RU2815219C1 - Method for assessing severity of chest injury - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to diagnostics, thoracic surgery. Method includes collecting clinical-anamnestic data, physical examination, instrumental methods of research, determining laboratory values. Derived values are scored according to table 1 of the description. Obtained points are summed up, after which the degree of injury severity is determined depending on the total score. If total scores are related to zones between groups or related to two groups simultaneously, result is referred to more unfavourable.

EFFECT: method enables assessing the severity of the chest injury and predicting the clinical course of the posttraumatic period in the patients.

1 cl, 2 tbl, 3 ex

Description

The invention relates to the field of medicine and can be used in emergency thoracic and general surgery. Can be used for isolated chest trauma and for combined injuries with a predominance of chest injuries.

One of the main tasks facing both the doctor at the prehospital stage and during inpatient treatment is the need to quickly assess the severity of injury in victims using a simple and accessible method. Currently, more than 50 different scales have been developed for sorting victims, assessing the severity of the condition and injuries upon admission and during examination and treatment in the hospital. Also, one of the key parameters is the assessment of the frequency of complications in surgery. However, despite the large selection of rating scales at present, each has its own pros and cons. The use of these scales in practical medicine depends on the tasks that the researcher sets for himself, therefore the correct choice of the system is extremely important.

There are analogues of the proposed method.

VPH-SP scales; VPH-SG. The scales were developed in the 1990s. by a team of authors led by E.K. Gumanenko (at the Department of Military Field Surgery of the S.M. Kirov Military Medical Academy) and were proposed to assess the severity of the condition of a patient entering the stage of medical evacuation and during treatment in the hospital (Gumanenko E.K. Combined injuries from the perspective of an objective assessment of the severity of injuries. Doctoral dissertation - St. Petersburg, 1992. RU 2109286 C1, 04/20/1998; Methodology for an objective assessment of the severity of injuries (Part 2. Assessing the severity of the condition of the wounded and injured) / E.K. Gumanenko, V.V. Boyarintsev, V.V. Vashchenkov [etc.] // Bulletin of Surgery named after Grekov. – 1997. – No. 4. – P. 22–27.)

The scales include 12 and 16 characteristics, respectively, to assess the severity of the condition and the effectiveness of treatment. The disadvantages of the scales include:

- absence of age among the criteria

- time of delivery to the hospital from the moment of injury

- biased assessment of blood loss

- lack of laboratory tests, including markers of hidden shock

- data from instrumental examination methods

- lack of an algorithm of actions after determining points

Clavien-Dindo classification of postoperative complications. The classification was developed by P. Clavien, 1992 (P. A. Proposed classification of complication of surgery with examples of utility in cholecystectomy / P. A. Clavien, J. R. Sanabria, S. M. Strasberg // Surgery. - 1992. - Vol. 111, No. 5. - P. 518 –526). In 2004, this classification was supplemented by D. Dindo (Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey / D. Dindo, N. Demartines, P. A. Clavien. – DOI: 10.1097/01 .sla.0000133083.54934.ae // Ann. Surg. – 2004. – Vol. 240, No. 2. – P. 205–213.)

The classification principle included a gradation of complications depending on the method of correction of complications. The disadvantages of the scale include its narrow focus (assessment of complications only after operations); Only the effectiveness of the treatment method is assessed.

The closest analogue is the R-AIS Scale (Express choice of tactics for managing a patient in the acute period of severe trauma: Patent 2411914 Russian Federation, IPC A61B 10/00 (2006.01), A61B 17/00 (2006.01). No. 2008132280/14 , application 04.08 .2008: published 02.20.2011 / Blazhenko Alexander Nikolaevich, Dubrov Vadim Erikovich, Afaunov Ali Ibragimovich, Blazhenko Alexey Alexandrovich). It is the result of clarifications, changes and additions to the AIS scale. R-AIS (Russian scale for determining the severity of injuries received) takes into account when assessing injuries the severity of manifestations of the dominant (leading) injury syndromes of 6 anatomical systems (head, face and neck; chest, abdomen, pelvic bones and extremities; skin and soft tissues) according to significant indicators. Significant indicators depending on the leading syndrome of injury in the acute period are: - in the syndrome of acute hypovolemia as a consequence of blood loss, traumatic toxicosis, microcirculation disorders, the differences in blood pressure, heart rate, respiratory rate values determined by retrospective analysis at the time of admission and after stabilization of the condition; differences in hemogram parameters (red blood cells, hemoglobin, hematocrit) upon admission and 3-6 hours after admission and data; - in acute cerebral compression syndrome - damage detected on CT scan of the brain (presence and number of areas of brain contusion; volume and localization of intracranial hematomas; - in acute respiratory failure syndrome (ARF) as a consequence of chest injury or impaired conduction of the respiratory tract - difference values of blood pressure, heart rate, respiratory rate at the time of admission and after stabilization of the condition; the difference in hemogram parameters (erythrocytes, hemoglobin, hematocrit) upon admission and 3-6 hours after admission, CT results (volume of hemopneumothorax, number of areas of pulmonary contusion); - with the syndrome acute ascending edema of the cervical spinal cord with a contusion or rupture of the spinal cord at the level of segments C1-C-3, leading to disruption of the vital functions of the body - the difference in the values of blood pressure, heart rate, respiratory rate at the time of admission and after stabilization of the condition; results (contusion, rupture spinal cord), magnetic resonance imaging (MRI) of the cervical spine.

Based on the results of assessing significant indicators from 3 to 5 points, the need for intensive therapy or maintenance infusion therapy is determined, indications for surgical treatment are set for life-saving or emergency indications; the need for dynamic monitoring of the patient. In the R-AIS injury severity scale for the acute period of a traumatic illness, 3-point (severe), 4-point (life-threatening), 5-point (conditionally fatal) injuries must be taken into account.

The disadvantages include:

- absence of risk factors such as age, time since injury among the criteria;

- lack of laboratory tests indicating “hidden” shock, which is possible in especially young patients;

- the scale is not selective for chest trauma;

- the scale does not take into account non-serious injuries

- the assessment must be performed repeatedly (every 3-6 hours), since the results may change under the influence of treatment, against the background of progression of pathological processes, as well as due to the development of complications, including postoperative ones;

- when assessing a chest injury and analyzing the same data (hemothorax 1000, 2000 ml), both emergency and delayed interventions may be required depending on the nature of the injury (open/closed). Also, the scope of interventions depending on the time period from the moment of injury may be different (drainage of the pleural cavity, thoracoscopy, abdominal surgery). The algorithm generated based on the results of the scale analysis does not determine the above factors.

The scale we developed to assess the severity of injuries and the condition of victims takes into account the shortcomings of similar scales. This assessment system can be used in victims of any age; it takes into account factors such as the duration of the injury, laboratory parameters, including markers of latent shock, and instrumental diagnostic methods.

The use of the scale is not limited to closed chest injuries and can be used for assessment of open trauma. The technical result of the method is the development and implementation of an integral scale for assessing the severity of the condition and damage in chest trauma.

This invention can be used in emergency thoracic and general surgery to improve treatment results and prevent the development of complications. The result is achieved by assessing the severity of the condition and injuries in victims with an isolated chest injury or combined injury with a predominance of chest injury using scoring in an integral table (Table No. 1).

Depending on the amount of points scored, all patients are divided into 5 groups and, thus, the course of the post-traumatic period in victims with open and closed types of injury is predicted (Table No. 2).

When creating the scale, a retrospective analysis of groups of victims with open and closed chest trauma (isolated and combined) was carried out. The total number of patients was 137, of which 113 had closed injuries, 24 had open injuries. The analysis was carried out to identify the dependence of the outcome (survival / mortality) and the development of complications on the influence of various factors.

Statistical processing of the results obtained was carried out using the programs Statisticafor Windows`6.0, SPSS 10.0.5 for Windows in compliance with the principles of statistical analysis adopted for research in biology and medicine.

Pearson's Chi-quadrant and Fisher's exact test were used to determine the relationship between clinical signs and outcome options.

Also, to establish the informativeness of the indicator for predicting the outcome of a clinical condition, ROC analysis (ReceiverOperatorCharacteristic) was performed.

The prediction accuracy was determined by retrospective analysis and corresponds to a value of 82.5%.

Based on the results of the analysis, clinically significant and statistically reliable clinical, anamnestic and laboratory criteria were selected.

The following were selected from the analyzed array of indicators: age, duration of injury, signs of hemotamponade, subcutaneous emphysema, indicators of lactate, lipocalin, hemoglobin, urine protein, its density, blood sodium level.

The scale also included data from a physical examination of victims with chest trauma - pulse indicators, breathing characteristics, and skin characteristics. The scale also included generally accepted criteria for assessing disorders of the central nervous system - the Glasgow Coma Scale (GCS), shock - the Algover index.

From the instrumental methods, the main ones for diagnosing chest trauma and associated trauma (radiography, multispiral computed tomography, ultrasonography, ultrasound) were selected.

Based on these criteria, an integral scale for assessing the severity of injury was developed (Tables 1-2). For each criterion in the scale, the minimum score is 0 (except for how long ago the injury was received), the maximum score is from 3 to 10. This is primarily due to the severity of the injury itself, as well as age, the presence and severity of concomitant pathology.

The first block of the table is presented by clinical and anamnestic data, such as age (from 0 to 3 points), duration of injury (for open injury - from 1 to 5, for closed injury - from 1 to 6 points) and the presence of clinical signs of cardiac hemotamponade (0 - no, 8 – yes).

The second block is physical examination data. Condition of the skin (0-7 points), character of external respiration (0-8 points), auscultatory changes in the lungs (0-7 points), assessment of consciousness on the Glasgow Coma Scale with inversion of the number of points (from 0 to 10 points), character pulse (0/6 points), Algover index (0-8 points), urine volume (0-5 points), subcutaneous emphysema (0-6 points).

Since on the Glasgow scale the number of points scored has an inverse relationship with the severity of the condition, and all other criteria of the integral scale have a direct relationship, for ease of use, an appropriate translation of the points scored on the Glasgow scale into integral scale points was made (Table 2).

The third block is laboratory parameters, such as hemoglobin (0-5 points), blood lactate (0-10 points), blood sodium (0-2 points), urine density (0-5 points), urine protein (0-6 points ), urine lipocalin (0-8 points). In the fourth block of data from instrumental research methods, if multislice computed tomography was performed, then the results of radiography (fluoroscopy) were not taken into account.

X-rays assessed damage to the bones of the chest frame, including the collarbone and scapula, with and without the presence of a rib valve (from 0 to 8 points), pneumothorax (0-7 points), hydrothorax (hemothorax) - from 0 to 8 points, free gas in the abdominal cavity (0 / 5 points).

MSCT assessed indicators similar to those of radiography and additionally - free fluid in the abdominal cavity (0/5 points), pulmonary contusion (0/3 points), post-traumatic pneumonia (0/5 points). When radiography and MSCT were performed on one patient, the results of computed tomography were assessed as a more informative method.

Ultrasonography of the pleural cavities and abdominal cavity assessed pneumothorax (0/5 points), hydrothorax (hemothorax) - from 0 to 8 points, free gas in the abdominal cavity (0/5 points) and free fluid in the abdominal cavity (0/5 points) .

The severity of the injury is assessed using four points of the integral scale.

Thus, based on the calculation results, the minimum possible number of points is 1, the maximum is 174. For group I, the variability of points ranges from 1 to 8. For group II, it ranges from 14 to 57 points. For group III a – from 24 to 105 points. For group III b – from 55 to 165 points. For group IV – from 78 to 174 points.

To assess the severity of the injury, a modified classification of the severity of surgical complications, created on the basis of the P. Clavien-D classification, was used. Dindo (for victims with a predominant chest injury).

The Clavien-Dindo classification of postoperative complications is based on assessing the effectiveness of any method used to eliminate complications - conservative or surgical. Due to its versatility, this classification has become widespread in various fields of surgery.

When modifying this classification, the basic principles were observed: all elements of the described system were indicated; the possibility of assigning the same indicators to several categories is excluded; the order of increasing clinical severity of symptoms is preserved; Each clinical case belongs to only one rubric.

However, the predicted results of treatment of patients with chest trauma cannot be assessed from the perspective of the Clavien-Dindo classification. For example: victims who received conservative therapy for injury (analgesic, antibacterial drugs, antipyretic agents), transfusion therapy to correct posthemorrhagic anemia caused by injury, patients diagnosed with dysfunction of one organ, after single operations or manipulations.

Therefore, in contrast to the original design, the gradation of degrees was changed: from I to IV degrees, IV, V, VI, VII headings were excluded.

Scale for assessing the severity of injury in victims with chest trauma (based on the Clavien-Dindo classification). I st. – the course of the post-traumatic and postoperative periods was smooth, no additional conservative and surgical measures were required (standard conservative therapy, transfusion therapy to correct anemia caused by injury, single surgical interventions performed for injury, planned correction of concomitant pathology).

Outcomes with complications (II, III, IV stages) included manifestations and complications of injury that were not treated in a timely manner, repeated manipulations/operations, complications after surgery for injury, as well as cases of the development of acute conditions and decompensation of chronic diseases due to injury, which required therapy or surgical interventions.

II Art. – complications requiring an increase in the volume of drug therapy, including transfusion of blood components, but managed conservatively (cardiovascular, neurovascular, stress ulcers of the digestive tract, hospital-acquired pneumonia, wound infection).

III a Art. – to relieve complications, manipulations and/or operations under local anesthesia were required.

III b art. – complications that required surgery under general anesthesia to relieve.

IV Art. – developed complications of injury and/or postoperative complications and/or acute conditions, decompensation of chronic diseases, leading to death.

The wide variability of scores is associated with a wide variety of clinical, anamnestic, laboratory and instrumental indicators, criteria, the possibility of taking into account a different number of criteria, both in general and within each block, with the possibility of the absence of a block of criteria completely, a range of points from 0 (1) to 10 This scatter is due to the need to indicate the “price” of each specific feature. The value of a point is determined by its importance for determining severity and choosing tactics. For example, the presence of signs of hemotamponade is rated at 8 points, and a decrease in blood Na level is only 2 points. The formation of the point system is modeled on similar scales (VPX, R-AIS).

The difference between the scores in the groups reflects the statistical significance of the prediction result. Between the groups in points there are so-called transition zones, when the number of points corresponds to the value between the groups. With this result, the predicted outcome is assessed as transitional - I-II gr., II-III a gr., IIIa-IIIb gr., III b-IV gr. In this case, the surgeon’s choice of actions is aimed at preventing the most unfavorable prognosis. That is, if the sum of points is in the transition zone between groups II and IIIa, then we consider being in group IIIa as an unfavorable prognosis - the risk of developing complications requiring measures/operations under local anesthesia.

An option to obtain a sum of points that can be assigned to either one or another group. For example, a sum of 39 points obtained when calculating a block without instrumental methods can be assigned to both group II and IIIa. The forecast will be assessed in favor of the most unfavorable.

Examples of method implementation.

Example 1. Group I.

Victim P., 28 years old.

Ds: Contusion of the chest on the right.

When assessed on an integral scale, the sum of points is 8. When predicting the course of the post-traumatic period, the case is assigned to group I. The recommended tactic is to refer the patient for outpatient treatment.

Example 2. Group IIIb.

Patient O., age 25 years.

Ds: Penetrating gunshot (shot) wound to the left side of the chest. Large hemothorax on the left. Penetrating wounds S3, S6 of the left lung. Multiple foreign bodies in the pleural cavity. Hemorrhagic shock 2 tbsp.

When assessed on an integral scale, the sum of the points scored was 55, which corresponded to group IIIb (the risk of complications, the management of which may require surgery under general anesthesia). Based on the data obtained, treatment tactics were determined: emergency surgery was performed: left thoracotomy, removal of hemothorax, stopping bleeding, suturing lung wounds. In the postoperative period he was in the intensive care unit.

Correctly chosen tactics allowed us to avoid complications.

Example 3. Group IV.

Patient S., age 36 years.

Ds: Penetrating stab wound to the left side of the chest. Injury to the left ventricle of the heart. Hemotamponade. Large hemothorax on the left. Hemorrhagic shock 3 tbsp.

When assessed on an integral scale, the total score was 84, without instrumental examination, which corresponded to group IV (high risk of developing lethal complications). An emergency operation was performed: resuscitation thoracotomy on the left, elimination of hemotamponade, suturing of the heart wound, removal of hemothorax. Intraoperative cardiac arrest was restored by direct massage. In the postoperative period he was in the intensive care unit. Against the background of massive blood loss, coagulopathy developed according to the type of disseminated intravascular coagulation syndrome, which, in combination with grade 3 hemorrhagic shock, caused death. In this case, the tactics were also chosen correctly, but the severity of the injury (determined on an integral scale) and complications became the cause of death.

Obtaining a number of points corresponding to the gap between groups is regarded as a transition result between groups (I-II, II-IIIa, IIIa-IIIb, IIIb-IV).

Thus, intermediate results (between groups) are assessed in the same way as within groups.

The technical result of the invention can be considered the developed integral scale (tables No. 1, 2). The use of the scale upon admission to the hospital allows you to assess the severity of injuries and conditions, determine treatment tactics depending on the severity of the condition, which in turn reduces the percentage of complications of injury and operations in victims .

Table 1 – Integral scale for assessing the severity of the condition and the severity of injuries

No. Index Number of points I. Clinical and anamnestic data 1. Age 18-40 years old 0 41 years - 50 years 1 51 years old - 70 years old 2 71 years or older 3 Open injury Closed injury 2. Duration of injury up to 1 hour 1 1 1-2 hours 3 2 2-6 hours 5 3 6-12 hours 4 12-24 hours 5 more than 24 hours 6 3. Clinical signs of cardiac hemotamponade No 0 There is 8 II. Physical examination findings 1. Skin covering ordinary 0 cyanotic 2 pale 4 grey 7 2. Nature of external respiration normal 0 rapid breathing (more than 22 per minute) 5 pathological 8 3. Auscultatory changes in the lungs Normal breathing 0 weakened 3 absent 7 4. Glasgow Coma Scale Opening your eyes arbitrary 4 How to react to a voice 3 How to react to pain 2 absent 1 Speech reaction quick and correct answer to the question 5 Confused speech 4 verbal okroshka, the answer does not correspond in meaning to the question 3 inarticulate sounds in response to a question 2 absent 1 Motor reaction Movements on command 6 expedient movement in response to pain (pushing away) 5 jerking a limb in response to pain 4 abnormal flexion in response to pain 3 pathological extension in response to pain 2 absent 1 GCS scores Compliance with the integral scale Clear consciousness 15 0 Moderate stun 14-13 2 Deep Stun 12-11 3 Sopor 10-9 5 Coma I 8 7 Coma II 7-6 8 Coma III 5-4 9 Brain death 3 10 5. Pulse character No arrhythmia 0 There is an arrhythmia 6 6. Algover Index 0.5-0.6 0 0.7-0.8 2 0.9-1.2 3 1.3-1.5 6 1.6 and more 8 7. Urine availability in sufficient quantity 0 availability in small quantities 1 absence 5 8. Subcutaneous emphysema No 0 relaxed 4 tense 6 III. Laboratory indicators 1. Hemoglobin normal (120-160 g/l) 0 mild anemia (119-90 g/l) 1 moderate severity (89-70 g/l) 3 severe anemia (69 g/l and below) 5 hemoconcentration 2 2. Blood lactate normal (1.0-1.8 mmol/l) 0 1.8-2.5 mmol/l 4 2.5-8.0 mmol/l 7 more than 8.0 mmol/l 10 3. Blood sodium normal (135.0-150.0 mmol/l) 0 below 135.0 mmol/l 2 4. Urine density norm (1003-1035) 0 prerenal AKI (more than 1020)/anuria 5 5. Urine protein normal (up to 0.033 g/l) 0 0.034-0.09 g/l 3 0.091-1.2 g/l 5 1.21 g/l or more/anuria 6 6. Urine lipocalin normal (0.9-9.0 ng/ml) 0 9.1-20.0 ng/ml 2 20.1-50.0 ng/ml 4 51.0-90.0 ng/ml 6 more than 91.0 ng/ml/anuria 8 IV. Data from instrumental research methods 1. X-ray (if MSCT was not performed) A) Damage to the bones of the chest frame, including the collarbone and scapula No 0 yes, ribless valve 4 yes, with rib valve 8 b) Pneumothorax No 0 unstressed 5 tense 7 V) Hydrothorax (hemothorax) No 0 small 4 average 6 big 8 G) Free gas in the abdominal cavity No 0 There is 5 2. MSCT (if MSCT is performed, then radiography is not taken into account) A) Damage to the bones of the chest frame, including the collarbone and scapula No 0 yes, ribless valve 4 yes, with rib valve 8 b) Pneumothorax No 0 unstressed 5 tense 7 V) Hydrothorax (hemothorax) No 0 small 4 average 6 big 8 G) Free gas in the abdominal cavity No 0 There is 5 d) Free fluid in the abdomen No 0 There is 5 e) Lung contusion No 0 There is 3 and) Pneumonia (post-traumatic) No 0 There is 5 3. Ultrasonography of the pleural cavities and abdominal cavity A) Pneumothorax No 0 There is 5 b) Hydrothorax (hemothorax) No 0 small 4 average 6 big 8 V) Free gas in the abdominal cavity No 0 There is 5 G) Free fluid in the abdomen No 0 There is 5

Table No. 2 Scale for assessing the severity of injury in victims with chest trauma

Group (degree) I II IIIa IIIb IV Number of points (based on assessment of all (4) blocks in full) 1-8 14-57 78-105 119-165 142-174 Number of points (based on all (4) blocks without lipocalin) 12-55 74-101 113-159 134-166 Number of points (based on all (4) blocks without ultrasonography) 14-53 57-84 96-142 119-151 Number of points (when assessed according to all criteria without the results of instrumental research methods, due to the severity of the victim) 14-40 24-51 55-101 78-110

Claims (8)

A method for assessing the severity of a chest injury, including the collection of clinical and anamnestic data, physical examination, and instrumental research methods, characterized in that the following indicators are determined: - clinical and anamnestic data: age, duration of injury, clinical signs of cardiac hemotamponade; - physical examination data: the condition of the skin, the nature of external respiration, auscultatory changes in the lungs, the Glasgow Coma Scale, the nature of the pulse, the Algover index, the presence and amount of urine, subcutaneous emphysema; - laboratory parameters: hemoglobin level, blood sodium lactate, blood sodium, urine density, urine protein, urine lipocalin; - data from instrumental research methods: perform radiography or MSCT and determine the presence and nature of damage to the bones of the chest frame, the presence and nature of pneumothorax, the presence and nature of hydrothorax, the presence or absence of free gas in the abdominal cavity; MSCT additionally determines the presence of a lung contusion and the presence of pneumonia; perform ultrasonography of the pleural cavities and abdominal cavity and determine the presence or absence of pneumothorax, the presence and degree of hydrothorax, the presence or absence of free gas in the abdominal cavity, the presence or absence of free fluid in the abdominal cavity; then a scoring of the obtained indicators is carried out in accordance with Table 1 of the description; sum up the points received, after which, depending on the amount of points scored, the severity of the injury is determined: I degree - 1-8 points, II degree - 14-57 points, IIIa degree - 24-105 points, IIIb degree - 55-165 points, IV degree - 78-174 points; if the sum of points scored belongs to zones between groups or belongs to two groups at the same time, the result is classified as more unfavorable.