RU2411914C2 - Express-selection of tactics of patient management in acute period of serious trauma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine of disasters, and can be used in emergency cases in case of serious isolated traumas, multiple injuries and combined trauma. For this purpose seriousness of trauma is estimated in accordance with injury severity scale by table No 9, represented in invention description. If in case of isolated trauma, combined trauma or multiple injuries the most severe injury is evaluated in 3 points, diagnostic measures are taken in full volume in order to detect possible hidden injuries, and specification of character of obvious injuries of anatomical areas. Also carried out is supporting infusion therapy and surgery is performed in case of emergency indications. If the most severe injury is evaluated in 4 or 5 points, intensive therapy is carried out, diagnostic measures are taken in minimal volume with further carrying out of surgery by vital indications. After surgery and relative state stabilisation diagnostic procedures are performed in full volume, and in case, if hidden injuries, requiring surgical correction by emergency indications, are detected, surgery is carried out.

EFFECT: method allows to ensure the most accurate estimation of injuries and in accordance with it to determine optimal tactics of patient's treatment in the first hours after trauma.

9 tbl, 2 ex

Description

The present invention relates to medicine, namely to surgery, traumatology, orthopedics, can be used in emergency cases with severe isolated injuries, multiple injuries and associated trauma.

An accurate assessment of the severity of the injuries sustained in the acute period of the traumatic disease allows us to determine the optimal tactics for providing assistance to the injured and helps to improve treatment outcomes.

There is a method of scoring the severity of injuries sustained in a patient at the time of admission to the medical institution “VPH-P (MT)" (scale of the Department of Military Field Surgery of the Military Medical Academy named after S.M. Kirov to determine the severity of injuries upon receipt of a victim with a mechanical injury) [ 2], developed at the Department of Military Surgery of the Military Medical Academy named after S.M. Kirova, St. Petersburg (table 1).

Table 1 Scoring of the severity of injuries on a scale "VPH-P (MT)" No. p / p Type of damage Points Head one Soft tissue wounds to the head 0.05 2 Closed Nose Fractures 0.2 3 Brain concussion 0.2 four Jaw fractures 0.3 5 Mild brain injury 0.3 6 Brain contusion of moderate severity with fractures of the cranial vault 0.5 7 Brain contusion of moderate severity with closed fractures of the arch and base of the skull 0.6 8 Brain contusion of moderate severity with open fractures of the arch and base of the skull 2 9 Compression of the brain against the background of not severe bruises 7 10 Severe brain contusion with damage to the upper trunk 12 eleven Cerebral compression due to severe bruises eighteen 12 Severe brain contusion with damage to the lower trunk 19 Chest one Soft tissue wounds, bruises 0.05 2 Single rib fractures (up to three) 0.1 3 Sternal fractures 0.3 four Multiple unilateral rib fractures 0.3 ⁵ Unilateral rib fractures with hemothorax 0.4 6 Multiple bilateral rib fractures without valve, without cavity damage 0.5 7 Chest compression with traumatic asphyxia 0.6 8 Bruised lung one 9 Multiple unilateral rib fractures with rupture of the lung, pneumothorax 2 10 Heart injury four eleven Rear or posterolateral rib valve 5 12 Bilateral multiple rib fractures with damage to one pleural cavity, rupture of one lung 5 13 Front and anterolateral rib valve 10 fourteen Damage to both lungs and both pleural cavities fourteen fifteen Rupture of the main bronchus 16 16 Rupture of the aorta, heart, lung rupture, damage to large vessels 19

Continuation of table 1 No. p / p Type of damage Points Stomach one Bruises and small wounds of the abdominal wall 0.05 2 Bruises of the kidneys 0.1 3 Inorganic lesions requiring laparotomy 0.1 four Edge damage to parenchymal organs 0.3 5 Ruptures of one parenchymal organ 2 6 Tears or tears of hollow organs four 7 Diaphragm damage with / without organ damage 8 8 Damage to two organs, one of which is mild 9 9 Damage to three organs (two - parenchymal) fifteen 10 Damage to the aorta, inferior vena cava, liver and portal veins 19 one Bruises and small wounds of soft tissues 0.05 2 Isolated pelvic fractures 0.3 3 Multiple pelvic fractures with a violation of the integrity of the pelvic ring in one place 0.6 four Multiple pelvic fractures with disruption of the pelvic ring in two places without displacement 3 5 Multiple pelvic fractures without displacement of the pelvic ring with rupture of organs
- extraperitoneal 6 - intraperitoneal 6 6 Multiple pelvic fractures with displacement or central dislocation of the femur without organ damage 7 7 Multiple pelvic fractures with displacement of the pelvic ring, with rupture of organs eleven 8 Pelvic bone destruction without damage to the pelvic organs fourteen 9 Pelvic bone fracture with rupture of one pelvic organ 17 10 Pelvic bone fracture with rupture of two pelvic organs 19 Type of damage Points 12 Two-, three-ankle fractures of the lower leg 0.7 13 Closed dislocation of the thigh, lower leg, open dislocation of the foot 0.9 fourteen Calcaneus or talus fractures 0.9 fifteen Discoveries by type of perforation or closed fracture; - shins 09 - shoulder 0.9 - forearm 0.9 16 Extensive soft tissue damage to the forearm, hand, foot one 17 Bone fractures - brushes one - feet with extensive soft tissue damage one eighteen Hand tears (3-5) one 19 Discovery fracture - shins 2 - shoulder 2 - forearms with extensive damage to soft tissues and nerve trunks 2 2 twenty Separation - feet 2 - brushes 2 - forearm 2 21 Open type of perforation, closed hip fracture 2 2 22 Medial femoral neck fracture 3 23 Separation - shins 2 - shoulder 2 24 Extensive soft tissue damage to the segment, skin detachment with / without long bone fracture four 25 Hips 7 26 Extensive soft tissue damage to the femur or damage to the femoral artery 8

Disadvantages:

Common disadvantages of the VPH-P (MT) scale when used in the acute period of injury:

a) inaccuracy in assessing the severity of the injuries received, does not use the instrumental method - computed tomography (CT) (due to the introduction of the CT method into the standard of diagnostic measures of many medical institutions, a more accurate assessment of the injuries became possible);

b) - in case of an anatomical organ trauma, in which the severity of the condition of the victim is determined by hypovolemic syndrome, an assessment standard is needed that allows you to objectively evaluate the damage received on the AIS scale taking into account the manifestation of the leading syndrome;

c) - inaccuracy in assessing the severity of the damage entails a risk of errors in the choice of tactics of surgical treatment;

d) - a clinical assessment of the severity of the damage in points does not allow to reliably determine the tactics of conservative treatment.

Particular disadvantages of the VPH-P (MT) scale when assessing damage to anatomical systems:

- when assessing injuries of the musculoskeletal system (OA), almost all possible injuries were determined in points - from the most mild to fatal, which allows post factum to accurately determine the severity of the resulting combined injury, but this is not necessary in the acute period of a traumatic disease, since even the totality of minor injuries does not affect the general condition of the victim, does not affect the choice of treatment tactics; in clinical practice, only the most severe injuries are taken into account, which pose a threat to the life of the victim and cause a mutual aggravation syndrome, leading to the development of a traumatic disease;

- when assessing damage to the pelvic ring, the relationship between the manifestations of the hypovolemic syndrome and the most characteristic injuries of the pelvic ring (the front half ring, the rear half ring, the vertical displacement of the half of the pelvis, rotational displacements of the pelvic ring, acetabular fractures) is not determined.

- when assessing damage to abdominal organs, there is no differentiation of organ damage according to the severity of hypovolemic syndrome;

- when assessing a chest injury, there is no differentiation in terms of hemopneumothorax volume, the number of zones of lung contusion, on which the severity of respiratory failure depends;

- when evaluating a traumatic brain injury, there is no differentiation according to the number of zones of brain contusion, the volume of intracranial hematoma, so it becomes possible to evaluate differently similar brain injuries.

For the closest analogue, a method for determining the severity of injuries was adopted - the AIS scale (Abbreviated injury skale. 1971 - 1990) [6]

Taking into account the requirements of the AIS scale, human ortzhism is divided into 6 anatomical areas: skin and soft tissues, head, neck and face, chest, abdomen and pelvic cavity, limbs and pelvic girdle. Damage to each of them is estimated from 1 to 5 points, while 0 means the absence of damage to the anatomical region, and 5 means the presence of severe damage [4, 5, 6].

AIS Severity Scale

Damage corresponding to the 1st point:

- skin and soft tissues - burns of the 1st or 2nd degree less than 10% of the body;

- head / neck - skull injuries without loss of consciousness, headache, injuries of the cervical spine without pathology on radiographs, mild eye injuries (corneal erosion, conjunctiva, eyelid damage, minor vitreous hemorrhages, tooth loss);

- chest: bruise of the chest wall;

- stomach: pain, abrasions in the abdominal wall;

- limbs: sprain or rupture of ligaments, joints, fracture of fingers or toes.

Damage corresponding to 2 points:

- skin and soft tissues - extensive injuries of soft tissues on one or two limbs, a 2-3-degree burn of 10-20% of the body surface;

- head / neck - skull injuries with loss of consciousness up to 15 minutes, lack of retrograde amnesia, fracture of the facial skull bones without displacement of fragments, multiple nose fractures, penetrating eye trauma, traumatic retinal detachment, whiplash injury of the cervical spine with the presence of changes in radiographs;

- chest - fractures of the ribs or sternum, extensive contusion of the chest with hemo- or pneumothorax;

- abdomen - extensive bruises of the abdominal wall;

- limbs - multiple fractures of the fingers and toes, closed fractures of the tubular bones of the pelvis without displacement, damage to large joints.

Damage corresponding to 3 points:

- skin / soft tissue - extensive damage to the soft tissues of 3-4 limbs, burn more than 20-30% of the surface of the body of the 2nd-3rd degree;

- head / neck: skull injuries with or without bone fracture, loss of consciousness for 15 minutes without focal neurological symptoms, post-traumatic amnesia up to 3 hours, fractures of the cranial fornix without displacement of fragments, eye damage, detachment of the optic nerve, fracture of the facial bones skulls with displacement of fragments and damage to the sinuses, fracture of the cervical spine without damage to the spinal cord;

- chest: multiple rib fractures, hemo- or pneumothorax, lung contusion, rupture of the diaphragm without signs of severe insufficiency of the function of external respiration;

- abdomen: contusion of the abdomen, retroperitoneal hematoma, retroperitoneal rupture of the bladder, rupture of the ureter, urethra, fractures of the lumbar or thoracic vertebrae without neurological disorders;

- limbs: amputation of several fingers and toes, simple closed ones - fractures of long bones with displacement of fragments, simple open fractures of long bones, fractures of pelvic bones with displacement, dislocation of large joints, damage to large nerves and vessels of limbs.

Damage corresponding to 4 points:

- skin / soft tissues - extensive injuries of soft tissues with bleeding, burns of the 2-3rd degree 30-50% of the body surface;

- head / neck: skull injuries with or without bone fracture with loss of consciousness for more than 15 minutes with the development of focal neurological symptoms, post-traumatic amnesia up to 3-12 hours, multiple fractures of the cranial vault;

- chest: multiple rib fractures with flotation of costal fragments, penetrating wound of the chest, pneumomediastinum, myocardial contusion without severe cardiac dysfunction, wound of the pericardium;

- stomach: rupture of the spleen, rupture of the kidney, damage to the tail of the pancreas, intraperitoneal rupture of the bladder, severe injuries of the genitals, fractures of the lumbar or thoracic vertebrae with the development of neurological disorders;

- limbs: multiple fractures of long tubular bones.

Damage corresponding to 5 points:

- skin / soft tissue - burns of the 2nd-3rd degree more than 50% of the body surface;

- head / neck - skull injuries with or without bone fracture with loss of consciousness for a day or more, post-traumatic amnesia for more than 12 hours, intracranial hemorrhage, intracranial hypertension, fractures of the cervical vertebrae with the development of severe neurological disorders (paraplegia), traumatic disorders of the upper patency respiratory tract;

- chest - chest injury with severe impairment of the function of external respiration, rupture of the trachea, rupture of the aorta, myocardial contusion with severe disorders of the heart, myocardial rupture;

- stomach - rupture of the liver, pancreas, perforation of hollow organs;

- limbs - amputation of limbs, multiple open fractures of long bones.

As a rule, with an increase in the indicators of the scale of severity of injuries, mortality increases, the length of stay in the intensive care unit, the duration of mechanical ventilation, and the volume of blood transfusion.

Our experience of using the AIS scale in the acute period of combined trauma revealed its shortcomings and inaccuracies that do not allow us to accurately determine the severity of the injuries received. The disadvantages of the AIS scale can be divided into 2 groups.

1. General disadvantages of the AIS scale when used in the acute period of combined injury:

a) inaccuracy in assessing the severity of the injuries, since it does not use the instrumental method - computed tomography (CT) (due to the introduction of the CT method into the standard of diagnostic measures of many medical institutions, a more accurate assessment of the injuries became possible);

b) - in case of an anatomical organ trauma, in which the severity of the condition of the victim is determined by the deficiency of the BCC, an assessment standard is needed that allows you to objectively evaluate the damage received on the AIS scale;

c) - assessment of the severity of the damage received by a certain score does not imply a specific tactic of surgical treatment;

d) - inaccuracy in assessing the severity of the damage entails a risk of errors in the choice of tactics of surgical treatment;

d) - a clinical assessment of the severity of the damage in points does not allow to reliably determine the tactics of conservative treatment.

2. The disadvantages of the AIS scale when it is used to determine the severity of damage to each of the 6 anatomical areas in the acute period of combined trauma:

a) - when evaluating a traumatic brain injury (TBI), there is a gradation only in terms of the duration of loss of consciousness and the presence or absence of gross neurological symptoms, which makes it impossible to use it in the acute period of a severe combined brain injury when the victim is unconscious (predict the time finding the patient in a coma is impossible; in the absence of consciousness, areflexia, atony, the correct assessment of the neurological status is doubtful).

A correct assessment of the severity of combined traumatic brain injury according to the above criteria of the AIS scale is possible only post factum, after stabilization, while treatment tactics should be determined in the first hours after the injury.

For this, it is necessary to make changes and refinements to the AIS scale, allowing in the acute period of the head injury to accurately assess the detected damage.

An accurate scoring of the injuries is possible after determining the correlations found on CT of the skull of the lesions (presence or absence of a concussion lesion or lesions in the brain; intracranial hematoma; subarachnoid hemorrhage; diffuse axonal damage to the brain) with clinical manifestations.

b) - when assessing a chest injury, there is no differentiation in terms of volume of hydro-, pneumothorax and the area of lung contusion zones for 3-, 4-, 5-point injuries.

This is necessary because in the acute period of combined trauma, a scoring of hemopneumothorax or the area of the zones of lung contusion implies a certain treatment tactic, especially intensive care;

c) - when assessing damage to abdominal organs and retroperitoneal space in the acute period of combined trauma, the absence of differences in the consequences of damage to parenchymal and hollow abdominal organs is unacceptable.

It does not take into account that damage to the hollow organs of the abdominal cavity does not pose a direct threat to life in the hours immediately after the injury, since it cannot be the cause of massive hemoperitoneum, in contrast to damage to the parenchymal organs.

Depending on the manifestations of the hypovolemic syndrome in case of damage to the parenchymal organs, a gradation of damage to the organs of the abdominal cavity and retroperitoneal space is necessary for 3-, 4-, 5-point injuries. The choice of treatment tactics in the acute period of combined trauma depends on this;

d) - there are no clear criteria to distinguish between 3-, 4-, 5-point injuries in case of injury to the musculoskeletal system; face and neck; skin and soft tissues;

e) - a point assessing the severity of the damage received does not imply a specific program of medical assistance to the victim.

All of the above makes updating and changing the AIS scale relevant.

The scale for determining the severity of injuries sustained in an acute traumatic period must satisfy several requirements:

- should not be bulky;

- must be accurate enough to exclude the possibility of inadequate assistance;

- there should be unambiguous interpretations of the severity of damage, excluding a different assessment of similar injuries;

- the scale should be clinical, adapted to the acute period of trauma, which implies a shortage of time to make a decision, therefore, minor injuries that do not affect the general condition of the body should be excluded from it;

- the assessment in points of the injuries received by different anatomical systems should be formed according to uniform criteria, the established score should provide a high degree of accuracy in choosing the tactics of surgical and therapeutic treatment.

SUMMARY OF THE INVENTION

The essence of the invention is the creation of an express method for scoring the severity of injuries and the choice of tactics for assisting a victim with a serious injury, performed according to the assessment of damage by this method.

The method is based on the R-AIS scale we developed (Russian scale for determining the severity of injuries received), adapted for the acute period of traumatic disease; which is the result of refinements, changes and additions to the AIS scale.

When assessing damage, R-AIS takes into account the severity of the manifestations of the dominant (leading) trauma syndromes of 6 anatomical systems (head, face and neck; chest, abdomen, pelvic and extremity bones; skin integuments and soft tissues) according to significant indicators.

Dominant trauma syndromes that determine the severity of injuries sustained.

The dominant syndromes that determine the severity of the injuries received are:

1) acute hypovolemia as a result of blood loss, traumatic toxicosis of microcirculation disorders;

2) acute respiratory failure (ARF) as a result of a chest injury or respiratory failure;

3) acute compression of the brain, leading to a violation of the vital functions of the body;

4) acute ascending edema of the spinal cord with contusion or rupture of the spinal cord at the level of the middle and upper cervical segments, leading to a violation of the vital functions of the body.

There are much more dominant syndromes in the acute period of traumatic disease [3], we selected those whose clinical manifestations most reliably correlated with the severity of the injuries received in the acute period.

Differential assessment of significant indicators of leading trauma syndromes from 3 to 5 points is made depending on their influence on the general condition of the body; the assessment determines the need for intensive care or maintenance infusion therapy, indications for surgical treatment for vital or emergency indications; the need for dynamic monitoring of the victim.

Damage Rating:

1-, 2-point (lungs): not affecting the general condition of the body (hypovolemic syndrome, acute respiratory failure, Glasgow score of a traumatic brain injury of at least 12 points do not develop), they do not pose a threat to life, with them not infusion therapy is indicated, if there are indications, surgical treatment in full can be performed in full, therefore it is excluded from the scale.

3-point (severe): severe trauma, but without disturbance of vital functions of the body (degree 1, 2 shock with corresponding changes in hemogram and hemodynamics, craniocerebral, spinal cord injury without pronounced changes in hemodynamics, consciousness and external respiration function, moderately expressed respiratory failure); do not need surgical treatment for health reasons, do not pose a direct threat to life, most cases require surgical treatment for emergency indications, supportive infusion therapy and dynamic monitoring are indicated, the recommended algorithm of care is to provide assistance to a victim with a disturbing trauma, multiple injuries and combined trauma without immediate threat to life.

4-point (life-threatening): trauma that poses an immediate threat to life (hypovolemia, unstable hemodynamics, microcirculation disorders with corresponding changes in the hemogram; acute compression of the brain or spinal cord, which caused a violation of vital functions of the body, acute respiratory failure); surgical treatment is necessary for vital and emergency indications, intensive care is indicated, dynamic monitoring, the recommended algorithm of actions is to help the victim with combined trauma and multiple injuries with an immediate threat to life in an unstable state.

5-point (conditionally fatal) (terminal state with corresponding changes in hemodynamics, hemogram; respiration, and consciousness in the victim); surgical treatment is necessary for health reasons, it poses a direct threat to life, intensive care is indicated, dynamic monitoring, the recommended algorithm of actions is to provide assistance to a victim with combined trauma and multiple injuries with an immediate threat to life in critical condition.

Significant indicators of leading trauma syndromes.

Significant indicators depending on the (dominant) leading trauma syndrome in the acute period are:

- in case of acute hypovolemia syndrome as a result of blood loss, traumatic toxicosis, microcirculatory disorders determined by a retrospective analysis of the difference in blood pressure, heart rate, NPV at the time of admission and after stabilization; differences in hemogram indicators (red blood cells, hemoglobin, hematocrit) at admission and 3-6 hours after admission and data.

- in case of acute cerebral compression syndrome - lesions detected during CT scan of the brain (presence and number of zones of brain contusion; volume and localization of intracranial hematomas;

- in case of acute respiratory failure syndrome (ARF) as a result of chest injury or airway conduction disturbance - difference in blood pressure, heart rate, NPV at the time of admission and after stabilization; difference in hemogram values (red blood cells, hemoglobin, hematocrit) upon admission and 3-6 hours after admission, CT results (volume of hemopneumothorax, number of zones of lung contusion);

- in acute ascending edema syndrome of the cervical spinal cord with bruising or rupture of the spinal cord at the level of segments C1-C-3, which led to a violation of the vital functions of the body, the difference in blood pressure, heart rate, NPV at the time of admission and after stabilization; results (bruise, rupture of the spinal cord), magnetic resonance imaging (MRI) of the cervical spine.

The results of a retrospective analysis of 573 injury histories of patients with injuries used in the development of the R-AIS scale.

The dominant syndromes formulated by us that determine the severity of the trauma of each anatomical region are presented in Table 2.

table 2 Dominant syndromes that determined the severity of the injury to each anatomical region Dominant Syndromes
Anatomical
areas Acute hypovolemia as a result of blood loss, traumatic toxicosis
a, microcirculation disorders Acute respiratory failure (ARF) as a result of a chest injury or conduction disorder
respiratory tract Acute compression of the brain, leading to a violation of the vital functions of the body Acute ascending spinal cord edema with contusion or rupture of the spinal cord at the level of C1-C-3 segments, leading to a violation of the vital
body functions Head - - + - Neck and face Injury of the facial skeleton and soft tissues of the neck + + - - Injury or rupture of the spinal cord at the level of C1-C-3 segments - - - + Spine and spinal cord - - - + Chest + + - - Abdomen and pelvic cavity + - - - Extremities and pelvic girdle + - - - Skin integument + - - -

The severity of injuries of the musculoskeletal system (OA), skin, and abdomen in the acute period was determined by the severity of acute hypovolemia syndrome and microcirculatory disorders in (95.4 ± 3.2%) cases, with breast injury in 21 (33 ± 3.5% ), with trauma to the facial skeleton and soft tissues of the neck in 4 (43.8, ± 4.2%) cases.

Comparative assessment of injuries sustained by patients in the acute period of trauma, where the prevailing syndrome was acute hypovolemia (chest, abdomen; limbs and pelvic ring; skin and adjacent soft tissues, facial skeleton and soft tissues of the neck), we performed according to the following parameters:

- the difference in blood pressure, heart rate, NPV at the time of receipt and after stabilization;

- the difference in hemogram values (red blood cells, hemoglobin, hematocrit) at admission and 3-6 hours after admission.

Table 3 Clinical and laboratory manifestations of 3-, 4-, 5-point breast injuries, fractures of the extremities and pelvic ring, organs of the abdominal cavity, skin and adjacent soft tissues, facial skeleton and soft tissues of the neck, where acute hypovolemia was the dominant syndrome Options HELL mmHg Art. Heart rate in 1 min NPV in 1 min 1 min NPV for chest injury RBC × 10 ¹² HBG g / l HCT% AIS Scores 3 22.5 ± 5.4 17.8 ± 6.5 3.1 ± 1.1 3.2 ± 1.6 1.2 ± 0.5 20.1 ± 5.6 6.7 ± 1.4 four 32.5 ± 9.8 26.8 ± 7.6 4.2 ± 1.5 6.2 ± 1.5 1.8 ± 0.4 28.6 ± 4.5 8.4 ± 1.2 5 48.1 ± 6.8 45.8 ± 5, 4 8.2 ± 1.5 12.2 ± 3.5 3.1 ± 0.4 50.2 ± 6.5 12.9 ± 1.9

The result of the analysis was a clear separation of the most typical combinations of injuries of the musculoskeletal system, abdomen, skin and adjacent soft tissues, facial skeleton and soft tissues of the neck into 3-, 4-, 5-point injuries (table 3).

For patients with a chest injury, a comparative analysis of clinical manifestations with CT results was performed (a decrease in the volume of the pleural cavity due to hemothorax or pneumothorax; the number of damaged lung segments with lung contusion).

The severity of a chest injury was determined in 41 (66.1 ± 1.2%) cases by the severity of respiratory failure due to various reasons: a decrease in the volume of the pleural cavity with hemothorax or pneumothorax; massive bruised lungs; flotation of a fragment of the chest wall in case of terminal rib fractures by hemopericardium; in 21 (33 ± 2.4%) - acute hypovolemia syndrome and microcirculation disorders.

In the analysis, we did not find a correlation between the severity of the patient's condition and the number of uncomplicated rib fractures.

We conducted a comparative analysis of the condition of the victims with comparable hemothorax and pneumothorax in volume; the data obtained are presented in table 4.

Table 4 The dependence of the difference in hemogram indicators, blood pressure, heart rate, NPV on the components of the volume of the pathological contents of the pleural cavity Options HELL mmHg Heart rate in 1 min NPV in 1 min RBC × 10 ¹² HBG g / l HCT% Clinical manifestations Hemothorax, occupying up to 20% of the pleural cavity. 15.5 ± 5.6 10.8 ± 3.5 1.6 ± 0.1 0.5 ± 0.7 12.1 ± 5.8 3.9 ± 1.5 Hemothorax, which occupies 20-50% of the pleural cavity volume. 22.5 ± 5.4 17.8 ± 6.5 3.1 ± 1.1 1.2 ± 0.5 20.1 ± 5.6 6.7 ± 1.4 Hemothorax, occupying more than 50% of the pleural cavity 38.1 ± 9.8 29.8 ± 7.4 6.2 ± 1.5 2.8 ± 0.4 36.2 ± 4.5 8.9 ± 1.9 Pneumothorax, up to 20% of the pleural cavity volume. 8.2 ± 1.3 5.9 ± 0.2 1.4 ± 0.4 0.3 ± 0.1 4.8 ± 0.5 4.4 ± 1.5 Pneumothorax 20-50% of the pleural cavity volume 8.2 ± 1.3 5.9 ± 0.2 1.4 ± 0.4 0.3 ± 0.1 4.8 ± 0.5 4.4 ± 1.5 Pneumothorax more than 50% of the pleural cavity. 7.2 ± 1.3 19.9 ± 0.2 10.4 ± 0.4 0.3 ± 0.1 4.8 ± 0.5 4.4 ± 1.5 Hemopneumothorax up to 20% of the pleural cavity volume 8.2 ± 1.3 5.9 ± 0.2 1.4 ± 0.4 0.3 ± 0.1 4.8 ± 0.5 4.4 ± 1.5 Hemopneumothorax from 20% to 50% of the pleural cavity volume 22.5 ± 5.4 17.8 ± 6.5 6.1 ± 1.1 1.9 ± 0.5 20.1 ± 5.6 6.7 ± 1.4 Hemopneumothorax more than 50% of the pleural cavity with a predominance of hemothorax 42.1 ± 6.8 35.8 ± 5.4 32.2 ± 3.5 2.6 ± 0.4 40.2 ± 6.5 12.9 ± 1.9 Hemopneumothorax more than 50% of the pleural cavity with a predominance of pneumothorax 31.1 ± 6.8 25.9 ± 5.2 33.3 ± 1.5 2.1 ± 0.4 30.2 ± 6.5 12.9 ± 1.9

The next step in our study was to determine the dependence of the severity of the injury on the area of the lung contusion, determined using computed tomography (table 5).

Table 5 The dependence of the clinical manifestations of ODN on the number of injured lung segments AIS Scores The number of injured segments of the lungs NPV HELL mmHg Heart rate in 1 min 3 1-2 22.4 ± 1.5 8.5 ± 5.4 14.8 ± 6.5 four 3-5 31.8 ± 2.4 11.5 ± 9.8 18.8 ± 7.6 5 6-7 - - -

It should be noted that we did not have patients with bruises of 6-7 segments of the lungs confirmed by CT; apparently, they died at the prehospital stage.

When it comes to saving the life of a victim with combined traumatic brain injury (TBI), in our opinion, it is permissible not to take into account the generally accepted classification of TBI. The severity of traumatic brain injury was determined by our severity of acute cerebral compression syndrome in 68 (96.4 ± 2.8%) cases, due to the volume and localization of intracranial hematoma, hygroma; a decrease in the volume of the cavity of the cerebral skull during the compression of bone fragments; the presence, size and localization of foci of contusion of the brain, the severity of acute cerebral edema identified during CT. The data obtained are presented in table 6.

Table 6 The dependence of the clinical manifestations of a traumatic brain injury on the presence and number of foci of brain contusion found during CT Mild brain injury Medium brain contusion Severe brain contusion 1 area of brain contusion 28 (%) four 0 2 contralateral foci of brain contusion 10 12 four Multiple foci of brain contusion 0 3 8 CT edema of the brain, diffuse axonal damage to the brain 0 0 four Intracranial hematoma more than 50 ml, intracerebral hematoma more than 30 ml 0 2 four

When conducting the analysis, we noticed that the clinic of combined traumatic brain injury does not correspond to the clinical manifestations of isolated traumatic brain injury with similar injuries found on CT of the skull.

Neurological disorders in the acute period of combined trauma were more pronounced, but at the same time, with a favorable course of the traumatic disease, neurological symptoms regressed faster, this is due to the peculiarities of the course of the traumatic disease (mutual burden syndrome and hypoxic encephalopathy).

Therefore, the assessment and prognosis of combined traumatic brain injury must be determined to a greater extent from the data obtained with CT scan of the skull than by the clinical manifestations of traumatic brain injury.

The anatomical region “face and neck” (according to AIS) is divided into two subregions due to the fact that the manifestations of damage to the facial skeleton and soft tissues of the neck are fundamentally different from the clinic of a bruise or rupture of the spinal cord at the level of the cervical spine.

The severity of injury with a bruise or rupture of the spinal cord at the level of the cervical spine was determined by the degree of violation of the vital functions of the body due to spinal shock and ascending spinal cord edema in 9 (90.0 ± 2.2%) cases.

In our approach, we sought to evaluate the effect of injuries of the facial skeleton on the degree of danger to life in case of stenosis of the respiratory tract and acute blood loss.

The severity of injury in injuries of the facial skeleton and neck was determined by respiratory failure due to post-traumatic stenosis of the upper respiratory tract in 5 (56.2 ± 2.2%) and acute hypovolemia in 4 (43.8, ± 4.2%) cases.

A feature of facial skeleton injury we consider:

- the absence of stenosis of the upper respiratory tract and bleeding from the nasopharynx does not allow attributing such an injury to the facial skeleton to severe 3-point damage, the severity of such damage is 2 points;

- if there was a violation of the conduction of the respiratory tract against the background of ongoing bleeding, then there was an immediate threat to life and the damage was rated at 4 points.

Among the studied case histories, we did not find such injuries that could be estimated at 5 points; apparently, the victims died at the prehospital stage. The vast majority of patients, 7 (84.3 ± 3.5%), who had respiratory failure and acute hypovolemia were with fractures of the facial skeleton type FOR 2, Form 3. The data obtained are presented in table 7.

Table 7 Changes in hemodynamic parameters and the severity of respiratory failure in patients with fractures of Forms 2, 3 in the first hours after an injury Facial Skeleton Damage HELL Heart rate NPV AIS Scores Fractures Fore 2, Fore 3 14.5 ± 5.6 9.8 ± 3.5 8.6 ± 0.1 four

The immediate threat to life in the acute period of injury was bruises and ruptures of the spinal cord at the level of C1-C3 segments, these patients needed resuscitation and intensive care (mechanical ventilation, prevention of ascending spinal cord edema), from the level of C4 segments and below, an immediate threat to no life was noted in the acute period of injury. The data obtained are presented in table 8.

Table 8 Changes in hemodynamic parameters and severity of impaired respiratory function with bruises and ruptures of the spinal cord at the level of the cervical spine Hemodynamic indicators and assessment of their changes in points HELL Heart rate NPV AIS Points Spinal cord segments C 1-3 38.1 ± 9.8 29.8 ± 7.4 12.2 ± 1.5 5 S 4-5 28.1 ± 9.8 19.8 ± 7.4 8.2 ± 1.5 four From 6-7 22.5 ± 5.4 17.8 ± 6.5 3.1 ± 1.1 3

Thus, taking as a basis the scale for determining the severity of AIS injuries, we removed unnecessary information, eliminated the possibility of a different assessment of the same injuries, added elements of a clinical assessment of the injury, taking into account the dominant trauma syndromes; clinical and CT manifestations of compression, brain contusion; clinical manifestations of acute respiratory failure and hypovolemic syndrome.

In the severity scale of R-AIS injuries for the acute period of traumatic disease, 3-point (severe), 4-point (life-threatening), 5-point (conditionally fatal) injuries should be taken into account.

Table 9 R-AIS damage severity scale 1 Graduation of fractures of limb bones and damage to the pelvic ring (according to AO / ASIF classification) by 3-, 4-, 5-point injuries according to the modified R-AIS scale. R-AIS Score Type, characteristic and combination of damage. 3 .- open 1 tbsp. or closed type A or B fractures of the metadiaphysis of the 2 tibia; - open 1 tbsp. or closed type A or B fractures of the metadiaphysis of the 2 humerus + open 1 tbsp. or closed type A, B fracture of the metadiaphysis of the tibia; - fracture of the acetabulum type B or C; - unstable damage to the pelvic ring type B. four - open 1 tbsp. or closed type A, B fractures of the metadiaphysis of the 2 femurs; - open 1 tbsp. or closed type A or B fractures of the metadiaphysis of the 2 tibia + open 1 tbsp. or closed type A or B fracture of the metadiaphysis of the femur; - open 1-2 tbsp. or closed type A or B fractures of the metadiaphysis of the 2 femurs + open 1 tbsp. or closed type A or B fracture of the metadiaphysis of the tibia; - unstable damage to the pelvis type C; - unstable damage to the pelvic ring type B + open 1 tbsp. or closed type A or B fracture of the metadiaphysis of the femur or its analogue; - open 3 tbsp. fracture of the metadiaphysis of the femur; - closed type C damage to the pelvic ring; - closed type C fracture of the metadiaphysis of the femur + open 2, 3 tbsp. or closed type C fracture of the metadiaphysis of the tibia. 5 - open 3 tbsp. pelvic fracture with damage to the pelvic organs; - open 3 tbsp. or closed type C fractures of the metadiaphysis of the 2 femurs + fractures of the metadiaphysis of the 2 tibia + damage to the pelvic ring of type B or C. The standard of three-point damage to the musculoskeletal system according to R-AIS is open 1 tbsp., Closed type A, B fracture of the metadiaphysis of the femur. The standard of four-point damage to the ODA according to R-AIS is open 1-2 tbsp., Closed type A, in the fracture of the metadiaphysis of 2 femurs. The standard of five-point damage to the ODE according to R-AIS is a set of open 3 tbsp. fractures of the metadiaphysis of 2 femurs and pelvic bones. 2. Graduation of traumatic brain injury for 3-, 4-, 5-point injuries
on a modified R-AIS scale R-AIS Score Type, characteristic and combination of head injuries 3 - a bruise of the brain of mild to moderate degree, with a contusion focus defined on CT and signs of cerebral edema; - small lamellar epidural and subdural hematomas with a volume of up to 20-30 ml. four - moderate brain contusion with or without skull fractures, with the development of focal, neurological symptoms; accompanied by changes in CT (at least 2 foci of brain contusion); - epidural or subdural hematomas with a volume of more than 50 ml. 5 - severe brain contusion with fractures of the bones of the skull or without them, on CT (multiple foci of brain contusion); - intracerebral (more than 50-60 ml), intraventricular hematomas; - epidural and subdural hematomas with a volume of more than 100 ml; - diffuse axonal damage to the brain. 3. Gradation of injuries of the face, neck to 3-, 4-, 5-point injuries according to the modified R-AIS scale R-AIS Score Type, characteristic and combination of damage to the face and neck 3 - Fractures of 6-7 cervical vertebrae with the development of neurological complications four - multiple unstable fractures of the facial skeleton of the type FOR-2, FOR-3 with an increasing clinic of impaired patency of the upper respiratory tract, ongoing bleeding, aspiration of blood or vomit. - Fractures of 3-5 cervical vertebrae with the development of neurological complications 5 - fractures of 1-2 cervical vertebrae with the development of neurological complications 4. Gradation of chest injury for 3-, 4-, 5-point injuries according to the modified R-AIS scale. R-AIS Score Type, characteristic and combination of chest injuries 3 - chest injury with or without rib fractures, with a hemothorax volume of 500 to 1000 ml or pneumothorax volume of up to 1000 ml without signs of acute respiratory failure - bruise 1-2 segments of the lungs; - uncomplicated rupture of the diaphragm; - clinically determined and recorded on the ECG heart injury with minor violations of the contractile function of the myocardium; four - multiple fragmentary fractures of the ribs with a violation of the skeleton of the chest and / or flotation of rib fragments; - chest injury with or without rib fractures, complicated by massive hemothorax from 1000 to 2000 ml; total pneumothorax with a clinic of acute respiratory failure; - open pneumothorax, mediastinal emphysema with a clinic of acute respiratory failure; - contusion of at least 3 segments of the lungs; - bruising of the heart with a pronounced violation of the contractile function of the myocardium. 5 - a chest injury with severe impaired respiratory function due to hemothorax with a volume of more than 2000 ml; - pneumothorax with an estimated volume of pathological contents in the pleural cavities of more than 3000 ml; - tracheal rupture; aortic rupture; myocardial rupture. 5. Gradation of abdominal trauma on 3-, 4-, 5-point injuries according to the modified R-AIS scale. R-AIS Score Type, characteristic and combination of abdominal injuries 3 Manifestations of hypovolemic syndrome in organ trauma, estimated at 3 points by the difference in hemodynamic and
hemograms:
- retroperitoneal rupture of the bladder, rupture of the ureter, urethra;
- intraperitoneal rupture of the bladder;
- damage to the colon or small intestine;
- rupture of parenchymal organs without clinical and laboratory manifestations of acute blood loss;
- common retroperitoneal hematoma;
- complicated fractures of the middle, lower thoracic and lumbar spine; four Manifestations of hypovolemic syndrome in organ trauma, estimated at 4 points by the difference in hemodynamic and hemogram parameters: - rupture of the liver, spleen, mesentery of the large or small intestine, kidney, with hemoperitoneum, accompanied by clinical and laboratory manifestations of acute blood loss. 5 Manifestations of hypovolemic syndrome in organ trauma, estimated at 5 points by the difference in hemodynamic and hemogram parameters: - rupture of the liver, spleen, mesentery of the large or small intestine, accompanied by clinical and laboratory manifestations of acute blood loss; - damage to the vessels of the abdominal cavity and retroperitoneal space, extensive retroperitoneal hematoma, accompanied by clinical and laboratory manifestations of acute blood loss. 6. Gradation of injury to the skin and adjacent soft tissues to 3-, 4-, 5-point damage on a modified R-AIS scale. R-AIS Score The type, characteristic and combination of damage to the skin and adjacent soft tissues. 3 - extensive soft tissue damage of 2-3 limbs, accompanied by clinical and laboratory manifestations of acute blood loss. four - extensive soft tissue injuries in 3-4 areas of the body, accompanied by clinical and laboratory manifestations of acute blood loss. 5 - destruction (burn of at least 2a degree) of more than 50% of the skin and soft tissues of the body and limbs.

The method is as follows:

Depending on the requirements of the R-AIS scale, each severe injury in an isolated, multiple, or combined injury is assigned from 3 to 5 points.

If, with an isolated injury, multiple injuries and a combined injury, the most severe damage is rated at 3 points, assistance is provided to the victim according to the algorithm for assisting victims with injuries that do not pose an immediate threat to life:

- carry out diagnostic measures in full to detect possible hidden damage and clarify the nature of obvious damage to the anatomical systems;

- carry out maintenance infusion therapy;

- perform surgical interventions according to emergency indications;

If, with an isolated injury, multiple injuries and a combined injury, the most severe damage is rated at 4 or 5 points, assistance is provided to the victim according to the algorithm of assistance to victims in an unstable (4 points) or critical (5 points) state with injuries that pose a direct threat to life, the algorithms differ in the time limit set for the start of operations for vital indications: with 4 points - up to 30 minutes, with 5 points - up to 7 minutes:

- carry out intensive care;

- perform diagnostic measures to a minimum extent before the start of operations for health reasons;

- perform surgical interventions for health reasons, after their completion and relative stabilization of the condition, carry out diagnostic measures in full; when hidden injuries are found that require surgical correction according to emergency indications, emergency operations are performed.

The method was tested for 3 years on over 400 patients. The reliability of using the method was p≤0.05.

The technical result of the invention is to ensure the reliability of determining the severity of injuries and the choice of treatment tactics for patients with severe injuries, mortality reduction with combined injury of 39.7 ± 3.2% (2003) to 18.9 ± 2.6% (2007 )

Date of:

Example 1

Injured at the age of 38 years. I.B. No. 7654.

Date of receipt 02.23.2007. Time - 03.10.

Diagnosis: concomitant injury, leading injury to the musculoskeletal system (OA) injury: unstable damage to the anterior and posterior pelvic rings, massive retroperitoneal hematoma, closed fracture of the diaphysis of the right thigh, hip hematoma, dislocation of the left shoulder, fracture of the left clavicle;

TSTM: a brain contusion with a focus of brain contusion in the fronto-basal region on the right, a scalped head wound with ongoing bleeding; blunt chest injury, multiple fractures of the ribs on the left, complicated by small hemo - pneumothorax, contusion of the left lung; blunt abdominal injury, bruise of the left kidney, macrohematuria; traumatic shock of 3 degrees.

According to the R-AIS scale, the most severe damage - pelvic and hip fractures were rated at 4 points, an algorithm was applied to assist the victim with an immediate threat to life, in an unstable condition.

5 minutes after admission, temporary hemostasis was performed by suturing bleeding vessels and a pressure bandage on a scalped head wound.

40 minutes after admission, operations for vital signs are started:

- surgical stabilization of the pelvic ring with an external fixation device (ANF);

- surgical stabilization of a femoral fracture with an external fixation device (ANF).

During and after the completion of operations for vital signs, intensive therapy was carried out:

- artificial ventilation of the lungs with the device RO-6, a respiratory mixture enriched with oxygen;

- the volume of infusion therapy in the intensive care room and emergency operating room was: 2000 crystalloids, 2000 ml of colloids, 3 doses of red blood cells, 5 doses of FFP, in the amount of about 6000 ml,

- after replenishing the volume of circulating blood, the introduction of subrenal doses of vasopressors (dopamine) has begun

- performed intravenous analgesia (fentanyl).

After 3 hours and 40 minutes, a relative stabilization of the state occurred, after which operations were performed according to emergency indications - drainage of the pleural cavity on the left due to small hemopneumothorax; - PHO head wounds, suturing.

After completing operations according to emergency indications that did not worsen the condition of the victim, the patient was transferred to the intensive care unit, where intensive therapy and dynamic monitoring were continued.

The dynamics of the course of the injury:

- 02.23.07, 15.00., During the control ultrasound revealed a small hemoperitoneum, a diagnostic laparoscopy was performed at 15.30, no abdominal organs were found, retroperitoneal hematoma was confirmed, and drainage into the abdominal cavity was established.

- 02.24.07, in connection with the stabilization of the state, the ventilation is off;

- On February 25, 07, an atelectasis of the left lung was suspected on a control chest x-ray, a chest CT was performed in dynamics, a rehabilitation bronchoscopy was performed, the patient was again examined by a thoracic surgeon,

- 02/26/07 - CT in the dynamics of the chest: hemopneumothorax remains on the left, there is bilateral pneumonia, RDSV is suspected, or a pulmonary form of fat embolism, is transferred again to mechanical ventilation, there is a moderate posthemorrhagic pneumonia;

- 2.03.07 g. - stabilization of the state, transferred to the specialized department;

- March 4, 07 — a blocked osteosynthesis of the right femur was performed;

- 03/11/07 - performed extracortical pelvic osteosynthesis with anterior access; - pubic articulation, sacroiliac articulation with plates, osteosynthesis failure, secondary displacement of the pelvic fragments;

03/20/07, - pelvic ring resynthesis was performed, metal structures were strengthened;

- 1.04.07, plastic sores on the sacrum and gluteal region;

- April 15, 07 - was discharged for outpatient treatment in satisfactory condition.

Conducted 43 beds.

Example 2

Affected for 37 years. I.B. No. 15592. Date April 15, 2007. Time is 10.21.

The mechanism of injury: accident (pedestrian), hit by a car.

Diagnosis: concomitant injury; leading damage - blunt trauma to the abdomen:

rupture of the spleen, retroperitoneal rupture of the bladder, massive hemoperitoneum, blunt chest injury, left-sided hemopneumothorax without signs of acute respiratory failure (ONE), bruised left lung, bruised heart; CCMT, mild brain injury; rupture of the pubic joint, bruised wound of the forearm; shock 3 degrees.

The most severe damage was rated at 4 points on the R-AIS scale, an algorithm was applied to assist the victim with an immediate threat to life, in an unstable state.

30 minutes after admission, the operation was started for health reasons:

- laparotomy, splenectomy, hemostasis, reinfusion of blood poured into the abdominal cavity, drainage of the abdominal cavity;

- drainage of the pleural cavity on the left.

During and after the completion of operations for vital signs, intensive therapy was carried out:

- artificial ventilation of the lungs with the device RO-6, a respiratory mixture enriched with oxygen;

- the volume of infusion therapy was: colloids - 3900 ml; crystalloids - 5150 ml; erythrocyte mass - 1620 ml; SZP - 1730; total - 12380 ml;

- after replenishing the volume of circulating blood, the introduction of subrenal doses of vasopressors (dopamine) has been started;

- performed intravenous analgesia (fentanyl).

After 7 hours 10 minutes after admission, relative stabilization of the state was achieved, after which operations according to emergency indications were performed.

- pelvic osteosynthesis ANF,

- PHO wounds of the forearm;

- suturing the rupture of the bladder, drainage of the cellular spaces of the pelvis, the imposition of epicystostomy.

After completing operations according to emergency indications that did not worsen the condition of the victim, the patient was transferred to the intensive care unit, where intensive therapy and dynamic monitoring were continued.

The dynamics of the course of traumatic disease:

- 04/27/2007, the condition is serious, bilateral pneumonia, septic state, CT in dynamics: bilateral pneumonia, there is no free fluid in the abdominal cavity and pelvis; the severity of the condition is due to bilateral pneumonia and urinary phlegmon of the pelvis.

- 04/27/2007 - 05/06/2007 - stabilization of the purulent process, pelvic inflammatory phlegmon was performed, pelvic wound closure, drainage, remounting of the ANF on the pelvic ring.

- 05/09/2007 - stabilization of the state, normalization of temperature.

- May 18, 2007, was discharged for outpatient treatment in satisfactory condition.

Spent in a hospital 33 days.

Bibliography.

1. Agadzhanyan V.V. Politrauma. Problems and practical issues. Materials of the international conference "New technologies in military field surgery and surgery for peacetime damage." St. Petersburg, 2006, p. 14-18.

2. Gumanenko E.K. Politrauma. Actual problems and new technologies in treatment. Materials of the international conference "New technologies in military field surgery and surgery for peacetime damage." St. Petersburg, 2006, p. 158-159.

3. Seleznev S. A., S. F. Bagnenko, Yu. B. Shapot, A. A. Kurygin. Traumatic disease and its complications. A guide for doctors. 2004, p. 24-57.

4. Sokolov V.A. with co-authors. Multiple and combined damage. A practical guide for doctors. 2006, Moscow, p. 45-49; p.124-146.

5. Glantz S. Biomedical statistics. Translation from English. M .: Practice, 1999, p. 27-45.

6. Abbreviated injury scale - (AIS) Association for the Advancement of Automotive Medicine, Committee on Injury Scaling. The Abbreviated Injury Scale-1990 Revision (AIS-90). Des Plains, IL: Association for the Advancement of Automotive Medicine; 1990.

7. New injury seventy score- NISS Osier T, Baker SP, Long W: A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma 1997; 43: 922-925

HYPERL INK "http://www.sfar.org/scores2/triss2.html"

HYPERLINK "http://www.sfar.org/scores2/triss2.html"

http://www.sfar.org/scores2/triss2.html

http://www.sfar.org/scores2/triss2.html.

8. B.A. Porkhanov, A.N. Blazhenko, V.E. Dubrov. Methodical recommendations “Assistance to victims with combined trauma, multiple injuries, alarming trauma in the acute period of a traumatic disease”, Krasnodar, 2008

Claims (1)

A method for selecting a patient management tactics in the acute period of a severe injury, characterized in that the severity of the injury is assessed in accordance with the scale of severity of damage according to table No. 9 presented in the description of the invention, and if, with an isolated injury, combined injury or multiple injuries, the most severe damage is assessed 3 points, then carry out diagnostic measures in full to detect possible hidden damage and clarify the nature of obvious damage to the anatomical areas, carry out maintenance th infusion therapy and perform surgery according to emergency indications; if the most severe damage is assessed at 4 or 5 points, then intensive therapy is carried out, diagnostic measures are performed to a minimum extent, followed by surgery according to vital indications, after surgery and relative stabilization of the condition, diagnostic measures are carried out in full and in the case of hidden injuries in need of surgical correction according to emergency indications, perform surgical intervention.