 12 hours from the start of treatment, 800 ml of cryoplasm warmed up to 40 ° C was introduced. The content of AT III by the end of the first day was 65%, which required the introduction of cryoplasma in a dose of 500 ml twice. Thermograms showed an increase in infrared radiation in the area of the hands and feet, leaving levels of amputation in the area of the fingers. On the third day, the level of AT III was 72%. 300 ml of cryoplasm was introduced with an interval of 12 hours.

Against the background of the therapy, the edema of the affected tissues was moderate. Preventive surgery was not performed.

Over the next five days, the level of AT III ranged from 71-82%. The dose of cryoplasm heated to 37 ° C was 300 ml once a day.

Dry necrosis was formed by the tenth day after the injury at the level of the base of the toes, median and nail phalanges of the hands, which required surgical treatment.

The patient was discharged with improvement, with normal rates of AT III. Examined after 6 months. Walks limping, serves himself.

Example 2

Patient G., 34 years old, was taken to the thermal trauma department by the ambulance carriage with signs of general hypothermia and frostbite of the lower extremities. Found on the street at an air temperature of minus 42 ° C in a state of intoxication, without shoes.

Upon receipt, drowsiness, delayed speech, chills, pallor of the skin, the presence of "goose bumps", rectal temperature + 34 ° С. The feet are cyanotic, cold to the touch, do not respond to pain stimuli, of dense consistency, like rigor mortis. Microslots leave the injection site during the Billroth-Rudaev test after massage of soft tissues. The survey thermogram clearly reveals the suppression of infrared radiation from the level of the middle third of both feet. According to the coagulogram recorded a decrease in AT-III to 63%.

Diagnosed: General hypothermia. Adynamic stage. Frostbite feet III degree. Prereactive period.

After isolation of the lower extremities with unified heat-insulating covers, the general warming of the patient by streams of warm air by the Veterok apparatus was started in the reception department. In a comprehensive program of infusion therapy in an initial dose, 350 ml of cryoplasm heated to 40 ° C are injected parenterally, with repeated infusion at a dose of 300 ml after 12 hours.

By the end of the first day in the previously insensitive segments of the lower extremities, numbness disappeared, paresthesia appeared. Affected areas turned pink. Edema of the affected tissues was insignificant, which did not require preventive surgery.

Thermograms recorded a noticeable increase in infrared radiation in the feet.

The next day, with an AT III of 71%, 300 ml of cryoplasm was transfused twice. By the end of the third day, the performance of AT III was 74%, which required a double injection of 300 ml of cryoplasma.

Subsequently, for three days, the level of AT III was 75-80%. The introduction of cryoplasm heated to 37 ° C was carried out in a dose of 300 ml once a day.

Coagulogram indices steadily returned to normal on day 6.

The patient was discharged with recovery. Examined after 8 months. There are no complaints. It works in the same place.

The method of using cryoplasma in the complex treatment of frostbite of the extremities forms the basis for the therapy of secretively flowing DIC of blood, correcting hemostasis disorders by compensating for the components supporting the antithrombotic potential of the blood and restoring the antiprotease activity of the plasma. Timely and justified use of cryoplasma, which contains all the necessary components of the blood coagulation system, helps to eliminate hemodynamic disturbances, improves hemorheology, microcirculation in the affected limb segments, weakens spontaneous platelet aggregation, and reduces intoxication.

In some cases, the proposed cryoplasma therapy not only arrests local ICE during frostbite, but also releases microcirculation in the affected limb segments, making the lesion accessible to antibacterial agents, terminates the expansion of the destruction zone by insufficiently vascularized tissues, and significantly accelerates the repair and recovery of patients.

The method is simple and accessible for use in clinical practice, in particular in the case of mass simultaneous admission of victims with general hypothermia and frostbite of the extremities of high degrees.

Claims (1)

A method for the treatment of frostbite of high extremities in the pre-reactive and early reactive periods by injecting parenterally heated cryoplasma and heparin, characterized in that the content of antithrombin III in the blood is determined daily and 300-400 ml of cryoplasma is administered at its 61-75% level, the content of antithrombin III 51-61% is administered 400-500 ml of cryoplasm, at the level of antithrombin III of 50% or less, 500-800 ml of cryoplasma is administered; a cryoplasm heated to 40 ° C is administered in the first three days from the moment of receipt and after 12 hours; further cryoplasm, heated to 37 ° C, is administered once a day during the acute period.