Polytrauma

Polytrauma in English-language literature - multiple trauma, polytrauma.

Combined trauma is a collective concept that includes the following types of injuries:

• multiple - damage to more than two internal organs in one cavity or more than two anatomical and functional formations (segments) of the musculoskeletal system (for example, damage to the liver and intestine, fracture of the femur and forearm bones),
• combined - simultaneous damage to two or more anatomical areas of two cavities or damage to internal organs and the musculoskeletal system (for example, the spleen and bladder, chest organs and fractures of the bones of the extremities, traumatic brain injury and damage to the pelvic bones),
• combined - damage caused by traumatic factors of various natures (mechanical, thermal, radiation), and their number is unlimited (for example, a fracture of the femur and a burn of any area of the body).

ICD-10 code

The principle of multiple coding of injuries should be used as widely as possible. Combined categories for multiple injuries are used when there is insufficient detail on the nature of individual injuries or in primary statistical developments, when it is more convenient to record a single code; in other cases, all components of the injury should be coded separately.

T00 Superficial injuries involving several areas of the body

• T01 Open wounds involving multiple body regions
• T02 Fractures involving several body regions
• T03 Dislocations, sprains and injuries of the capsular-ligamentous apparatus of joints, affecting several areas of the body
• T04 Crushing injuries involving several areas of the body
• T05 Traumatic amputations involving multiple body regions
• T06 Other injuries involving multiple body regions, not elsewhere classified
• T07 Multiple injuries, unspecified

In combined trauma, it may be necessary to code for damage caused by other factors:

• T20-T32 Thermal and chemical burns
• T33-T35 Frostbite

Sometimes some complications of polytrauma are coded separately.

• T79 Certain early complications of trauma, not elsewhere classified

Epidemiology of polytrauma

According to the WHO, up to 3.5 million people die from trauma worldwide every year. In economically developed countries, trauma is the third leading cause of death, and the second leading cause in Russia. In Russia, traumatic injuries are the leading cause of death among men under 45 and women under 35, with 70% of cases being severe combined injuries. Victims with multiple trauma account for 15-20% of the total number of patients with mechanical injuries. The prevalence of multiple trauma is subject to significant fluctuations and depends on the specific conditions of a particular locality (demographic indicators, production characteristics, prevalence of rural or urban population, etc.). However, overall, the world has seen a trend toward an increase in the number of victims with multiple injuries. The incidence of multiple trauma has increased by 15% over the past decade. Mortality is 16-60%, and in severe cases, 80-90%. According to American researchers, 148 thousand Americans died from various traumatic injuries in 1998, and the fatality rate was 95 cases per 100 thousand of the population. In Great Britain in 1996, 3740 deaths were registered as a result of serious traumatic injuries, which was 90 cases per 100 thousand of the population. In the Russian Federation, large-scale epidemiological studies have not been conducted, however, according to a number of authors, the number of fatal cases of multiple injuries per 100 thousand of the population is 124-200 (the latter figure is for large cities). The approximate cost of treating the acute phase of traumatic injuries in the USA is 16 billion dollars per year (the second most expensive division of the medical industry). The total economic damage from injuries (taking into account the death and disability of victims, lost income and taxes, the cost of providing medical care) in the USA is 160 billion dollars per year. Approximately 60% of victims do not survive to receive qualified medical care, but die in the immediate aftermath of the injury (on the spot). Among hospitalized patients, the highest mortality rate is observed in the first 48 hours, which is associated with the development of massive blood loss, shock, damage to vital organs and severe TBI. Subsequently, the leading causes of death are infectious complications, sepsis and MOF. Despite the achievements of modern medicine, the mortality rate from multiple injuries in intensive care units has not decreased over the past 10-15 years. 40% of surviving victims remain disabled. In most cases, the working-age population aged 20-50 years suffers, with the number of men approximately 2 times greater than women. Injuries in children are recorded in 1-5% of cases. Newborns and infants are more often affected as passengers in accidents, and at an older age - as cyclists and pedestrians. When assessing the damage from multiple trauma, it should be noted that in terms of the number of years lost, it significantly exceeds that from cardiovascular, oncological and infectious diseases combined.

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Causes of multiple trauma

The most common causes of combined trauma are car and train accidents, falls from height, violent injuries (including gunshot wounds, mine blast wounds, etc.). According to German researchers, in 55% of cases, multiple trauma is the result of a traffic accident, in 24% - industrial injuries and active recreation, in 14% - falls from height. The most complex combinations of injuries are noted after traffic accidents (57%), with chest injuries occurring in 45% of cases, TBI - in 39%, and limb injuries - in 69%. TBI, chest and abdominal trauma (especially with bleeding not stopped at the prehospital stage) are considered important for the prognosis. Injuries to the abdominal organs and pelvic bones as a component of multiple trauma occur in 25-35% of all cases (and in 97% they are closed). Due to the high frequency of soft tissue damage and bleeding, the mortality rate for pelvic injuries is 55% of cases. Spinal injuries as a component of polytrauma occur in 15-30% of all cases, which is why every unconscious patient is suspected of having a spinal injury.

The mechanism of injury has a significant impact on the prognosis of treatment. In a collision with a car:

• In 47% of cases, pedestrians suffer from TBI, 48% from lower limb injuries, and 44% from chest trauma.
• In cyclists, 50-90% of cases involve limb injuries and 45% involve traumatic brain injury (moreover, the use of protective helmets significantly reduces the incidence of severe injuries); chest trauma is rare.

In passenger car accidents, the use of seat belts and other safety features determines the types of injuries:

• In people not wearing seat belts, severe TBI is more common (75% of cases), while in those using them, abdominal (83%) and spinal injuries are more common.
• Side impacts often result in injuries to the chest (80%), abdomen (60%), and pelvic bones (50%).
• In rear-end collisions, the cervical spine is most often injured.

The use of modern safety systems significantly reduces the number of cases of severe injuries to the abdominal cavity, chest and spine.

Falls from height can be either accidental or an attempt at suicide. In unexpected falls, severe TBI is more often observed, and in suicides - injuries to the lower extremities.

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How does polytrauma develop?

The mechanism of development of combined trauma depends on the nature and type of injuries received. The main components of pathogenesis are acute blood loss, shock, traumatic disease:

• the simultaneous occurrence of several foci of nociceptive pathological impulses leads to the disintegration of compensatory mechanisms and the breakdown of adaptive reactions,
• the simultaneous existence of several sources of external and internal bleeding makes it difficult to adequately assess the volume of blood loss and correct it,
• early post-traumatic endotoxicosis observed with extensive damage to soft tissues.

One of the most important features of the development of polytrauma is mutual aggravation, caused by the multiplicity of mechanical injuries and the multifactorial nature of the impact. At the same time, each injury aggravates the severity of the general pathological situation, proceeds more severely and with a greater risk of complications, including infectious ones, than with an isolated injury.

Damage to the central nervous system leads to disruption of regulation and coordination of neurohumoral processes, sharply reduces the effectiveness of compensatory mechanisms and significantly increases the likelihood of purulent-septic complications. Chest trauma inevitably leads to aggravation of manifestations of ventilation and circulatory hypoxia. Damage to the abdominal cavity and retroperitoneal space organs is accompanied by severe endotoxicosis and a significant increase in the risk of infectious complications, which is due to the structural and functional features of the organs of this anatomical region, their participation in metabolism, and functional conjugacy with the vital activity of intestinal microflora. Trauma to the musculoskeletal system increases the risk of secondary damage to soft tissues (bleeding, necrosis), and enhances pathological impulses from each affected area. Immobilization of damaged body segments is associated with prolonged hypodynamia of the patient, aggravating the manifestations of hypoxia, which, in turn, increases the risk of infectious, thromboembolic, trophic and neurological complications. Thus, the pathogenesis of mutual aggravation is represented by many diverse mechanisms, but for most of them the universal and most important link is hypoxia.

Symptoms of multiple trauma

The clinical picture of combined trauma depends on the nature, combination and severity of its components, an important element is mutual aggravation. In the initial (acute) period, there may be a discrepancy between visible damage and the severity of the condition (degree of hemodynamic disorders, resistance to therapy), which requires increased attention from the doctor for timely recognition of all components of polytrauma. In the early post-shock period (after stopping the bleeding and stabilizing systemic hemodynamics), the victims have a fairly high probability of developing ARDS, acute disorders of systemic metabolism, coagulopathic complications, fat embolism, liver and kidney failure. Thus, the distinctive feature of the first week is the development of multiple myocardial infarction.

The next stage of traumatic disease is characterized by an increased risk of infectious complications. Various localizations of the process are possible: wound infection, pneumonia, abscesses in the abdominal cavity and retroperitoneal space. Both endogenous and nosocomial microorganisms can act as pathogens. There is a high probability of generalization of the infectious process - the development of sepsis. The high risk of infectious complications in polytrauma is due to secondary immunodeficiency.

During the recovery period (usually protracted), asthenia phenomena predominate, and gradual correction of systemic disorders and functional disturbances in the functioning of internal organs occurs.

The following features of combined trauma are distinguished:

• objective difficulties in diagnosing damage,
• mutual burden,
• a combination of injuries that exclude or complicate the implementation of certain diagnostic and therapeutic measures,
• high frequency of severe complications (shock, acute renal failure, acute renal failure, coma, coagulopathy, fat and thromboembolism, etc.)

A distinction is made between early and late complications of trauma.

Complications of the early period (first 48 hours):

• blood loss, hemodynamic disorders, shock,
• fat embolism,
• coagulopathy,
• disturbance of consciousness,
• OPN,
• breathing disorders,
• deep vein thrombosis and pulmonary embolism,
• hypothermia.

Late complications:

• infectious (including hospital-acquired) and sepsis,
• neurological and trophic disorders,
• PON.

Domestic researchers combine early and late manifestations of polytrauma under the concept of "traumatic disease". Traumatic disease is a pathological process caused by severe mechanical trauma, and the change in the leading factors of pathogenesis determines the natural sequence of periods of the clinical course.

Periods of traumatic disease (Bryusov PG, Nechaev EA, 1996):

• shock and other acute disorders - 12-48 hours,
• MON - 3-7 days,
• infectious complications or a special risk of their occurrence - 2 weeks - 1 month or more,
• delayed convalescence (neurological and trophic disorders) - from several weeks to several months.

Classification of polytrauma

By the distribution of traumatic injuries:

• isolated trauma - the occurrence of an isolated traumatic focus in one anatomical region (segment),
• multiple - more than two traumatic foci in one anatomical region (segment) or within one system,
• combined - the occurrence of more than two traumatic foci (isolated or multiple) in different anatomical areas (segments) or damage to more than two systems or cavities, or cavities and a system,
• combined - the result of the influence of more than two physical factors.

By the severity of traumatic injuries (Rozhinsky M M, 1982):

• non-life-threatening injury - all types of mechanical damage without significant disruption of the body's functioning and immediate danger to the life of the victim,
• life-threatening - anatomical damage to vital organs and regulatory systems that can be eliminated surgically with timely provision of qualified or specialized care,
• fatal - destruction of vital organs and regulatory systems that cannot be eliminated surgically even with timely qualified assistance.

By localization of traumatic injuries: head, neck, chest, abdomen, pelvis, spine, upper and lower limbs, retroperitoneal space.

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Diagnosis of polytrauma

Questioning the patient allows to clarify complaints and the mechanism of injury, which significantly facilitates the diagnostic search and examination. Often, collecting anamnesis is difficult due to impaired consciousness in the victim. Before examining the victim, you should completely undress him. Pay attention to the general appearance of the patient, the color of the skin and mucous membranes, the pulse, the localization of wounds, abrasions, hematomas, the position of the victim (forced, passive, active), which allows you to tentatively identify damage. Using percussion and auscultation methods, examine the chest, palpate the abdomen. Examine the oral cavity, remove mucus, blood, vomit, removable dentures, fix the retracted tongue. When examining the chest, pay attention to the volume of its excursion, determine whether there is a retraction or bulging of parts, air suction into the wound, swelling of the jugular veins. An increase in muffled heart sounds, revealed by auscultation, may be a sign of cardiac damage and tamponade.

To objectively assess the condition of the victim, the severity of injuries and prognosis, the Glasgow Coma Scale, APACHE I, ISS, and TRISS are used.

Most of the activities shown in the figure are carried out simultaneously.

In stable patients, CT of the skull and brain is performed before abdominal examination.

If patients are in an unstable condition (there are focal neurological symptoms, according to ultrasound and peritoneal lavage data - free fluid in the abdominal cavity) infusion therapy is able to maintain safe blood pressure levels, then CT of the head is performed before laparotomy.

Until the neurological status is assessed, it is best not to prescribe sedatives to the victims. If the patient has respiratory disorders and/or impaired consciousness, it is necessary to ensure reliable airway patency and constant monitoring of blood oxygenation.

To select the correct treatment tactics and sequence of surgical interventions, it is necessary to determine the dominant injuries (which currently determine the severity of the victim's condition) as quickly as possible. It is worth noting that over time, different injuries may take the leading place. Treatment of multiple injuries is conventionally divided into three periods: resuscitation, treatment, and rehabilitation.

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Instrumental studies

Urgent research

• peritoneal lavage,
• CT of the skull and brain,
• X-ray (chest, pelvis), if necessary - CT,
• Ultrasound of the abdominal and pleural cavities, kidneys

Depending on the severity of the condition and the list of necessary diagnostic procedures, all victims are conditionally divided into three classes:

1. The first - severe, life-threatening injuries, there are pronounced neurological, respiratory and hemodynamic disorders. Diagnostic procedures: chest X-ray, abdominal ultrasound, echocardiography (if necessary). In parallel, resuscitation and emergency treatment measures are carried out: tracheal intubation and artificial ventilation (in case of severe TBI, respiratory dysfunction), puncture and drainage of the pleural cavity (in case of massive pleural effusion), surgical stopping of bleeding.
2. The second - severe injuries, but against the background of massive infusion therapy, the condition of the victims is relatively stable. Examination of patients is aimed at finding and eliminating potentially life-threatening complications: ultrasound of the abdominal organs, chest X-ray in four positions, angiography (with subsequent embolization of the bleeding source), CT of the brain.
3. The third group are victims in a stable condition. For quick and accurate diagnosis of injuries and determination of further tactics, such patients are recommended to undergo CT of the whole body.

Laboratory research

All necessary laboratory tests are divided into several groups:

Available within 24 hours, results are ready in an hour

• determination of hematocrit and hemoglobin concentration, differential leukocyte count,
• determination of the concentration of glucose, Na+, K chlorides, urea nitrogen and creatinine in the blood,
• determination of hemostasis and coagulation parameters - PTI, prothrombin time or INR, APTT, fibrinogen concentration and platelet count,
• general urine analysis.

Available within 24 hours, the result is ready in 30 minutes, and in patients with severe oxygenation and ventilation disorders they are performed immediately:

• gas analysis of arterial and venous blood (paO2, SaO2, pvO2, SvO2, paO2/ FiO2), acid-base balance indicators

Available daily:

• microbiological determination of the pathogen and its sensitivity to antibiotics,
• determination of biochemical parameters (creatinine phosphokinase, LDH with fractions, serum alpha-amylase, ALT, AST, concentration of bilirubin and its fractions, alkaline phosphatase activity, y-glutamyl transpeptidase, etc.),
• monitoring the concentration of drugs (cardiac glycosides, antibiotics, etc.) in the body's biological fluids (desirable).

When a patient is admitted to hospital, his blood type and Rh factor are determined, and tests for blood-borne infections (HIV, hepatitis, syphilis) are performed.

At certain stages of diagnosis and treatment of victims, it may be useful to study the concentration of myoglobin, free hemoglobin and procalcitonin.

Monitoring

Constant observations

• heart rate and rhythm control,
• pulse oximetry (S 02),
• concentration of CO2 in the exhaled gas mixture (for patients on artificial ventilation),
• invasive measurement of arterial and central venous pressure (if the victim's condition is unstable),
• measuring central temperature,
• invasive measurement of central hemodynamics using various methods (thermodilution, transpulmonary thermodilution - in case of unstable hemodynamics, shock, ARDS).

Regularly performed observations

• blood pressure measurement with a cuff,
• measurement of SV,
• determination of body weight,
• ECG (for patients over 21 years old).

Invasive methods (catheterization of peripheral arteries, right heart) are indicated for victims with unstable hemodynamics (resistant to treatment), pulmonary edema (against the background of infusion therapy), as well as patients requiring arterial oxygenation monitoring. Catheterization of the right heart is also recommended for victims with ALI/ARDS who require respiratory support.

Equipment and facilities for the intensive care unit are needed

• Equipment for providing respiratory support.
• Resuscitation kits (including Ambu bags and face masks of various sizes and shapes) - for transferring patients to mechanical ventilation.
• Endotracheal and tracheostomy tubes of various sizes with low-pressure cuffs and cuffless (for children).
• Equipment for aspiration of contents of the oral cavity and respiratory tract with a set of disposable sanitation catheters.
• Catheters and equipment for providing permanent venous vascular access (central and peripheral).
• Sets for performing thoracentesis, drainage of pleural cavities, tracheostomy.
• Special beds.
• Heart pacemaker (equipment for pacemaker).
• Equipment for warming the victim and controlling the room temperature.
• If necessary, devices for renal replacement therapy and extracorporeal detoxification.

Indications for hospitalization

All victims with suspected polytrauma are hospitalized for examination and treatment in a hospital with specialized care capabilities. It is necessary to adhere to a logical hospitalization strategy that ultimately allows for the fastest possible recovery of the victim with the least number of complications, rather than simply delivering the patient to the nearest medical facility as quickly as possible. The condition of most victims with combined trauma is initially assessed as severe or extremely severe, so they are hospitalized in the intensive care unit. If surgery is necessary, intensive care is used as preoperative preparation, its purpose is to maintain vital functions and minimally sufficiently prepare the patient for surgery. Depending on the nature of the injury, patients need hospitalization or transfer to specialized hospitals - spinal cord injury, burns, microsurgery, poisoning, psychiatric.

Indications for consultation with other specialists

Treatment of victims with severe combined trauma requires the involvement of specialists from different fields. Only by combining the efforts of intensive care physicians, surgeons of various specializations, traumatologists, radiologists, neurologists and other specialists can we hope for a favorable outcome. Successful treatment of such patients requires coordination and continuity in the actions of medical personnel at all stages of care. A prerequisite for obtaining the best results in the treatment of multiple trauma is trained medical and nursing personnel, both at the hospital and pre-hospital stages of care, effective coordination of the hospitalization of the victim in a medical institution where specialized care will be immediately provided. Most patients with multiple trauma require long-term restorative and rehabilitation treatment after the main course with the involvement of doctors of the relevant specialties.

Treatment of multiple trauma

Treatment goals - intensive therapy for victims with combined trauma - a system of therapeutic measures aimed at preventing and correcting disorders of vital functions, ensuring normal responses of the body to injury and achieving stable compensation.

Principles of providing assistance at the initial stages:

• ensuring airway patency and chest tightness (in case of penetrating wounds, open pneumothorax),
• temporary stopping of external bleeding, priority evacuation of victims with signs of ongoing internal bleeding,
• ensuring adequate vascular access and early initiation of infusion therapy,
• anesthesia,
• immobilization of fractures and extensive injuries with transport splints,
• careful transportation of the victim to provide specialized medical care.

General principles of treatment of victims with multiple injuries

• the fastest possible restoration and maintenance of adequate tissue perfusion and gas exchange,
• if general resuscitation measures are required, they are carried out in accordance with the ABC algorithm (Airways, Breath, Circulation - airway patency, artificial respiration and indirect cardiac massage),
• adequate pain relief,
• ensuring hemostasis (including surgical and pharmacological methods), correction of coagulopathies,
• adequate provision of the body's energy and plastic needs,
• monitoring the patient's condition and increased alertness regarding the possible development of complications.

Therapy for circulatory disorders

• Constant monitoring of the victim's condition is necessary.
• Victims often present with hypothermia and vasoconstriction, which can mask and complicate timely recognition of hypovolemia and peripheral circulatory disorders.
• The first stage of hemodynamic support is the introduction of infusion solutions for rapid restoration of adequate perfusion. Isotonic crystalloid and isooncotic colloid solutions have the same clinical efficacy. To maintain hemodynamics (after restoration of the volume status), the introduction of vasoactive and/or cardiotonic drugs is sometimes indicated.
• Monitoring oxygen transport allows us to identify the development of multiple organ dysfunction earlier than its clinical manifestations occur (they are observed 3-7 days after injury).
• If metabolic acidosis increases, it is necessary to check the adequacy of the intensive therapy being administered, exclude hidden bleeding or soft tissue necrosis, acute heart failure and myocardial damage, and acute renal failure.

Correction of respiratory disorders

All victims are prescribed neck immobilization until fractures and instability of the cervical vertebrae are excluded. First of all, neck trauma is excluded in unconscious patients. For this purpose, an X-ray examination is performed, and the victim is examined by a neurologist or neurosurgeon.

If the patient is on artificial ventilation, before stopping it, it is necessary to make sure that hemodynamics are stable, gas exchange parameters are satisfactory, metabolic acidosis has been eliminated, and the victim is adequately warmed. If the patient's condition is unstable, it is advisable to postpone the transition to spontaneous breathing.

If the patient breathes independently, oxygen supply must be provided to maintain adequate arterial oxygenation. Non-depressive but effective anesthesia is used to achieve sufficient depth of breathing, which prevents pulmonary atelectasis and the development of secondary infection.

When predicting long-term mechanical ventilation, the earliest possible formation of a tracheostomy is indicated.

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Transfusion therapy

Adequate oxygen transport is possible with a hemoglobin concentration of more than 70-90 g/l. However, in victims with chronic cardiovascular diseases, severe metabolic acidosis, low CO and partial pressure of oxygen in mixed venous blood, it is necessary to maintain a higher value - 90-100 g/l.

In case of recurrent bleeding or development of coagulopathy, a reserve of red blood cell mass, matched by blood group and Rh factor, is required.

Indications for the use of FFP are massive blood loss (loss of circulating blood volume in 24 hours or half of it in 3 hours) and coagulopathy (thrombin time or APTT more than 1.5 times longer than normal). The recommended initial dose of FFP is 10-15 ml/kg of the patient's body weight.

It is necessary to maintain the platelet count above 50x10 ⁹ /l, and in victims with massive bleeding or severe TBI - above 100x10 ⁹ /l. The initial volume of donor platelets is 4-8 doses or 1 dose of platelet concentrate.

The indication for the use of blood coagulation factor VIII (cryoprecipitate) is a decrease in fibrinogen concentration to less than 1 g/l. Its initial dose is 50 mg/kg.

In intensive care of severe bleeding in closed injuries, the use of factor VII of blood coagulation is recommended. The initial dose of the drug is 200 mcg/kg, then after 1 and 3 hours - 100 mcg/kg.

Anesthesia

Adequate pain relief is necessary to prevent the development of hemodynamic instability and an increase in the respiratory excursion of the chest (especially in patients with chest, abdominal, and spinal injuries).

Local anesthesia (in the absence of contraindications in the form of local infection and coagulopathy), as well as methods of analgesia controlled by the patient, contribute to better pain relief.

Opioids are used in the acute period of injury. NSAIDs are more effective in relieving pain in bone damage. However, they can cause coagulopathy, stress ulcers of the gastric and intestinal mucosa, and renal dysfunction.

When determining indications for pain relief, it is important to remember that the victim’s anxiety and agitation may be caused by reasons other than pain (brain damage, infection, etc.)

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Nutrition

Early administration of nutritional support (immediately after normalization of central hemodynamics and tissue perfusion) leads to a significant reduction in the number of postoperative complications.

You can use total parenteral or enteral nutrition, as well as their combinations. While the victim is in a serious condition, the daily energy value of nutrition is at least 25-30 kcal/kg. The patient should be transferred to total enteral nutrition as soon as possible.

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Infectious complications

The development of infectious complications largely depends on the location of the injury and the nature of the damage (open or closed, whether the wound is contaminated). Surgical treatment, tetanus prophylaxis, antibacterial therapy (from a single prescription to treatment for several weeks) may be required.

Intravenous catheters inserted during emergency and resuscitation procedures (sometimes without observing aseptic conditions) must be replaced.

Patients with multiple injuries have an increased risk of developing secondary infections (in particular, respiratory tract and wound surface infections associated with catheterization of large vessels, the abdominal cavity and retroperitoneal space). For their timely diagnosis, it is necessary to conduct regular (every 3 days) bacteriological studies of the body's environment (blood, urine, tracheobronchial aspirate, discharged from drainage), as well as monitor possible foci of infection.

Peripheral injuries and complications

When a limb is injured, nerves and muscles are often damaged, blood vessels become thrombosed, and blood supply is disrupted, which can ultimately lead to the development of compression syndrome and rhabdomyolysis. Increased vigilance is required in relation to the development of these complications in order to perform corrective surgery as soon as possible if necessary.

To prevent neurological and trophic disorders (bedsores, trophic ulcers), special methods and equipment are used (in particular, special anti-bedsore mattresses and beds that allow for full-fledged kinetic therapy).

Prevention of major complications

To prevent the development of deep vein thrombosis, heparin preparations are prescribed. Their use is especially important after orthopedic operations on the lower extremities, pelvis, and during prolonged immobilization. It should be noted that the administration of small doses of low-molecular heparins is associated with a smaller number of hemorrhagic complications than treatment with unfractionated preparations.

Proton pump inhibitors are the most effective for preventing stress ulcers of the gastrointestinal tract.

Prevention of nosocomial infection

Regular monitoring of the patient's condition is necessary for the timely detection and correction of possible late complications (pancreatitis, non-calculous cholecystitis, PON), which may require repeated laparotomies, ultrasound, and CT.

Drug treatment of polytrauma

Stage of resuscitation measures

If tracheal intubation is performed before central venous catheterization, adrenaline, lidocaine, and atropine can be administered endotracheally, increasing the dose by 2-2.5 times compared to that required for intravenous administration.

To replenish the BCC, it is most appropriate to use saline solutions. The use of glucose solutions without glycemia monitoring is undesirable due to the adverse effect of hyperglycemia on the central nervous system.

During resuscitation, adrenaline is administered starting with a standard dose of 1 mg every 3-5 minutes; if it is ineffective, the dose is increased.

Sodium bicarbonate is administered in cases of hyperkalemia, metabolic acidosis, and prolonged circulatory arrest. However, in the latter case, the drug can only be used with tracheal intubation.

Dobutamine is indicated for patients with low CO and/or low mixed venous oxygen saturation but adequate BP response to infusion load. The drug may cause a decrease in BP and tachyarrhythmia. In patients with signs of organ blood flow impairment, dobutamine administration may improve perfusion parameters by increasing CO. However, routine use of the drug to maintain central hemodynamic parameters at a supranormal level [cardiac index over 4.5 L/(min x m ² )] is not associated with a significant improvement in clinical outcomes.

Dopamine (dopamine) and norepinephrine effectively increase blood pressure. Before using them, it is necessary to ensure adequate replenishment of the circulating blood volume. Dopamine increases cardiac output, but its use is limited in some cases due to the development of tachycardia. Norepinephrine is used as an effective vasopressor drug.

The use of low doses of dopamine to support kidney function is not recommended.

Phenylephrine (mesaton) is an alternative drug for increasing blood pressure, especially in patients prone to tachyarrhythmia.

The use of adrenaline is justified in patients with refractory hypotension. However, its use often causes side effects (for example, it can reduce mesenteric blood flow and provoke the development of persistent hyperglycemia).

To maintain adequate values of mean arterial pressure and cardiac output, simultaneous separate administration of vasopressor (norepinephrine, phenylephrine) and inotropic drugs (dobutamine) is possible.

Non-drug treatment of polytrauma

Indications for emergency tracheal intubation:

• Airway obstruction, including moderate to severe damage to the soft tissues of the face, facial bones, and airway burns.
• Hypoventilation.
• Severe hypoxemia due to O2 inhalation.
• Depression of consciousness (Glasgow Coma Scale less than 8 points).
• Heart failure.
• Severe hemorrhagic shock.

Guidelines for emergency tracheal intubation

• The main method is orotracheal intubation with a direct laryngoscope.
  • If the patient has preserved muscle tone (the lower jaw cannot be moved away), then pharmacological drugs are used to achieve the following goals:
    • neuromuscular blockade,
    • sedation (if necessary),
    • maintaining a safe level of hemodynamics,
    • prevention of intracranial hypertension,
    • prevention of vomiting.

Increasing the safety and effectiveness of the procedure depends on:

• from the doctor's experience,
• pulse oximetry monitoring,
• maintaining the cervical spine in a neutral (horizontal) position,
• pressure on the thyroid cartilage area (Selik's technique),
• CO2 level monitoring.

Conicotomy is indicated if the vocal cords are not visible during laryngoscopy or the oropharynx is filled with a large amount of blood or vomit.

Laryngeal mask airway is an alternative to conicotomy when there is insufficient experience in performing it.

Surgical treatment of polytrauma

The main problem in case of multiple trauma is the choice of the optimal time and scope of surgical interventions.

In patients requiring surgical hemostasis, the interval between the injury and the operation should be as short as possible. Victims in hemorrhagic shock with an established source of bleeding (despite successful initial resuscitation measures) are operated on immediately for definitive surgical hemostasis. Victims in hemorrhagic shock with an unidentified source of bleeding are immediately examined additionally (including ultrasound, CT, and laboratory methods).

Operations performed in cases of multiple trauma are divided into:

• urgent first priority - urgent, aimed at eliminating a direct threat to life,
• urgent second-priority - designed to eliminate the threat of developing life-threatening complications,
• urgent third-priority - ensure the prevention of complications at all stages of traumatic disease and increase the likelihood of a good functional outcome.

At a later date, reconstructive and restorative surgeries and interventions are performed to address complications that have developed.

When treating victims in extremely serious condition, it is recommended to adhere to the "damage control" tactics. The main postulate of this approach is to perform surgical interventions in a minimal volume (short time and least trauma) and only to eliminate the immediate threat to the patient's life (for example, stopping bleeding). In such situations, the operation can be suspended for resuscitation measures, and after correction of gross violations of homeostasis, resumed. The most common indications for the use of the "damage control" tactics:

• the need to speed up the completion of surgery in victims with massive blood loss, coagulopathy and hypothermia,
• sources of bleeding that cannot be eliminated immediately (for example, multiple ruptures of the liver, pancreas with bleeding into the abdominal cavity),
• the inability to suture the surgical wound in the traditional way.

Indications for emergency operations are ongoing external or internal bleeding, mechanical respiratory disorders, damage to vital internal organs, and conditions that require anti-shock measures. After their completion, complex intensive therapy is continued until the main vital parameters are relatively stabilized.

The period of relatively stable condition of the victim after recovery from shock is used to perform urgent surgical interventions of the second stage. The operations are aimed at eliminating the syndrome of mutual aggravation (its development directly depends on the timing of full surgical assistance). Particularly important (if not performed during the first stage operations) is the early elimination of disturbances of the main blood flow in the extremities, stabilization of damage to the musculoskeletal system, elimination of the threat of complications in case of damage to internal organs.

Pelvic bone fractures with disruption of the pelvic ring must be immobilized. Angiographic embolization and surgical arrest, including tamponade, are used for hemostasis.

Hypodynamia is one of the important pathogenetic mechanisms of the mutual aggravation syndrome. For its rapid elimination, surgical immobilization of multiple fractures of the limb bones with lightweight rod devices for extrafocal fixation is used. If the patient's condition allows (there are no complications, such as hemorrhagic shock), then the use of early (in the first 48 hours) surgical repositioning and fixation of bone damage leads to a reliable decrease in the number of complications and reduces the risk of death.

Prognosis of multiple trauma

Among more than 50 classifications proposed for quantitative assessment of the severity of traumatic injuries and disease prognosis, only a few have received widespread use. The main requirements for scoring systems are high prognostic value and ease of use:

• TRISS (Trauma Injury Severity Score), ISS (Injury Severity Score), RTS (Revised Trauma Score) are specially developed to assess the severity of injury and prognosis for life.
• APACHE II (Acute Physiology And Chronic Health Evaluation - a scale for assessing acute and chronic functional changes), SAPS (SimpliFied Acute Physiology Score - a simplified scale for assessing acute functional changes) are used for an objective assessment of the severity of the condition and prognosis of the outcome of the disease of most patients in the intensive care unit (APACHE II is not used to assess the condition of burn victims).
• SOFA (Sequential Organ Failure Assessment) and MODS (Multiple Organ Dysfunction Score) allow for a dynamic assessment of the severity of organ dysfunction, and to evaluate and predict treatment results.
• GCS (Glasgow Coma Score) is used to assess the severity of impaired consciousness and the prognosis of the disease in patients with brain damage.

Currently, the international standard for assessing the condition of victims with multiple injuries is considered to be the TRISS system, which takes into account the patient’s age and the mechanism of the injury (it consists of the ISS and RTS scales).

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