RU2444347C2 - Method of treating permanent mechanical injures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely surgery, traumatology, intensive care and can be used for treating patients with a permanent mechanical injury. That is ensured by 3 to 12 hyperbaric oxygenation (HBO) sessions at partial pressure of oxygen pO₂ 0.1 to 0.25 MPa. Duration of a session makes 20 to 30 minutes. Additionally, the method can involve introducing the blood-substitute solution heparin. Also, with regard to a degree of the injury, the method can involve the peritoneal lavage, abdominal drainage and intestinal decompression.

EFFECT: method provides higher clinical effectiveness in the patients with the presented pathology ensured by fast normalisation of microcirculation that leads to better hemodynamics values, acid-base metabolism and stabilised cardiac performance.

12 cl, 3 ex

Description

Technical field

The invention relates to medicine, specifically to a method for treating severe mechanical injuries, in particular gunshot wounds, for example, chest and abdomen, mine-blast injuries of limbs, and injuries resulting from a traffic accident.

State of the art

The treatment of severe mechanical injuries is an important task of modern surgery. One way to solve the problem of improving the results of treatment of such injuries is to find and use therapeutic factors of a wide spectrum of action that contribute to the restoration of the viability of damaged tissues, normalization of general and tissue homeostasis.

According to the scientific literature, HBO, which is the treatment with oxygen under increased pressure in the pressure chamber, is an antihypoxic treatment method (see, for example, Zhironkin A.G. Oxygen. Physiological and toxic effects. - L., 1972).

The literature also disclosed the use of HBO for blood loss (for example, Petrovsky B.V., Efuni S.N. Fundamentals of hyperbaric oxygenation. - M. - 1976).

However, clinical experience has shown that along with the positive results of the therapeutic effect of HBO, there are cases where HBO does not have a significant effect or even contributes to deterioration. So, for example, it was shown that the use of HBO only in traumatic and hemorrhagic shock is not effective (Sherman D.M., Sennik V.T. Efficiency of hyperbaric oxygenation in the treatment of traumatic shock \\ Military-medical journal - 1987. 11. - S. 67).

The main method of treating severe mechanical injuries, in particular gunshot wounds, is the surgical correction of injuries. However, surgical correction often fails to avoid complications.

Thus, there is a need to improve the treatment of severe mechanical injuries, which include gunshot, mine-blast and injuries resulting from a traffic accident.

This problem is unexpectedly solved by the treatment method according to the present invention.

SUMMARY OF THE INVENTION

The present invention relates to a method for treating severe mechanical injury in humans, in which hyperbaric oxygenation (HBO) is performed. Such an injury may be, for example, an injury resulting from a traffic accident, a mine-blast wound to a limb, a gunshot wound, such as a chest and abdomen.

DETAILED DESCRIPTION OF THE INVENTION

Injuries

The term “severe mechanical trauma” is universally recognized and widely used in the field of medicine (see “Handbook of an emergency medical doctor” under the editorship of S. F. Bagnenko and I. N. Ershova, 2007). However, as a synonym for this type of injury, the term “multiple trauma” is also used.

In the context of the present invention, the term "severe mechanical injury" refers to injuries resulting from mechanical stress on the human body, which are characterized by impaired functions of the basic life support systems of the body. The indicated mechanical influences that cause severe mechanical injuries are, for example, a traffic accident (accident), a fall, a blow, a wound with a cold weapon, a mine blast, a shot from a firearm.

In one embodiment of the present invention, a severe mechanical injury is a gunshot wound.

In one embodiment of the present invention, the gunshot wound is a gunshot wound to the chest. In another embodiment of the invention, the gunshot wound is a gunshot wound to the abdomen.

In another embodiment of the present invention, a severe mechanical injury is a mine-blast wound to the extremities.

In yet another embodiment of the present invention, a severe mechanical injury is an injury resulting from an accident.

All these types of injuries are characterized by the presence of tissues with varying degrees of impaired viability.

Method of treatment

A method of treating severe mechanical injury of the present invention includes the step of conducting hyperbaric oxygenation. In particular, the treatment method according to the invention includes surgical correction of the injuries received and HBO, preferably after surgical correction.

Used in the context of the present invention, the term "surgical correction of damage" is understood by a specialist in the field of medicine, in particular surgery. The surgical correction measures performed by the doctor depend on the nature and severity of the injury and are selected by the doctor based on knowledge and experience. These activities include both preparing the injured for a surgical operation, and the operation itself.

In addition, the treatment method includes postoperative measures, also selected by the doctor on the basis of their knowledge and experience, depending on the nature and severity of the injury and the surgical operation performed (surgical correction of injuries). Postoperative treatment of injuries is aimed at creating the conditions for their quickest healing without complications.

Postoperative treatment for a gunshot wound to the chest may include, in particular, the elimination of hypovolemia and stabilization of blood pressure at a level not lower than 100 mm Hg.

The program for the surgical correction of injuries in case of a gunshot wound to the abdomen provides for measures that complete the surgical intervention. These events are well known and represent, in particular:

- peritoneal lavage (in the postoperative period, novocaine with penicillin or kanamycin is added into the abdominal cavity through a narrow lumen of the drainage tube, and then Ringer's solution, Ringer-Locke or physiological NaCl solution. After that, after 30 minutes, changing the angle of the patient’s body position and opening a wide lumen of the tube, allowing fluid to pour out from the abdominal cavity),

- intracranial administration of drugs (a drug mixture consisting of novocaine, papaverine, platifillin and kanamycin or monomycin is administered through a catheter),

- intestinal decompression (using a nasogastrointestinal probe such as Miller-Abbot).

Abdominal drainage may also be provided.

In addition, postoperative treatment may include intensive care measures aimed at eliminating endotoxemia, microcirculation disorders, reducing the activity of proteolytic enzymes, eliminating intestinal paresis, and normalizing metabolism.

Treatment of mine-explosive wounds of limbs, if desired, includes intravenous administration of blood-replacing solutions that selectively improve the rheological properties of blood and microcirculation in tissues. Such blood substituting solutions (disaggregants) are known in medicine. A preferred blood substitute solution, if used, is a reopoliglyukin solution. The blood substitute solution is used in an amount of from 0.5 to 2 liters, preferably from 1 to 2 liters, or preferably 0.5 to 1.5 liters, most preferably from 1 to 1.5 liters. If desired, a blood substitute solution is administered before surgical correction of injuries, during surgery and within a few days, for example 3-4 days, of the postoperative period. Preferably, during the postoperative period, intravenous administration of a blood-replacing solution is combined with intramuscular administration of heparin. The dose of heparin is from 3 to 7 thousand units, preferably from 4 to 6 thousand units, most preferably 5 thousand units. Heparin is administered 1-2 times daily, preferably 2 times daily.

Thus, the surgical correction of injuries and postoperative measures used in the method of the present invention are generally accepted for the respective types of injuries, and their choice is left to the discretion of the doctor who is treating the injured.

The method of the present invention includes HBO, preferably at the stage of postoperative treatment.

Hyperbaric oxygenation (HBO)

In the context of the present invention, the term "hyperbaric oxygenation" means exposure to a injured person with oxygen under increased pressure in a pressure chamber.

An example of a pressure chamber that can be used in the method according to the invention is the Irtysh-MT pressure chamber. This portable folding mobile and transported pressure chamber allows you to conduct HBO sessions both in the field on the spot and during transportation of the injured on the vehicle. Its deployment takes 3-5 minutes. At a maximum overpressure of 1 kgf / cm ² (0.1 MPa), the oxygen supply in the cylinder allows it to be used offline for 90 minutes.

The HBO course begins 3–20 hours after the end of the operation (surgical correction of injuries), for example, 6–10 hours after the operation or 12–18 hours after the operation.

The HBO course includes at least 3 HBO sessions. The longest course of HBO includes 12 sessions of HBO. Thus, according to the present invention, the course of HBO includes 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 sessions.

In a HBO session, the exposure lasts from 20 to 70 minutes, preferably from 30 to 60 minutes, for example 30-50 minutes, 40-60 minutes or 60 minutes. The partial pressure of oxygen pO ₂ with HBO is from 0.1 to 0.25 MPa, for example 0.15-0.18 MPa or 0.18-0.2 MPa.

In one of the embodiments of HBO is carried out with a frequency of 1 session daily. In another embodiment, 2 HBO sessions per day are performed for the first 2-3 days and then 1 HBO session daily. In any case, the choice of the HBO regimen is left to the discretion of the doctor based on his own knowledge and based on the nature of the injury.

In another aspect, the invention relates to the use of HBO in the treatment of severe mechanical injuries in which surgical correction of injuries is performed.

In another aspect, the invention relates to the use of HBO for the prevention of infectious complications in severe mechanical injuries, in particular gunshot wounds, such as gunshot wounds to the chest.

The author of the present invention unexpectedly found that when HBO is included in the postoperative treatment of severe mechanical injuries, the frequency of fatal outcomes decreases, the frequency of infectious purulent complications decreases, the microcirculatory indices, central hemodynamics, blood gas and acid-base conditions are normalized and normalized hearts.

Below the present invention is illustrated by experimental data, which do not limit the scope of the invention defined by the claims.

Examples

The use of HBO in the treatment of gunshot wounds

HBO was used in the complex postoperative therapy of 62 wounded in the chest. There were 44 isolated wounds of the chest, 5 thoraco-abdominal and combined wounds of the chest and abdomen, 12 combined wounds of the chest and extremities, 1 thoraco-spinal wounds. Open pneumothorax was diagnosed in 18, closed - in 44, large hemothorax - in 24 , medium - at 35, small - at 3 wounded.

HBO was used only after performing urgent surgical interventions: stopping bleeding, suturing open pneumothorax, draining the pleural cavity, eliminating valvular and intense pneumothorax.

We studied gases and the acid-base state of arterial blood in 16 wounded patients who received HBO in the postoperative period. It was noted that after 1-2 sessions of HBO, an increase in the partial pressure of blood oxygen and a decrease in metabolic acidosis occurred. By the time HBO was completed (usually 6-8 days after being wounded), the blood gases and the acid-base state were approaching normal values. For comparison, in a group of the wounded who did not receive HBO, which was similar in nature to the damage and severity, the indicators usually returned to normal 9-10 days after the wound.

We also analyzed changes in the indicators of central hemodynamics (CH) under the influence of HBO, which were evaluated using integral body reography according to M.I. Tishchenko in 12 wounded. After 1-2 sessions of HBO, distinct positive changes were observed: the stroke index (SI) increased, which, along with the persisting tachycardia, ensured an increase in the minute volume of blood circulation (IOC). Under the influence of HBO, the compensatory tension of the functioning of the external respiration apparatus decreased.

Values of such indicators of CH as BH (respiration rate), heart rate (heart rate), CDI (coefficient of respiratory changes), PND (indicator of respiratory tension), SI (cardiac index), CR (reserve ratio), PGO (indicator of hemodynamic provision ) and CIT (coefficient of integral tonicity), also approached normal during HBO.

In addition, it was noted that HBO favorably affects the wound surface.

The treatment of HBO contributed to the normalization of microcirculatory parameters, and in 78% of cases, both intravascular and extra-vascular changes, determined by conjunctival biomicroscopy, were stopped.

When analyzing the effectiveness of HBO according to the direct clinical result, assessed comprehensively, it was found that 71% of patients with gunshot wounds to the chest improved, 14.5% had no changes, 8.1% worsened, and 6.4 % is death.

It was noted during a retrospective analysis that all deaths of the wounded in the main group were due to defects in medical care at the previous stages of evacuation.

It was also noted that the use of HBO in the complex treatment of the wounded with risk factors for infectious purulent complications significantly (by 8.4%) reduced the incidence of pleural empyema in comparison with a similar group of the wounded in whose treatment HBO was not used.

The use of HBO in the treatment of gunshot peritonitis

We analyzed the mortality rate among the wounded in the stomach who were admitted to the hospital within the first 48 hours after the wound. Corresponding surgical correction of injuries was carried out for these wounded, after which HBO was included in the complex postoperative treatment (including removal of the source of peritonitis, peritoneal lavage and intestinal decompression) of the wounded. The ratio of the total number of wounded to the number of deaths in the group in which the complex treatment was performed without HBO was 40/10 (i.e. 25% mortality), and in the group in which the complex treatment with HBO was carried out, 21/1 (4 , 8% mortality). It was found that the effect of HBO on the reduction in mortality was significant (X ² = 3.82, p <0.05).

The main clinical and laboratory parameters were significantly better in the group of wounded treated with HBO. In particular, they noted earlier (on average 2-3 days after surgery) restoration of intestinal motility. Often, after 1-2 sessions of HBO, the wounded noted a decrease in abdominal pain, improved well-being, and an acid-base state was corrected to normal values. After completing the HBO course, the indicators of gas composition and acid-base composition of peripheral blood were as close to normal as possible.

A comparative study was also conducted of the results of biochemical blood tests in wounded in the abdomen who received (12 observations) and did not receive (17 observations) HBO in complex postoperative treatment. In the examined wounded, alanine aminotransferase, aspartate aminotransferase and urea nitrogen, sharply increased in the first days after the injury, mainly returned to normal after 2-3 sessions of HBO performed in the postoperative period. The differences in the indications of aspartate aminotransferase and urea nitrogen in these groups of wounded were statistically significant on the 5th and 7th day after the wound, respectively. This indicates the normalizing effect of HBO on liver and kidney function.

A comprehensive study of the state of the microcirculation system made it possible to draw a conclusion about the improvement of its performance in wounded with gunshot peritonitis under the influence of HBO. Due to the use of HBO, normalization of such microcirculation (MC) indices as the general conjunctival index (OCI), viscometer coefficient (VC), rectal-skin gradient (RCG) and axial limb gradient (OGK) was noted - their values did not differ significantly after 5 HBO sessions from normal indicators. The values of OCI and RCH in the wounded who were treated without HBO at the same time were significantly worse.

The use of HBO in the prevention and comprehensive treatment of mine explosive wounds

HBO was used in the treatment of 63 patients with mine explosive detachments and destruction of distal limb segments. Studies have shown that the main group (treatment with HBO) showed a tendency to a more pronounced marginal nature of the exudative inflammatory reaction with the formation of a more distinct demarcation zone around the foci of primary traumatic tissue necrosis at the edges of the wound. The lymphoid component of perivascular infiltrate in the underlying tissues was also more noticeable in those treated with HBO.

In the main group of the wounded treated with HBO, the newly formed granulation tissue appeared to be less swollen and less infiltrated by polymorphonuclear leukocytes, infiltration by lymphoid elements seemed more uniform. Accordingly, the proliferation of pericytes and the activation of fibroblasts was more diffuse than in the wounded from the comparison group. Moreover, in the wounded, the treatment of which was carried out without HBO, the frequency and size of the foci of secondary necrosis differed by considerable variability and were large.

The use of HBO helped to reduce the severity of purulent inflammation. In the wounded of the main group, purulent infectious complications took on a more local character with a tendency to delimit foci of inflammation.

In the wounded of the main group, the maturation of granulation tissue proceeded more evenly in different parts of the wound and a more uniform replacement of granulation tissue with a scar was observed compared to the wounded, whose treatment was carried out without the use of HBO.

Thus, the use of HBO contributed to the activation of collagen formation by fibroblasts of granulation tissue.

In 11 injured limb injured patients who received HBO, in the first 14 days after the injury, a mathematical analysis of the heart rhythm was performed by the method of variational pulsometry. It was established that already the first HBO sessions were characterized by a more pronounced positive dynamics of indicators compared with the group of the wounded who did not receive HBO. In particular, the duration of the cardiac cycle and the amplitude of fluctuations in its values increased.

Conducting HBO sessions in patients with mine-blast wounds was accompanied by a clear decrease in the number of mannitose and mannitone-negative colonies of microorganisms on the skin, a significant decrease in the number of colonies of Escherichia coli on the mucous tongue.

The wound condition in patients receiving HBO allowed in 65.1% of cases (41 observations) to use the most preferred primary delayed or early secondary sutures for closing the wound surface of the amputation stump from 5 to 10 days after amputation, while in the wounded with similar injuries that did not receive HBO (comparison group), the state of the wound of the amputation stump made it possible to use primary-delayed or early secondary sutures in only 17.2% of cases (30 observations). The differences were statistically significant (X ² = 49.1, p <0.002).

To assess the effectiveness of HBO in the treatment of wounded with mine-blasting wounds of the extremities, such a common clinical indicator as the duration of inpatient treatment was analyzed. With conventional methods of treatment, the treatment period was 33.6 ± 4.3 days (n = 10, p <0.05), while with the addition of HBO - 30.1 ± 1.8 days (n = 10, p <0, 05). As you can see, the complex treatment regimen using HBO contributes to a significant reduction in the duration of inpatient treatment.

In addition, by the 5-7th day after the wound, persons receiving HBO had significantly better microcirculation rates. In addition, HBO eliminated or reduced the severity of myocardial hypodynamia.

The effect of HBO on ECG indicators

HBO sessions contribute to the correction of functional disorders from the main life support systems of the body, characteristic of the acute period of traumatic disease. This is evidenced, in particular, by the results of an electrocardiographic examination. The use of HBO contributed to the rapid normalization of ECG parameters: after 4-5 sessions on the 5-7th day after the wound, the heart rate significantly decreased, Q-T and SP returned to their proper values, metabolic disturbances were stopped. If by the end of the 3rd week after the wound (17-21 days) only in 19% of the wounded who received HBO, the state of electrical activity of the heart did not reach the level of normal indicators, in the group of the wounded without HBO, similar ECG changes were detected in 80% of cases. In the group of the wounded who received HBO, less often than in the comparison group, signs of diffuse changes in the myocardium were observed in the form of rhythm disturbances, a decrease in the amplitude of P and T waves (9.1% and 19%, respectively).

Claims (12)

1. A method of treating severe mechanical injury in humans, characterized in that from 3 to 12 sessions of hyperbaric oxygenation (HBO) are carried out at a partial oxygen pressure pO ₂ of 0.1 to 0.25 MPa for a duration of 20 to 30 minutes. 2. The method according to claim 1, where the severe mechanical injury is a mine-explosive wound of the limb. 3. The method according to claim 1, characterized in that the severe mechanical injury is a gunshot wound. 4. The method according to claim 3, where the gunshot wound is a gunshot wound to the chest. 5. The method according to claim 3, where the gunshot wound is a gunshot wound to the abdomen. 6. The method according to claim 2, further comprising administering a blood substitute solution. 7. The method according to claim 6, where the specified blood substitute solution is a solution of reopoliglyukin. 8. The method according to claim 6, further comprising administering heparin. 9. The method according to claim 5, in which peritoneal lavage is performed. 10. The method according to claim 5, wherein the abdominal cavity is drained. 11. The method according to claim 5, wherein the intestine is decompressed. 12. The method according to claim 1, where the severe mechanical injury is an injury received as a result of a traffic accident.