Damage control in traumatology. Damage control - the concept of modern treatment of long bones in patients with polytrauma
«© V.A. Sokolov, 2005 “DAMAGE CONTROL” – MODERN CONCEPT OF TREATMENT OF PATIENTS WITH CRITICAL POLYTRAUMA V.A. Sokolov Moscow Research Institute...»
© V.A. Sokolov, 2005
“DAMAGE CONTROL” – MODERN
THE CONCEPT OF TREATMENT OF VICTIMS WITH
CRITICAL POLYTRAUMA
V.A. Sokolov
Moscow Research Institute of Emergency Medicine
them. N.V. Sklifosovsky
Improving care for victims with polytrauma is one of the most
actual tasks of modern traumatology, since polytraumas are the main cause of death among young and middle-aged people and contribute to the depopulation of the Russian population.
The second half of the 20th century was a period of significant progress in the treatment of severe injuries, primarily in the developed countries of the West. The number of cases of polytrauma with a fatal outcome decreased by 2 times or more, the number of cases of permanent disability decreased by the same amount, and the duration of treatment was reduced by 4 times.
In the early 80s, the concept of the nearest (immediate) total assistance (early total car - ETC) was proposed, which assumed surgery all injuries - both abdominal and orthopedic, in the first 24 hours.
This concept was applied universally in all groups of victims, regardless of the severity and extent of injuries. The success was facilitated by the development of new methods of osteosynthesis - initially stable according to the principles of AO-ASIF, and then minimally invasive lockable osteosynthesis of long bones.
After osteosynthesis, patients became mobile, pain impulses from the fracture zone stopped, and bleeding stopped. There was also an economic effect, since the treatment time was reduced several times.
However, in the late 1980s, it became clear that ETC is not a universal system and is effective only in patients who do not have critical injuries (although they make up the majority). Lengthy surgical procedures early period nolitraumas were fatal, especially with significant thoracic, abdominal and craniocerebral injuries.
The death of the victims occurred both in the first hours after the injury during these operations and on the 5-7th day - from the developed severe complications: adult respiratory distress syndrome, multiple organ failure, pneumonia, sepsis.
In order to improve the outcomes of the treatment of the most severe polytraumas, the Hannover School of Polytrauma in 1990 proposed a system of so-called "damage control" (damage control), according to which the surgical treatment of injuries to both internal organs and the musculoskeletal system is divided into two stages: in the first a day, minimal life-saving short operations such as decompressive trifination or mini-trepanation of the skull are performed for epi- and subdural hematomas, laparotomy with Bulletin of Traumatology and Orthopedics. N.N. Priorov. 2005, No. 1, pp. 81-84 by applying clamps to the spleen pedicle and tamponade of liver rupture, puncture epicystomy, etc., and fractures of large bones, primarily the thigh, are immobilized with external fixation devices. Then the victim is given intensive therapy until hemodynamic and other indicators of homeostasis are completely stabilized, and after 1-2 days, recovery operations on the internal organs, and after 5-7 days and later - minimally invasive osteosynthesis of fractures of long bones. This tactic significantly improved the outcomes of severe polytrauma and allowed to save the life and health of the victims, who were previously considered hopeless. Separate “damage control” protocols for abdominal, thoracic, craniocerebral, spinal and orthopedic injuries have been identified, which have received appropriate abbreviations - for example, DCS (damage control surgery - “damage control”
abdominal and thoracic cavity), DCO (damage control orthopedics - “damage control” of the musculoskeletal system).
The term "damage control" is still little known to most domestic traumatologists, and there are still recommendations to operate on patients with polytrauma by two or three teams of surgeons, to perform amputations with low blood pressure, to perform open osteosynthesis of the femur in case of extremely severe brain injury, etc. It is misleading to think that surgical interventions are anti-shock measures, despite the additional trauma inflicted. In fact, any operation is aggression and, to one degree or another, worsens the patient's condition. In a bleeding patient with polytrauma, even a small surgical blood loss can be fatal.
According to the assessment of the severity of injuries according to AIS (Abbreviated Injury Scale), currently accepted in most countries, those injuries that give a lethality of 25% or more are considered critical. These include, for example, intracranial hematomas greater than 80 cm3, bilateral large hemothorax, multiple ruptures of the liver with hemoperitoneum greater than 1500 ml, multiple unstable pelvic fractures with joint ruptures, and similar lesions in each of the six anatomical regions (structures) human body. These injuries correspond to an AIS score of 5. The same situation develops if the victim has two or more injuries at the same time with an AIS score of 4, i.e. life-threatening injuries.
The basis for the introduction of the "damage control" system was immunological studies conducted in patients with polytrauma in the 80-90s of the XX century. According to the results of these studies, damage, i. destruction of tissues, causes a local inflammatory response (MIR) with an increase in the total concentration of pro-inflammatory cytokines. The level of cytokines correlates with the degree of damage to soft tissues and bones. MVO activates polymorphonuclear leukocytes, which attach to capillary endothelial cells and stimulate the release of free oxygen radicals and proteases, resulting in damage to the vessel wall, leading to interstitial edema. All these processes are known abroad as multiple organ dysfunction syndrome (MODS), and in our country as disseminated intravascular coagulation syndrome (DIC), deeply developed by Acad. A.P. Vorobyov and his school. The release of pro-inflammatory cytokines and products of damaged cells forms the system. N.N. Priorov. 2005, No. 1, pp. 81-84 nye inflammatory changes, which is facilitated by the presence of ischemic patients. dead and infected tissues. This explains the high frequency of infectious complications (primarily pneumonia) in patients with full trauma and specific complications such as adult respiratory distress syndrome, early multiple organ failure, etc.
In order to apply "damage control" in practice, three factors must be carefully evaluated:
1) the severity of the initial injury ("first blow" - the first hit);
2) the biological constitution of the patient (age, body weight, concomitant diseases);
3) the number of necessary trauma operations, their expected duration and trauma (blood loss). These operations are the "second blow" (second hit) for the seriously injured.
The deep mechanisms of the fatal action of the "second blow" are not fully understood, but it is clear that they are characterized by systemic inflammation in combination with microvascular damage, increasing interstitial edema, primarily of the lungs, and multiple organ failure. This can explain the cases when in severely injured patients who underwent several operations, the blood loss was formally replenished by transfusion of donor blood, the acid-base and electrolyte balance was restored, however, severe complications with a fatal outcome develop after 1-2 days.
With advances in laboratory technology, it is becoming possible to quantify the inflammatory response to trauma and operative procedures. Markers of inflammation are cytokines (interleukins). The most reliable marker was interleukin-6, which can be used to predict the development of DIC.
The concept of "damage control" in orthopedics is used only for fractures of the femur, pelvis with damage to the anterior and posterior half-ring, multiple fractures of long bones lower extremities, detachments of the thigh, lower leg. Great importance It has something with damage to which areas the injury of the musculoskeletal system is combined. Most of all, the outcome of injury and the development of complications are affected by closed injury chest and traumatic brain injury.
Severe closed chest trauma is always accompanied by damage to the lung parenchyma, which can not be detected by x-ray in all cases. Fractures of the femur and lower leg are accompanied by fat embolism of the pulmonary circulation, which exacerbates pulmonary disorders. Boss et al. showed that intraosseous osteosynthesis of the femur with reaming of the medullary canal, performed on the first day after injury, sharply enhances fat embolization, so adult respiratory distress syndrome and pneumonia develop in such victims more often than in non-operated patients.
If a patient, along with fractures of the femur and tibia, has a severe craniocerebral injury, then with early osteosynthesis, cerebral perfusion decreases and an additional stroke of the damaged brain is possible. This can explain the cases when a patient after hip osteosynthesis cannot be transferred to spontaneous breathing, whereas before the operation he was breathing on his own.
Bulletin of Traumatology and Orthopedics. N.N. Priorov. 2005, No. 1, pp. 81-84 For effective application"damage control" it is necessary to determine the appropriate group of victims.
Clinical experience suggests that it is advisable to adhere to the tactics of controlling the severity of damage in the following so-called "borderline" cases:
Polytrauma with ISS20 in the presence of thoracic injury with AIS2. An ISS score (Injury Severity Score) is obtained by summing the AIS scores of the three most severely damaged areas squared. For example: combined trauma of the chest - fracture of the V-IX ribs on the right with damage to the lung tissue, pneumothorax and pneumomediastinum (AIS=4);
closed supracondylar fracture of the right femur (AIS=3); closed fracture of the diaphysis of the left femur (AIS=3); closed fracture of the neck of the left shoulder (AIS=2). ISS = 42 + Z2 + Z2 = 34 points.
Polytrauma in the presence of organ damage abdominal cavity or pelvis (AIS3) and shock with BP90 mm Hg. Art. For example: closed fractures of the ischial bones on both sides, rupture of the sacroiliac joint on the left with displacement of half of the pelvis upwards (AIS=4); open fracture of the right shoulder (AIS=3);
closed fracture of the right ulna (AIS=2); shock II degree. ISS = 42 + Z2 = 25 points.
Polytrauma with ISS40 without thoracic injury. For example: brain injury medium degree severity, epidural hematoma 40 cm3 (AIS=4); closed abdominal trauma, rupture of the spleen (AIS=4); rupture of the sacroiliac joint, fracture of the pubic bone (AIS=3); closed fracture of the diaphysis of the left femur (AIS=3);
open fracture of both bones of the left leg (AIS=3). ISS = 42 + 42 + Z2 = 41 points.
Bilateral pulmonary contusion according to X-ray examination.
In addition, to identify patients for whom immediate full surgical intervention (ETC) is not a viable option. the best choice the following may help clinical options:
Difficulties in resuscitation and stabilization of the condition of the victims, when the period of unstable hemodynamics lasts more than 2 hours;
Coagulopathy with thrombocytopenia below 90x109l;
Hypothermia (T32°C);
Traumatic brain injury with a Glasgow coma score of less than 8 points or intracerebral hematoma;
The expected duration of operations is more than 6 hours;
Damage to the main artery and hemodynamic instability;
Systemic inflammatory response (interleukin-6 more than 80 pg/mm::).
The specific actions of the traumatologist when applying the “damage control” tactics are as follows. When a seriously injured person is admitted, priority is still given to operations on the internal organs of the abdomen, small pelvis, chest, and brain.
However, the execution of these operations is also divided into two and, in exceptional cases, three phases. In the first phase, with minimal stabilization of the victim's condition ( arterial pressure at the level of 90 mm Hg. Art., pulse 120 per minute) perform drainage of the pleural cavity to eliminate pneumo- or hemothorax, then laparotomy with clamping of bleeding vessels (pedicles of the spleen, kidneys) with temporary clamps (clips), ruptures of the liver are plugged, the damaged intestine is removed and Bulletin of Traumatology and Orthopedics named after . N.N. Priorov. 2005, No. 1, pp. 81-84 is isolated from the free abdominal cavity. In the wound, only the skin is sutured with a continuous suture. After that, resuscitation continues. If it is possible to stabilize the patient's condition, after 24-36 hours he is again taken to the operating room, the laparotomic wound is opened and the second phase is performed. surgical treatment- splenectomy, suturing of wounds of the liver, intestinal wounds with complete suturing of the laparotomic wound.
Damage to the musculoskeletal system in the first phase is fixed with plaster splints, fractures of the femur and lower leg - with rod external fixation devices.
Wounds and open fractures in extremely serious patients are not subjected to surgical treatment, but are only washed with antiseptics, visible foreign bodies, the edges are chipped with antibiotics and covered with bandages with antiseptics. In case of traumatic detachments of the limbs, clamps are applied to main vessels, treat wounds with hydrogen peroxide and antiseptics, chip with antibiotics and apply bandages with antiseptics. After that, intensive therapy is continued.
Surgical treatment of open fractures, amputations are also performed 24 hours after the second phase of operations for abdominal injuries, taking a break between these operations for 2-3 hours, especially if a pressure drop was noted during laparotomy. Carrying out any simultaneous operations by two or three teams of surgeons is excluded.
Submerged osteosynthesis for closed fractures is postponed on the 6-8th day, but minimally invasive intramedullary osteosynthesis of the femur and lower leg is allowed on the 3rd day in order to facilitate the care of the victim and give him greater mobility.
Rare et al. proposed a relatively simple scheme that reflects the algorithm for the treatment of fractures of long bones in patients with polytrauma (see below).
The use of such a flexible approach to the treatment of "large fractures" in patients with polytrauma has significantly reduced the incidence of general complications. Thus, the frequency of adult respiratory distress syndrome decreased from 40 to 15-20%, pneumonia and sepsis - more than 2 times. Accordingly, the mortality rate also decreased.
It should be said that "control of orthopedic injuries" is not a fundamentally new provision. Individual approach for the treatment of victims by domestic scientists has been promoted over the past 15-20 years. A great contribution to the development of this problem was made by specialists from the St. I.I. Dzhanelidze (Yu.N. Tsybin, Yu.B. Shapot, M.V. Grinev, S.F. Bagnenko) and the Department of Military Field Surgery of the Military Medical Academy (I.A. Eryukhin, E.K. Gumanenko), who created various therapeutic and tactical schemes for providing assistance to victims with combined trauma, depending on the severity of their condition. Similar developments have been underway since 1975 at the Moscow Research Institute of Emergency Medicine named after. N.V. Sklifosovsky (V.P. Okhotsky, L.G. Klopov, V.A. Sokolov, E.I. Byalik). The merit of the representatives of the Hannover school of polytrauma, who put forward the concept of “damage control” in 1990, is that they substantiated this tactic based not only on clinical experience, but also on a deep study of changes in immune system, biochemical changes, morphological changes in the lungs, which made it possible to objectify the choice of treatment tactics depending on various combinations of injuries and the severity of the patient's condition.
Bulletin of Traumatology and Orthopedics. N.N. Priorov. 2005, No. 1, pp. 81-84
– – –
CONCLUSIONS 1. "Damage control" is a tactic for the treatment of life-threatening and critical polytraumas, according to which, depending on the severity of the victim's condition, assessed by objective indicators, only those methods are used in the early period that do not cause a serious deterioration in the patient's condition.
2. “Orthopedic damage control” is subject to victims with a total severity of injury according to ISS more than 20 points in the presence of serious injuries of the chest, skull, abdominal organs and retroperitoneal space.
3. "Damage control" in traumatology of the musculoskeletal system consists of two phases. In the first phase, within 24 hours from the moment of injury, the victims in critical condition are given a minimum of traumatological benefits (secondarily after operations on the brain and internal organs of the abdomen) with immobilization of fractures with plaster casts and external fixation devices, after which intensive therapy. Internal osteosynthesis is performed on the 6-8th day after the injury with complete stabilization of the patient's condition (second phase).
4. In extremely severe patients at an early stage, operations by two or three teams of surgeons are excluded; if during even a minimal operation the patient's condition worsens, a break is made between operations to continue intensive care.
L I T E RAT U RA
1. Gumanenko E.K. Objective assessment of the severity of the injury. - St. Petersburg, 1999-109 p.
2. Eryuhin I.A., Shlyapnikov S.A. Extreme states of the body. - St. Petersburg, 1999. - 109 p.
3. Okhotsky V.P., Lebedev V.V., Klopov L.G. Tactics of treatment of fractures of extremities in Bulletin of Traumatology and Orthopedics im. N.N. Priorov. 2005, No. 1, pp. 81-84 in patients with traumatic brain injury. In book. Proceedings of the III All-Union Congress of Traumatologists and Orthopedists. M. 1976 p. 42-45.
4. Sokolov V.A., Bialik E.I. Tactics of surgical treatment of fractures of long bones of extremities in the early period of concomitant trauma. Guidelines. M. 2000. 17 pages.
5. Tsibin Yu.N. Multivariate assessment of severity traumatic shock. J. Bulletin of Surgery. 1980, no. 9, p. 62-67.
6. Shapot Yu.B., Seleznev S.A., Remizov V.B. and others. Multiple and associated trauma, accompanied by shock. Chisinau, 1993, p. 240.
7. Boss M., Mac-Kenzie E., Riemer A. et all. ARDS, pneumonia, and morfality following thoracic injury anl a femoral fracture treated either with in tramedullary nai ling with reaming or with a plate. J.Bone Joint Surg.Am. 1997, 79-A; 799-809.
8. Eppiheimer M.J., Granger D.N. Ischemia/reperfusion-induced leukocyte-endothelal interctions in post capillary venules. Shock. 1997; 8:16-26.
9. Greene R. Lung alterations in thoracic trauma. J Thorac Imag 1987; 2:1-8.
10. Guerrero-Lopez F, Vazguez-Mata G, Alcazar PP, Fernandez-Mondejar E, Aguayo-Hoyas E, Linde-Valverde LM. Evaluation of the utility of computed tomography in the initial assessment of the critical care patent with chest trauma. Crit Care Med 2000; 28:1370-5.
11. Hauser CJ, Zhou X, Joshi P, Cuchens MA, Kregor P, Devidas M, et al. The immune microenvironment of humman fracture /soft-tissue hematomas and its relationship to systemic immunity. J Trauma 1997; 42:895-903.
12. Mclntyre TM, Modur V, Prescott SM, Zimmermann GA. Molecular mechanisms of early inflammation. Throm Haemost 1997; 77:302-9.
13. Pape HC, van Griensven M, Rice J, et all. Major secondary surgery in blunt trauma patients and perioperativ cytokine liberation: determination of the clinical relevance of biochemical markers. J Trauma 2001; 50:989-1000.
14. Perl M, Gebhard F, Knoferl MW, Bachn M, Gross HJ, Kinzl L, et all. The pattern of preformed cytokines in tissue frequently affected by blunt trauma. Shock 2003; 19: 299Rotondo MF, Schwab CW, MC gonigal et all. “Damade contol” an approach for improved survival in exsanguinafing penetrafing abdominal injuries. J Trauma. 1993; 35:375-382.
16. Przkova R, Bosch U, Zelle et all. Damage control orthopedics: a case Report. J of Trauma 2002: 53, no. 4, 765-769.
17. Scalea TM, Boswekk SA, Scott ID et all. External fixation as a bridge to intramedullary
nailing for patients with multiple injuries: damage control orthopedics. J Trauma, 2000; 48:
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Discussion Practical application of the “damage control” concept in the treatment of long bone fractures in patients with polytrauma
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DAMAGE CONTROL SURGERY
"Modern surgery is safe for the patient. The modern surgeon must make the patient safe for modern surgery." - Lord Moynihan
INTRODUCTION Surgical tactics
Standard surgical approach: Resuscitation - Operation - Death
Damage control: Resuscitation - Operation - IT - Operation - IT
The central principle of tactics
If metabolic failure is already established, it is extremely difficult to stop bleeding and correct disorders. In order for the patient to survive, it is necessary to plan the operation so that the patient can be transferred to the ICU, where he can be warmed and corrected for hypothermia and acidosis. Only after this correction can the necessary definitive surgery be performed, i. e.<этапная операция>.
STAGE LAPAROTOMY.
Principles of the first operation
Surgery
Three disorders - hypothermia, acidosis and coagulopathy - develop rapidly in a patient with massive traumatic blood loss and create a vicious circle that is sometimes impossible to break. 1. HYPOTHERMIA
Most patients with massive trauma present with hypothermia on admission to the intensive care unit due to weather conditions at the scene. Inadequate protection, intravenous fluid therapy, and continued blood loss worsen hypothermia. Hemorrhagic shock leads to decreased cellular perfusion and oxygenation, and to inadequate heat production. Hypothermia has impressive systemic effects on bodily functions, but most importantly in our context, it enhances coagulopathy and acts on the mechanisms of hemostasis.
Uncorrected hemorrhagic shock results in inadequate cell perfusion, anaerobic metabolism, and lactic acid production. This leads to a profound metabolic acidosis which affects the coagulation mechanisms and increases coagulopathy and blood loss. 3. COAGULOPATHY
Hypothermia, acidosis and the consequences of massive blood transfusion lead to the development of coagulopathy. Even if mechanical control of bleeding is achieved, the patient may continue to bleed from all incision surfaces. This leads to increased hemorrhagic shock, deepening hypothermia and acidosis, reinforcing the vicious circle.
Some studies have attempted to determine<пороговые
уровни>parameters to switch to the "damage control" operation. Criteria such as pH are mentioned<7.2, температура
<ядра>less than 32C, transfusion to the patient of a volume exceeding the BCC. However, once these levels are reached, it is already too late. The trauma surgeon must decide on the transition to tactics
So, the principles of the primary operation
1. Stop bleeding
2. Prevention of infection
3. Protection from further damage
PREPARATION. The time of delivery of such patients to the hospital and stay in the intensive care unit should be minimal. All unnecessary and redundant studies that do not immediately change the patient's treatment tactics should be postponed. Cyclic fluid therapy before surgery is useless and only aggravates hypothermia and coagulopathy. Colloidal solutions also affect the quality of the blood clot. The patient should be quickly taken to the operating room without attempts to restore the BCC. Requires surgical arrest of bleeding and simultaneous vigorous therapy with blood and clotting factors. Anesthesia induction is performed on the operating table while the patient is being treated and dressed and the surgeons are washing. A patient in shock usually requires minimal analgesia and a gentle, hemodynamically neutral method of induction should be used. The use of arterial catheterization for intraoperative monitoring is valuable, and a small diameter venous central catheter is of little benefit. Blood, fresh frozen plasma, cryoprecipitate, and platelets should be available, but clotting factors should be given rapidly only after bleeding has stopped. All solutions should be warm, the patient should be lined and, if possible, intensively heated. GENERAL QUESTIONS AND PHILOSOPHY.
The patient is quickly swabbed from neck to knees with large swabs moistened with an antiseptic skin solution. The incision should be from the xiphoid process to the pubis. This incision may require expansion to either the right side of the chest or a median sternotomy, depending on the injury. Decrease in intra-abdominal pressure due to paralysis of the muscles and opening of the abdominal cavity can lead to severe bleeding and hypotension. The bleeding needs to be stopped immediately. Initially, 4 quadrants are tamponed with large tampons. Aortic clamping may be necessary at this stage. It is usually best performed at the level of the aortic orifice of the diaphragm by blunt digital dissection, finger pressure by an assistant, followed by clamping (dc1). It is sometimes difficult to locate the aorta in severe hypovolaemia, and direct visualization may be required after division of the right crus of the diaphragm. Some surgeons prefer to perform a left anterolateral thoracotomy to clamp the descending thoracic aorta into the pleural space. However, this requires opening a second body cavity, is accompanied by additional heat loss, and is rarely necessary. The next step is to find the main source of bleeding. A thorough revision of the 4 quadrants of the abdomen is performed. A moment of silence can help to hear the bleeding. Emergency stop of bleeding is performed by direct blunt pressure using the surgeon's hand, tupfer or tampon. The technique of proximal and distal control is rarely used in urgent conditions. Bleeding from the liver, spleen, or kidneys can usually be stopped with several large swabs. Examination of the abdomen must be complete. It includes, if necessary, mobilization of the retroperitoneal structures using some rotation of the internal organs (Fig. dc2 - right medial rotation, dc3 - left medial rotation according to Mattox). All intra-abdominal and most retroperitoneal hematomas require exploration and evacuation. Even a small paracolic or parapancreatic hematoma may mask a vascular or intestinal injury. Revision should be performed whether the hematoma is pulsating, enlarged or not, due to blunt trauma or injury. Non-growing perirenal and retrohepatic hematomas, as well as pelvic hematomas with blunt trauma, should not be revised and can be packed. Occasionally, simultaneous angiographic embolization may be required. Prevention of infection is achieved by rapid suturing of damage to hollow organs. This may be the definitive intervention when there are only a few small bowel wounds requiring primary closure. More complex interventions such as resection with primary anastomosis should be deferred and the ends of the bowel stapled, sutured or tied (dc4). End evaluation and anastomosis are performed in the second operation.
CLOSURE OF THE STOMACH.
Rapid temporary closure of the abdomen is performed. If possible, only the skin is sutured with a fast continuous suture or even clipping. Abdominal compartment syndrome is common in these patients, and if in doubt, the abdomen should be left open, as in laparostomy.
FEATURES IN DAMAGE TO INTERNAL ORGANS.
LIVER. Main
SPLEEN. For large lesions of the spleen, splenectomy is the treatment of choice, except for minor lesions that can be sutured. Attempts to preserve the spleen are usually time consuming and prone to failure, so recommend them when
VESSELS OF THE ABDOMINAL CAVITY.
Access to the abdominal aorta is best achieved by a complete medial left rotation of the viscera according to Mattox (Figure dc5). The left half of the colon, spleen, and kidney are mobilized and rotated medially to expose the entire length of the abdominal aorta. In the hands of an experienced vascular surgeon, the aorta should be quickly sutured or replaced with PTFE. However, as a last resort, or when there is no such experience, intravascular shunting may be considered. For the abdominal aorta, a large piece of pleural drainage is used. Shunts can also be used for trauma to the iliac vessels, superior mesenteric artery. Injuries to the inferior vena cava in accessible areas are sutured; in case of injury in the retrohepatic space, tamponing is performed. Temporary stoppage of bleeding is best done by direct pressure with tupfery above and below the injury. All other venous injuries under conditions
After the bleeding has stopped, attention shifts to the prevention of subsequent infection by stopping the flow of intestinal contents. Small wounds of the stomach and onkoy intestine can be quickly sutured with a single-row continuous suture. With extensive damage, bowel resection with primary anastomosis is required. This may take time, and the integrity of the anastomosis is compromised by generalized hypoperfusion. In addition, it is often difficult to determine the resection margins under these conditions. In this case, especially in case of trauma to the colon or multiple wounds of the small intestine, it is wiser to resect the non-viable bowel and close the ends, leaving them in the abdomen for anastomosis during the second operation. This uses a linear stapler or a continuous suture, or even an umbilical cord. Ileostomies and colostomies should not be performed in tactic
PANCREAS.
Trauma to the pancreas rarely requires or allows for definitive intervention under conditions
INTENSIVE THERAPY.
The meaning of the intensive care phase is the rapid and complete correction of metabolic disorders. Operation
Massive bowel edema is often observed after laparotomy for massive trauma, especially when there has been prolonged shock. This tissue edema is caused by the use of crystalloids, capillary disturbances due to the activation of inflammatory mediators, and reperfusion injury. When combined with abdominal packing or retroperitoneal hematoma, it may be difficult or impossible to close the abdomen. If the abdomen is closed, then intra-abdominal pressure can exceed 25 cm of water, which leads to significant cardiovascular, respiratory, renal and cerebral disorders.
CARDIOVASCULAR DISORDERS
An increase in IAP leads to a decrease in cardiac output, mainly due to compression of the inferior vena cava and a decrease in venous return to the heart. Cardiac output is reduced despite an apparent increase in CVP, pulmonary artery wedge pressure, and systemic vascular resistance. This distortion of standard monitoring measures makes adequate intensive care difficult.
RESPIRATORY DISORDERS.
An increase in IAP effectively fixes the diaphragm, which leads to an increase in peak airway pressure and intrapleural pressure, which also reduces venous return to the heart. An increase in airway pressure can also provoke barotrauma and lead to the development of acute ARDS.
KIDNEY DISORDERS
An acute increase in IAP leads to oliguria and anuria, probably due to compression of the renal vein and renal parenchyma. Renal blood flow, glomerular filtration decrease, and renal vascular resistance increases.
CEREBRAL DISORDERS.
An increase in IAP and intrathoracic pressure leads to an increase in CVP, which interferes with adequate venous outflow from the brain, leads to an increase in ICP and increased cerebral edema. DIAGNOSIS OF AKS
ACS should be suspected and sought in every patient with multiple trauma who has experienced a period of deep shock. Clinically, ACS is characterized by a decrease in diuresis in combination with an increase in CVP. The diagnosis is confirmed by measurement of IAP. This is done with either a Foley catheter in the bladder or a nasogastric tube in the stomach. Simple water column manometry is used at intervals of 2-4 hours, although it is possible to connect a pressure transducer to a catheter. Normal IAP is 0 or subatmospheric. Pressure above 25 cm of water. suspicious, and above 30 cm of water. speaks unambiguously about the AKC.
TREATMENT OF AKS.
It is better to prevent the development of ACS and use an alternative technique for closing the abdomen. If the abdomen is difficult to close, an alternative technique must be used. A good rule of thumb is that if the abdomen is viewed horizontally and the intestines are visible above the level of the wound, the abdomen should always be left open and a temporary closure used. The simplest method of an open belly is a closure
REPEAT OPERATION.
The principles of reoperation are removal of swabs and blood clots, complete revision of the abdomen to detect missed lesions, hemostasis, restoration of intestinal continuity, and closure of the abdomen. The timing of the operation is decisive. There is usually a convenient<окно>between the correction of metabolic failure and the onset of systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF). This window is usually observed within 24-48 hours after the first operation. A choice must be made between early reoperation, when the patient may be less stable and bowel wall edema still present, and late reoperation, when cardiovascular, respiratory, and renal failure makes the operation risky. Vascular grafts should be removed and replaced as soon as possible, as they may become displaced or thrombose when the coagulopathy is corrected. If tampons have been left in the abdomen, it is usually recommended to remove them within 48-72 hours, although there is no evidence that leaving them longer is harmful. Tampons, especially those from the liver and spleen, must be removed carefully, as they can stick to the parenchyma and removal can lead to bleeding. Wetting tampons can help with this. Bleeding, however, is rarely severe and is stopped with argon diathermy or fibrin glue. Rarely is it necessary to refill. All bowel closures performed at the first operation should be checked to determine their validity. The ends of the intestine that have been stapled or tied are examined, resected if necessary, and a primary end-to-end anastomosis is placed. In a hemodynamically stable patient without hypothermia, a colostomy is rarely necessary. Abundant washing of the abdominal cavity is carried out and the abdomen is closed by standard suturing through all layers, the skin is sutured. If the aponeurosis cannot be mapped, use
LITERATURE. 1 Rotondo MF, Schwab CW, McGonigal MD et al. Damage Control - an approach for improved survival in exsanguinating penetrating abdminal injury J Trauma 1993;35:375-382 2. Hirshberg A, Mattox KL. Planned reoperation for severe trauma Ann Surg1995;222:3-8 3. Moore EE. Staged laparotomy for the hypothermia, acidosis andcoagulopathy syndrome Am J Surg 1996;172:405-410 4. Cue JI, Cryer HG, Miller FB et al. Packing and planned reexploration for hepatic and retroperitoneal hemorrhage - critical refinements of a useful technique J Trauma 1990;30:1007-1013
5. Carvillo C, Fogler RJ, Shafton GW. "Delayed gastrointestinal reconstruction following massive abdominal trauma" J Trauma 1993;34:233-235 6. Richardson JD; BergaminiTM; Spain DA et al. "Operative strategies formanagement of abdominal aortic gunshot wounds" Surgery 1996; 120:667-671 7. Reilly PM, Rotondo MF, Carpenter JP et al. "Temporary vascular continuity during damage control - intraluminal shunting for proximal superior mesenteric artery injury" J Trauma 1995;39:757-760
8. Velmahos GC; Baker C; Demetriades D et al. "Lung-sparing surgery after penetrating trauma using tractotomy, partial lobectomy, and pneumonorrhaphy" Arch Surg 1999;134:86-9
9. Wall MJ Jr; Villavicencio RT; Miller CC et al. "Pulmonary tractotomy as an abbreviated thoracotomy technique" J Trauma 1998;45:1015-23 10. Schein M, Wittman DH, Aprahamian CC, Condon RE. The abdominal compartment syndrome - the physiological and clinical consequences of raised intra-abdominal pressure J Am Coll Surg 1995;180:745-753
11. Morris JA, Eddy VA, Blinman TA. "The staged celiotomy for trauma -issues in unpacking and reconstruction" Ann Surg 1993;217:576-586
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Improving care for polytrauma is one of the most pressing issues of modern traumatology, since they are the main cause of death among young and middle-aged people and contribute to the depopulation of the Russian population.
The second half of the 20th century was a period of significant progress in the treatment of severe injuries, primarily in the developed countries of the West.The number of deaths from polytrauma decreased by 2 timesand more with the same reduction in the number of persistent disabled; the treatment time was reduced by 4 times.
In the early 1980s, the concept of early total care (ETC) was proposed, which meant surgical treatment of all injuries, both abdominal and orthopedic, in the first 24 hours. It was used universally in all patients regardless of the severity and extent of the injury. The success was facilitated by the development of new methods of osteosynthesis - initially stable osteosynthesis according to the AO-ASIF principles, and then minimally invasive lockable osteosynthesis of long bones. After osteosynthesis, patients became mobile, pain impulses from the fracture zone stopped, and bleeding stopped. There was an economic effect, since the treatment time was reduced several times.
However, in the late 1980s, it became clear that ETC is not universal and is effective only in patients who do not have critical injuries, although they make up the majority. Long-term surgical procedures in the early period of polytrauma led to death, especially in patients with significant thoracic, abdominal and craniocerebral injuries. The death of patients occurred both in the first hours after the injury during these operations, and on the 5-7th day from the developed severe complications - adult respiratory distress syndrome, multiple organ failure, pneumonia, sepsis.
To improve the outcomes of the most severe polytraumas, the Hannover School in 1990 proposed the so-calleddamage control (damage control), according to which the surgical treatment of injuries of both internal organs and the musculoskeletal system was divided into 2 stages: on the 1st day, minimal life-saving short operations such as decompression trifination or mini craniotomy for epi- and subdural hematomas, laparotomy with clamps on the spleen pedicle were performed and tamponade of liver rupture, puncture epicystomy, etc., and fractures of large bones, especially the hip, were immobilized with external fixation devices. The patient then underwent intensive therapy until hemodynamic and other indicators of homeostasis were completely stabilized, and after 1–2 days, reconstructive operations on internal organs were performed, and after 5–7 days, minimally invasive osteosynthesis of fractures of long bones was performed. This tactic significantly improved the outcomes of severe polytrauma and allowed to save the life and health of previously hopeless victims with a poor prognosis. Separate injury control protocols for abdominal, thoracic, craniocerebral, spinal, and orthopedic injuries have been identified with appropriate abbreviation. For example, DCA stands for damage control abdomen, i.e. damage control of the abdominal cavity, DCO - damage control orthopedics, i.e. ODA damage control.
The term “damage control” is still little known to most domestic traumatologists, and there are still recommendations to operate on patients with polytrauma by the 2nd and 3rd teams, perform amputations at low blood pressure, perform open osteosynthesis of the femur in case of extremely severe brain injury, etc. It is a delusion to consider the opinion that surgical interventions are anti-shock measures, despite the additional trauma caused. In fact, any operation is aggression and, to one degree or another, worsens the patient's condition.
In a bleeding patient with polytrauma, even a small surgical blood loss can be fatal.
According to the AIS injury severity score, which is now generally accepted in most countries, injuries are considered to be critical injuries, more than 25% of which end in death. These include intracranial hematomas with a volume of 80 cm3, bilateral large hemothorax, multiple ruptures of the liver with a hemoperitoneum of more than 1500 ml, multiple unstable pelvic fractures with joint ruptures, and similar lesions in each of the 7 anatomical regions of the human body. These injuries correspond to a score of 5 according to AIS. The same situation arises if the patient has 2 or more lesions at the same time with an AIS score of 4, i.e. life-threatening damage.
The basis for the introduction of the "damage control" system was immunological studies of victims with polytrauma, conducted in the 80-90s of the XX century (Dehuven K., Evarts V., 1971; Copeland C. et al, 1998; Nast-Kolb D., 1997; Arazi M. et al., 2001; Henry S. et al., 2002). According to these studies, damage, i.e. destruction of tissues, causes a local inflammatory response with an increase in the total concentration of pro-inflammatory cytokines. The level of cytokines correlates with the degree of damage to soft tissues and bones. The local inflammatory response activates polymorphonuclear leukocytes, which attach to capillary endothelial cells and stimulate the release of free oxygen radicals and proteases, resulting in damage to the vessel wall, leading to interstitial edema. All these processes are known abroad as multiple organ dysfunction syndrome, and in our country - as DIC syndrome, comprehensively studied by Acad. A.P. Vorobyov and his school. The release of inflammatory markers and products of damaged cells generates systemic inflammatory changes, which is facilitated by ischemic, dead, and infected tissues. This explains the high frequency of infectious complications (primarily pneumonia) in victims and specific complications such as ARDS, early PON, etc.
In order to apply the system "damage control" in practice, a careful assessment of 3 factors is necessary.
. The severity of the initial injury (first impact).
The biological constitution of the patient (age, body weight, concomitant diseases).
The number of necessary trauma operations, their expected duration and trauma (blood loss). These operations are the second blow for the seriously injured.
The deep mechanisms of the fatal effect of the second stroke are not fully understood, but it is clear that they are characterized by systemic inflammation in combination with microvascular damage, increasing interstitial edema, primarily in the lungs, and multiple organ failure. This can explain the cases of death of seriously injured patients who underwent several operations, the blood loss was formally replenished by transfusion of donor blood, the acid-base and electrolyte balance were normalized, and nevertheless, after 1-2 days, severe complications develop.
With advances in laboratory technology, it is becoming possible to quantify the inflammatory response to trauma and operative procedures. Interleptins are markers of inflammation. The most reliable marker was interleptin-6, which can be used to predict the development of DIC (Muhr O., Ostermann P., 1997).
The damage control system in orthopedics is used only for fractures of the femur, pelvis with damage to the anterior and posterior half rings, multiple fractures of the long bones of the lower extremities, avulsions of the femur, tibia. Of great importance is the damage to which areas of the musculoskeletal injury is combined. Most of all, the outcome of the injury and the development of complications are affected by closed chest trauma and TBI. Severe closed chest trauma is always accompanied by damage to the parenchyma, which can not always be detected by X-ray examination (Burgess A., 1992; Brundage S. et al, 2002). Fractures of the femur and lower leg are accompanied by fat embolism of the pulmonary circulation, which exacerbates pulmonary disorders. Krichevsky A.L. (1994) showed that intraosseous osteosynthesis of the femur with reaming of the medullary canal on the 1st day rarely enhances fat embolization; therefore, adult respiratory distress syndrome and pneumonia develop more often than in non-operated patients.
If a patient, along with fractures of the femur and lower leg, has a severe TBI, then with early osteosynthesis, cerebral perfusion decreases and there may be an additional stroke of the damaged brain. This may explain the impossibility of transferring the patient to spontaneous breathing after hip osteosynthesis, while before the operation he was breathing on his own.
For the effective application of the damage control system, it is necessary to determine the appropriate group of victims. Clinical experience suggests that in the following so-called borderline cases, tactics of controlling the severity of injuries should be followed.
Polytrauma with ISS > 20 in the presence of thoracic injury with A1S > 2.
Polytrauma in the presence of damage to the organs of the abdominal cavity or pelvis (according to the AIS i 3 scale) and the presence of shock with blood pressure< 90 мм рт.ст.
Polytrauma with ISS > 40 without thoracic injury.
Bilateral pulmonary contusion according to X-ray examination.
In addition, the following clinical options may help identify patients for whom ETC is not the best choice.
Difficulties in resuscitation and stabilization of the condition of the victims, when the period of unstable hemodynamics lasts more than 2 hours.
Coagulopathy with thrombocytopenia< 90 тыс.
Hypothermia (<32°).
TBI< 8 по шкале комы Глазго либо внутримозговая гематома.
Estimated time of operations more than 6 hours.
Damage to the main artery and hemodynamic instability.
Systemic inflammatory response (interleptin-6 > 80 pg/mm in the third degree).
The specific actions of the traumatologist when monitoring the severity of injuries are as follows. When a seriously injured person is admitted, priority still belongs to operations on the internal organs of the abdomen, small pelvis, chest, and brain. However, this operation is also divided into 2 and, in exceptional cases, 3 phases. In the first phase, with minimal stabilization of the condition (BP 90 mm Hg, pulse 120 per minute), the pleural cavity is drained to eliminate pneumo- or hemothorax, then laparotomy with clamping of bleeding vessels (spleen pedicles, kidneys) with temporary clamps (clips), liver ruptures are plugged, the damaged intestine is removed and isolated from the free abdominal cavity. In the wound, only the skin is sutured with a continuous suture. After that, resuscitation continues. If it is possible to stabilize the patient's condition, after 24-36 hours he is taken back to the operating room, the wound is opened and the second phase of surgical treatment is carried out - splenectomy, suturing of liver and intestinal wounds with complete suturing of the laparotomic wound.
Damage to the musculoskeletal system in the first phase is fixed with plaster splints, fractures of the femur and lower leg - with rod external fixation devices. Wounds and open fractures in extremely seriously ill patients are not surgically treated, but only washed with antiseptics, visible foreign bodies are removed, the edges are chipped with antibiotics and covered with bandages with antiseptics. In case of traumatic detachment of the limbs, clamps are applied to the main vessels, the wounds are treated with hydrogen peroxide and antiseptics, they are chipped with antibiotics and dressings with antiseptics are applied. After that, intensive therapy is continued. Surgical treatment of open fractures, amputations are also performed 24-36 hours after the second phase of operations for abdominal injuries with a break of 2-3 hours between these operations, especially if a pressure drop was observed during laparotomy. No simultaneous operations by 2 and 3 brigades are allowed.
Submerged osteosynthesis for closed fractures is postponed for 6-8 days, minimally invasive intramedullary osteosynthesis of the femur and lower leg is allowed on the 3-5th day in order to facilitate the care of the victim and give him greater mobility.
Rare et al. (2002) proposed a relatively simple diagram showing the algorithm for treating long bone fractures in patients with polytrauma (Fig. 3-1).
Rice. 3-1. The algorithm for providing care to patients with polytrauma, depending on the severity of the condition (according to Rara et al., 2002, with changes).
The use of such a flexible approach to the treatment of large fractures in patients with polytrauma has led to a significant reduction in overall complications. Thus, cases of ARDS decreased from 40 to 15-20%, pneumonia and sepsis - more than 2 times. Accordingly, the mortality rate also decreased.
It should be noted that the control of orthopedic injuries is not a fundamentally new position. An individual approach to the affected domestic scientists has been promoted over the past 15-20 years. A great contribution was made by scientists of the St. Petersburg Research Institute of Emergency Medicine named after. Yu.Yu. Dzhanelidze (Yu.N. Tsibin, Yu.B. Shapot, M.V. Grinev, S.F. Bagnenko) and the Department of Military Field Surgery of the Military Medical Academy (Yu.A. Eryukhin, E.K. Gumanenko), who created various therapeutic and tactical schemes for providing assistance to victims with combined trauma, depending on the severity of their condition. Similar developments are being carried out at the Research Institute of Emergency Medicine. N.V. Sklifosovsky since 1975 (V.P. Okhotsky, L.G. Klopov, V.A. Sokolov, E.I. Byalik).
The merit of the Hanoverian school of polytrauma, which proposed the concept of “damage control” in 1990, is the substantiation of control tactics based not only on clinical experience, but also on a deep study of immunological, biochemical, morphological changes in the lungs, which made it possible to objectively justify the choice of treatment tactics depending on various combinations of injuries and the severity of the patient's condition.
V.A. Sokolov
Multiple and combined injuries
The damage control resuscitation strategy is aimed at combating the components of the “lethal triad” — coagulopathy, hypothermia, and acidosis, which occur against the background of traumatic blood loss and contribute to its continuation. Developing hypoperfusion leads to a decrease in oxygen delivery, a transition to anaerobic metabolism, lactate accumulation, and metabolic acidosis. Anaerobic metabolism limits the production of endogenous heat, increasing hypothermia. There is a vicious pathogenetic circle. A core body temperature of less than 35°C is an independent predictor of death in severe trauma (R.S. Martin et al., 2005).
The main components of the damage control resuscitation strategy are:
1) permissible (intentional) hypotension with limited infusion volume until reliable hemostasis is formed;
2) hemostatic resuscitation strategy, including the earliest possible use of blood components as primary infusion therapy and the appointment of hemostatic pharmacological agents;
3) surgical control of damage.
A hypotensive resuscitation strategy (taking into account suboptimal target organ perfusion requirements) involves delaying or limiting the volume of colloid and crystalloid infusion until reliable hemostasis is achieved and is aimed at preventing dilutional coagulopathy. Thus, the study showed that the mean arterial pressure (MAP), equal to 40 mm Hg. within 2 hours, led to the development of fatal hypoperfusion, and vice versa, hypertension, when SBP was more than 80% above normal, led to the development of fatal rebleeding (T. Li et al., 2011). In another study, it was noted that systolic blood pressure (SBP) at the level of 80 mm Hg. in comparison with the group of patients with ADsyst. > 100 mmHg provide effective control of bleeding. In this connection, in patients with active bleeding, maintenance of the target BPsyst is recommended. less than 100 mmHg The effectiveness of this approach has also been confirmed by a number of other studies (R.P. Dutton et al., 2012), although it is still a matter of debate. Guidelines for tolerable hypotension are included in US military medical doctrine (T.J. Hodgetts et al., 2007) and in the 8th edition of Advanced Trauma Life Support (ATLS, 2008). Tolerable hypotension is contraindicated in TBI due to the need to maintain cerebral perfusion pressure.
The hemostatic resuscitation strategy is aimed at the rapid and active treatment of acute post-traumatic coagulopathy and is recognized as an important factor in improving the outcome of therapy (E. Kirkman et al., 2008). It includes the use of fresh frozen plasma, platelets, cryoprecipitate, fibrinogen, recombinant factor VIIa, tranexamic acid, prothrombin complex concentrate, replenishment of calcium deficiency. To control the state of the hemostasis system, it is not enough to use only publicly available diagnostic tests (prothrombin time, activated partial thromboplastin time) due to their low sensitivity and the duration of obtaining results, but the method of "bedside" thromboelastography is recommended.
The decision on the need for a massive blood transfusion is based on clinical assessment (visually massive bleeding; bilateral proximal traumatic limb amputations; bleeding in the trunk and unilateral proximal traumatic amputation), as well as the presence of such clinical signs, as a decrease in body temperature below 35 ° C, BPsyst. less than 90 mm Hg and laboratory changes (INR > 1.5; base deficiency (BE > -6); hemoglobin< 110 г/л). При этом необходимо отметить, что лабораторные данные не являются обязательным требованием для активации протокола массивной трансфузии (J. Mark et al., 2011). В случае использования протокола массивной гемотрансфузии рекомендуется соблюдение соотношения свежезамороженной плазмы и эритроцитарной массы 1: 1, которое способствует снижению летальности (M.A. Borgman, 2007; J.C. Duchesne et al., 2008), а также трансфузия тромбоцитов в соотношении 1: 1 с препаратами крови (O.L. Gunter et al., 2008; J.B. Holcomb et al., 2008) или по крайней мере одной дозы тромбоцитов на каждые пять доз эритроцитарной массы. Не рекомендуют применение эритроцитарной массы со сроком хранения более двух недель, так как это связано с увеличением частоты инфекционных осложнений и полиорганной недостаточности.
Correction of metabolic acidosis requires the restoration of normal organ perfusion and only occasionally the use of buffer solutions (Boyd J.H. et al., 2008).
Surgical control of damage is an important component of anti-shock therapy and involves the priority restoration of normal physiological parameters, rather than anatomical integrity: bleeding control, primary surgical treatment of wounds, prevention of compartment syndrome, primary (often extrafocal) metal osteosynthesis of bone fractures. Recovery and reconstructive operations are carried out after the restoration of normal physiological parameters in the patient (Shapiro M.B. et al., 2000).
Thus, the formation and ongoing development of the “damage control” strategy during intensive care for patients with polytrauma allows influencing the components of the “lethal triad” and is the basis for improving treatment outcomes and increasing patient survival both in peacetime and during military operations ( Holcomb J.B., 2007; Jansen J.O. et al., 2009).
