Severe Concomitant Trauma Research Articles

Клинический случай лечения пострадавшего с тяжелой сочетанной травмой с множественной жировой эмболией с преимущественным поражением головного мозга

Road traffic accidents occupy the first positions due to severe combined injuries of the population. One of the most dangerous and poorly diagnosed complications of the acute period of combined skeletal injury is the syndrome of fatty embolism with predominant brain damage. Despite the large number of proposed methods and treatments for this complication, the mortality rate remains very high at the moment. A clinical case of successful treatment of multiple fatty embolism of the microvascular bed of internal organs with predominant brain damage in a patient with severe concomitant trauma is presented. Despite the difficulties of diagnosis and treatment, a high percentage of disability, complications and mortality, and the difficulty of preventing this complication of fat embolism with a predominant manifestation in the form of cerebral fat embolism, a favorable outcome is possible for patients with concomitant trauma.Keywords: traffic accident, fractures of long bones, traumatic shock, polytrauma, fat embolism, cerebral fat embolism, intensive care.

Pathogenetic Mechanisms of Organ Dysfunction in Severe Concomitant Trauma

Severe concomitant trauma has been a major demographic and medical problem for many years , being the cause of high mortality of the able-bodied population . The simultaneous formation of an array of destroyed tissues triggers a systemic inflammatory reaction , which , against the background of traumatic and hemorrhagic shock , leads to an imbalance in immune reactivity and predisposes to the development of septic complications . The review presents the basic concepts of post-traumatic reactions and violations of the balance of cellular and humoral immune mechanisms leading to the development of complications .

Интенсивная терапия острого нарушения кровообращения вследствие жировой эмболии у пациента с множественной травмой

Every year, the number of victims with severe concomitant trauma, who need assistance in the intensive care unit is growing. Mortality and disability in this category of patients remain high due to both the severity of the injury and the development of life- threatening complications [1, 2]. One of such complications is fat embolism. To date, there is no specific treatment or specific prevention of this syndrome. The article presents the experience of managing a patient with a brain-damaged disease as a result of a fat embolism.

Prognosis, Early Diagnosis and Treatment of Multiple Organ Failure in a Patient With Severe Concomitant Trauma

On the example of a clinical observation, we demonstrate the possibilities of dynamic multimodality imaging techniques and clinical and laboratory data, taking into account the severity of the concomitant trauma, which allow us to reflect objectively the dynamics of post-traumatic changes in the organs and tissues and predict the course of multiple organ failure (MOF). Consistency and adequate choice of treatment tactics with early use of active detoxification methods contribute to a favorable outcome.

The use of anti-shock suit "chestnut" in the treatment of severe concomitant trauma

Antishock Kashtan costume was used in complex treatment of 31 injureds with severe comcomitant trauma (in 13 patients at prehospital stage, in 18 at hospital stage). Application of Kashtan gave the possibility to decrease the lethality up to 25.8%. Timely use of antishock costume was shown to provide the stabilization of hemodynamics, prolong the golden hour (the period of relative compensation), prevent the torpid shock development, perform required surgical intervention and to improve the outcomes. Indications and contrindications to Kashtan use are given.

Применение инновационных технологий при лечении пострадавших с тяжелой сочетанной травмой с повреждением печени. Клиническое наблюдение

Liver injury is one of the most common abdominal injuries in patients with severe trauma. A total of 2988 patients with concomitant injuries were treated at the city clinical hospital named after S.S. Yudin during the period from 2010 to 2020, of which 371 (12.4%) were found to have closed abdominal trauma. Damage to the liver was revealed in 124 (33.4%) patients with closed abdominal trauma. The number of discharged patients was 78 (62,9%), lethal outcome — 46 patients (37,1%). The severity of injury according to ISS was (38,1±11,3) points. The development of innovative multimodal approaches, such as endovascular trauma and bleeding management (EVTM), as well as damage control tactics have significantly increased the likelihood of nonoperative treatment for individual patients. A clinical observation is presented that allows to evaluate the effectiveness of innovative technologies in the treatment of patients with severe concomitant trauma with liver damage.

Rhinological tactics in the complex treatment of patients with severe combined cranio-facial trauma who are on mechanical ventilation

Introduction. In recent years, injuries ranked fourth among the main causes of death of the population after diseases of the cardiovascular system, malignant neoplasms and infectious diseases. The clinical course of associated injuries, as a rule, is characterized by a high number of complications, much more than in isolated injuries.Objective. Explore approaches to improving otorynolaryngological tactics from the standpoint of normalizing the functional state of the nasal mucosa, as well as increasing the effectiveness of treatment of patients with severe concomitant trauma on prolonged mechanical ventilation.Materials and methods. In the process of studying the problem of impaired mucociliary clearance of the nasal mucosa, the functional state of the mucous membrane in patients with severe concomitant head trauma undergoing prolonged artificial lung ventilation was analyzed. We studied the state of one of the most important mechanisms of sanitation and local protection of the respiratory tract - mucociliary clearance, which provides the necessary potential for barrier, cleansing and immune functions. A study was made of the thermal effect of the nasal cavity, pH + of the mucous membrane, the study of the frequency of beating of the cilia of the ciliated epithelium and the rate of mucociliary transportResults and discussion. The results of the study showed that the problem of post-traumatic and nosocomial sinusitis in patients with severe concomitant head trauma must be resolved as soon as possible, with the involvement of modern diagnostic and treatment methods, including the proposed method of artificial ventilation of the nose. The severity of the patient's condition, the severity of the injuries received excludes the use of advanced methods of surgical, otorhinolaryngological treatment.Conclusion. 12:30 PMThe use of minimally invasive methods of treatment, precision technical execution, including under endovideo control, polysinusotomy made it possible not to burden the condition of the victims and exclude iatrogenic damage that could entail irreversible changes in the body and condition of the victim.

Retrospective analysis of ultrasound and dopplerographic parameters of liver hemodynamics in prognosis of mortality in patients with severe concomitant injury

Purpose. According to the assessment of liver hemodynamics, to determine the criteria for the probability of death in patients with severe concomitant injury and to establish the decisive time range in which these indicators are prognostic.Material and methods. The analysis of ultrasound (US) indicators in 57 patients with severe concomitant trauma was carried out in order to identify criteria for the probability of death and determine the time range in which these indicators have a prognostic character. All patients were divided into two groups: the first group of 40 surviving patients; the second of 17 dead. For comparison, three values were taken for each ultrasound indicator on the 1st, 3rd, 5th, 7th days from the moment of admission to the hospital. Comparison of the first and second groups of patients by these parameters revealed signs characterizing the violation of liver hemodynamics. The Mann-Whitney test, correlation analysis and stepwise logistic regression were used to study the relationships. Differences were considered statistically significant at a significance level of p < 0.05. Correlation was considered strong when R > 0.5. The best reliable regression model was chosen according to the highest value of the Akaike criterion.Results. In the first three days after trauma in patients of the first and second groups, the most significant were such ultrasound signs as a decrease in the diameter of the own hepatic artery (OHA), a decrease in the linear blood flow velocity (LBFV) along the SPA to 27–38 cm/s, and a decrease in volumetric blood flow in OHA, an increase in the index of resistance (IR) in OHA of more than 0.7, in combination, indicate liver dysfunction in patients in a state of traumatic shock. From the 5th day in the second group of patients, an increase in LBFV in the OHA (100–135 cm/s), an increase of 0.70–0.84, a decrease in volumetric blood flow less than 270 ml/min indicate violations of liver hemodynamics during the formation of organ dysfunction. On the 5–7th day, due to edema of the liver parenchyma against the background of an increase in the size of the liver and spleen and the formation of portal hypertension, arterialization of blood circulation occurs, which is characterized by a significant increase in LBFV in the OHA, a decrease in LBFV and volumetric blood flow in the portal vein. The third-fifth day after the injury can be considered a turning point – the correlation of most of the indicators with the fact of death and significant differences in the criterion in 9 out of 11 indicators indicate significant differences in all indicators in patients of the first and second groups. At the same time, not only dopplerographic indicators of hepatic blood flow, but also linear indicators of the size of the liver, spleen, signs of portal hypertension characterize the severity of the patient’s condition. Findings. 1). Carrying out an ultrasound of the liver with the use of Doppler ultrasound allows in the first 3 days from the moment of injury to conclude that there is liver dysfunction against the background of traumatic shock. 2). Statistical analysis of Doppler parameters of liver hemodynamics makes it possible to identify patients with a poor prognosis, severe liver dysfunction in the first 3–5 days from the moment of injury, as well as with developing multiple organ failure. 3). The obtained ultrasound results, indicating liver dysfunction in the early post-traumatic period, are confirmed by autopsy data.

Extracorporeal detoxification for septic complications in children during the acute period of severe combined craniocerebral trauma

BACKGROUND: The clinical application of extracorporeal detoxification methods in patients with severe concomitant traumatic brain injury has several features and limitations due to intracranial hypertension, traumatic cerebral edema, and the risk of their growth during extracorporeal detoxification. The modern literature presents the results of using extracorporeal detoxification methods in severe concomitant trauma in children. However, practically no data are available on the possibility of their use in severe concomitant craniocerebral trauma, which determines the relevance of research in this direction.
 AIM: This study aims to improve the treatment results of affected children with severe concomitant craniocerebral trauma with the addition of septic complications using extracorporeal detoxification methods.
 MATERIALS AND METHODS: The experience using extracorporeal detoxification methods, including prolonged veno-venous hemodiafiltration combined with LPS sorption and plasma separation membrane in patient intensive care with severe concomitant craniocerebral trauma complicated by sepsis and septic shock development, is presented.
 RESULTS: The use of extracorporeal detoxification methods contributed to eliminating septic shock, stabilization of hemodynamic and internal homeostasis parameters, and regression of multiple organ failure in patients with severe concomitant traumatic brain injury. Monitoring the intracranial pressure and preventing disequilibrium syndrome development enabled avoiding an increase in intracranial hypertension in studied patients.
 CONCLUSIONS: Timely and adequate use of extracorporeal detoxification methods improves the clinical course of the acute period of traumatic illness in children with severe concomitant traumatic brain injury. The safe use of efferent therapy methods in patients with severe concomitant traumatic brain injury is ensured by invasive monitoring of intracranial pressure and preventing the development of disequilibrium syndrome.

MODERN ASPECTS OF THE DIAGNOSIS OF SEVERE COMBINED TRAUMA USING COMPUTED TOMOGRAPHY

Relevance. The variety of options for combining injuries and disorders occurring in the body with a combined injury, the need for rapid decision-making on treatment require rapid diagnosis of the entire volume of injuries and determining the severity of the injury, but there is still no single protocol for examining such victims. The aim of the work was to present a modern CT study protocol for patients with concomitant trauma.Materials and methods. The results of computed tomography of 30 patients with severe concomitant trauma were analyzed. All the victims were admitted in the first hours after the injury. Men were 30 (67 %), women – 10 (33 %), the average age was 41.3 ± 7.6 (22–79) years. Traditional multiphase full-body MSCT was performed in 20 patients, in 10 patients a special protocol was used for the study of the "whole body" by the method of divided bolus.The results of the study. Craniocerebral injuries were detected in 15 (50 %), spinal injuries – in 7 (23.3 %). Simultaneous injuries to the chest and abdomen were detected in 19 (63.3 %) of the victims. When subjectively evaluated, the quality of the images obtained using the full-body MSCT protocol with bolus separation and the standard multiphase protocol for the diagnosis of traumatic injuries was equivalent. The average radiation load per patient with traditional multiphase full-body MSCT is 66 % higher than with the split-bolus protocol.Conclusions. Full-body MSCT using a split bolus is a modern technique that fully meets the diagnostic conditions for severe combined trauma and, with a decrease in the radiation dose, allows you to determine all possible injuries in the victim in a single study.

MODERN ASPECTS OF THE DIAGNOSIS OF SEVERE COMBINED TRAUMA USING COMPUTED TOMOGRAPHY

Relevance . The variety of options for combining injuries and disorders occurring in the body with a combined injury, the need for rapid decision-making on treatment require rapid diagnosis of the entire volume of injuries and determining the severity of the injury, but there is still no single protocol for examining such victims. The aim of the work was to present a modern CT study protocol for patients with concomitant trauma. Materials and methods . The results of computed tomography of 30 patients with severe concomitant trauma were analyzed. All the victims were admitted in the first hours after the injury. Men were 30 (67 %), women – 10 (33 %), the average age was 41.3 ± 7.6 (22–79) years. Traditional multiphase full-body MSCT was performed in 20 patients, in 10 patients a special protocol was used for the study of the "whole body" by the method of divided bolus. The results of the study . Craniocerebral injuries were detected in 15 (50 %), spinal injuries – in 7 (23.3 %). Simultaneous injuries to the chest and abdomen were detected in 19 (63.3 %) of the victims. When subjectively evaluated, the quality of the images obtained using the full-body MSCT protocol with bolus separation and the standard multiphase protocol for the diagnosis of traumatic injuries was equivalent. The average radiation load per patient with traditional multiphase full-body MSCT is 66 % higher than with the split-bolus protocol. Conclusions. Full-body MSCT using a split bolus is a modern technique that fully meets the diagnostic conditions for severe combined trauma and, with a decrease in the radiation dose, allows you to determine all possible injuries in the victim in a single study.

STRATEGY OF EARLY DIFFERENTIATED TRAUMATOLOGICAL CARE IN TREATMENT OF VICTIMS WITH SEVERE COMBINED TRAUMA AND POLYTRAUMA WITH LONG TUBULAR BONES FRACTURES

Introduction. With the new organizational system, victims with severe concomitant trauma (TCT) and political injuries are allocated to a separate stream upon admission to the hospital, undergo damage diagnostics in the anti-shock ward, after which they are sent either to the anti-shock operating room when indications for an emergency operation are established or to the intensive care unit and intensive care for prolonged diagnosis and intensive care. Materials and methods. The analysis of the methods of treatment of 413 patients with fractures of long bones with severe concomitant trauma (TCT) and polytrauma, who received treatment using the strategy of "Differentiated early trauma care" and in relation to the treatment of fractures of long tubular bones with TCT and polytrauma of three tactics: 1 ) tactics of early (within 24 hours from the moment of injury) full volume of trauma care "Early total care" (ETC); 2) tactics of programmed multistage surgical treatment of fractures of the DTC "Damage control orthopedics" (DCO); 3) tactics of early individualized volume of trauma care "Early appropriate care" (EAC). Results. In the present study, 189 victims approached the third stage of DCO tactics: of all 413 patients studied with TST and polytrauma of the main array, 158 were performed ETC, 66 victims died - 189 remained. Of these 189 victims, the third stage of DCO tactics was performed by 116 (61.4%), and in 73 patients (38.6%) the third stage of DCO tactics was not performed due to a serious condition or long-term infectious complications. Long-term results of treatment were assessed as positive

Синдром жировой эмболии: выбор и эффективность методик лабораторной диагностики

The review on the use of traditional and new methods of laboratory diagnostics of fat embolism syndrome - a complication that in some cases asymptomatically accompanies severe concomitant trauma is presented. The main currently used laboratory diagnostic methods are described: traditional methods and new markers (interleukin-6, neuroglial protein S100B, surfactant protein SP-D). A review of the literature data in terms of assessing the pathogenetic and diagnostic significance of some methods of laboratory diagnosis of fat embolism syndrome, the relationship between the dynamics of the considered laboratory parameters, the clinical picture and inflammation. Own observation is presented. The results show the importance of integrating the whole range of available methods in the diagnosis of fat embolism syndrome.

ROLE OF THE FAMILY PHYSICIAN IN THE TREATMENT OF PATIENTS WITH POLYTRAUMA ON THE OBESITY BACKGROUND ON AN AMBULATORY STAGE

Introduction: Obesity rates have continued to increase recently, what is connected to the reduction of physical activity of population. The aim: To determine the peculiarities of treatment of patients with obesity, who sustained a severe concomitant body trauma on an outpatient basis by family physicians. Materials and methods: Clinical material composed of 67 patients who sustained severe concomitant body trauma. Results: On the grounds of the long-term outcomes assessment cards developed by us, treatment of the severe concomitant trauma in persons with obesity, we found typical complications of the traumatic disease, which family physicians faced on an ambulatory stage. These cards contained by system analysis of consequences of the sustained polytrauma on the systems and organs respectively to the body mass index meaning. In general, treatment of such patients was complex and included applying of the diet therapy (a low-calorie diet with enough protein, vitamins and low levels of animal fats and carbohydrates, especially easily digestible), pharmacological therapy (antibiotics, mucolytics, solvents) as well as therapeutic exercise, which played almost dominant role. In particular, therapeutic massage was prescribed for improvement of general body tone, activation of peripheral circulation and lymph flow, oxidation-reduction and metabolic processes, retroaction to the impaired motor-evacuation function of the large intestine, eliminating fatigue and increasing muscle tone and functioning. Conclusions: Role of the family physician in the process of traumatic disease treatment is especially important and lies in the organization of medical treatment of patients on an ambulatory stage.

Sedation with dexmedetomidine reduces the duration of delirium treatment in sufferers with severe concomitant trauma

Rationale : Delirium would deteriorate the outcomes and treatment results in the patients with severe concomitant trauma. Its treatment efficacy is especially relevant for such patients. Aim : To identify an optimal sedation strategy for delirium in the sufferers with severe concomitant trauma. Materials and methods : Sixty (60) patients with delirium that developed against the background of severe concomitant trauma were included into this randomized, retrospective-prospective study. One group of patients (n=30) was sedated with dexmedetomidine, the other one (n=30), with propofol. Results : In the group with dexmedetomidine sedation, the duration of delirium was 6 [5–6] days, whereas in the propofol group, 7 [6–8] days (p=0.003). The type of sedation was not associated with the severity of delirium, whose maximum ICDSC score was 7 [4–7] points in the propofol group and 6 [4–6] points in the dexmedetomidine group (p=0.32). Conclusion : Compared to propofol, dexmedetomidine may help to reduce the duration of treatment for non-specific delirium in severe concomitant trauma by 1 day.

ФАКТОРЫ, ОПРЕДЕЛЯЮЩИЕ КЛИНИЧЕСКИЕ ИСХОДЫ У ПАЦИЕНТОВ С ТЯЖЕЛОЙ СОЧЕТАННОЙ ТРАВМОЙ, ОСЛОЖНЕННОЙ ДЕЛИРИЕМ

Search for most effective way of management of non-specific delirium is an important aspect of treatment of severe concomitant trauma. The objective of the study: to investigate the correlation and impact of sedation method on those injured with delirium during the intensive care of severe concomitant trauma. Subjects and Methods. The retrospective prospective analysis of two groups of patients with delirium was performed, 30 patients in each group, who received sedation with dexmedetomidine or propofol. Results. After stopping delirium, the intensity of multiple organ dysfunctions was lower in the group of patients who had sedation with dexmedetomidine. The complex of unfavorable events – death within 1 year and continuous cognitive deficiency was 4 times more frequent in the group of patients after sedation with propofol. Evaluation of the trauma severity was a significant predictor of unfavorable outcomes. Conclusions. The use of dexmedetomidine for management of delirium resulted in the reduction of multiple organ dysfunctions versus propofol. The severity of trauma was associated with chances to develop a continuous cognitive dysfunction and lethal outcome. Use of dexmedetomidine promoted early rehabilitation in case of cognitive dysfunction.

Characteristics of Alcohol-Related Facial Fractures

Excessive indulgence in alcohol is a key causative factor in facial fractures especially in settings of interpersonal violence (IPV) and motor vehicle accidents. This study aims to explore characteristics of alcohol-involved facial fractures in the state of Victoria, Australia, over a 10-year period. This retrospective study analyzed data from the Victorian Admitted Episodes Dataset between 2004 and 2014; the Victorian Admitted Episodes Dataset is a standardized database reported by all Victorian hospitals for every admission. Admission details included patient age group and gender, fracture site (or sites), injury cause, and surgical management. During the study period, 4,293 patients were treated for alcohol-related facial fractures, 27% of whom were in the 20- to 29-year-old age group. The male-to-female ratio was 7:1. There was a rising trend over most of the study period. Of the patients, 36% had multiple facial bone fractures, followed by nasal and midface fractures (22% and 6%, respectively). IPV was the most frequent cause (38%), followed by falls and transport-related injuries (30% and 18%, respectively). Surgery was required in 16% of patients, and 62% were inpatients for 1 to 3days. Concomitant fractures were frequently reported; 20% of patients had fractures of another site, 12% had skull fractures, and 4% had cervical spine fractures. There were statistically significant relationships between age group and gender, between gender and fracture site, and between fracture site and need for surgery (P < .05). This study reports a high incidence of alcohol-involved facial fractures in young men with IPV being a predominant cause. Such injuries often involve multiple facial bone fractures and severe concomitant trauma necessitating brief hospitalizations, but a high proportion of patients were treated nonsurgically.

Diagnostic and treatment features of concomitant injuries of pelvis and abdomen in the emergency traumatology

Aim. Analysis of experience of treatment of patients with concomitant injuries of pelvis and abdomen in the emergency traumatology.Methods. Analysis of features of diagnosis and treatment of 77 patients with concomitant pelvic injuries admitted to Kazan City Clinical Hospital №7 was conducted.Results. The structure of concomitant pelvic injuries is characterized by a variety of injuries, often accompanied by severe shock. Concomitant pelvic injury in 74% of patients was accompanied by shock, and in 80% of cases it was II-III grade shock. To reduce the patient’s displacement in the admission ward full body CT scan was performed, and for clarifying the scope of injuries and tactics of management CT scan of injured organs was administered. During the first hour after admission to prevent dislocation of fractures and to stop intrapelvic bleeding external fixation devices in different modifications were used depending on the injury; that allowed stabilizing hemodynamics and condition of the victims. In the second step after stabilization of the patient’s state and hemodynamics and correction of homeostasis minimally invasive surgical interventions are recommended on day 5 to 7. If abdominal injury is identified, the optimal way of external fixation of fractures is C-type fixation frame, which allows adequate access for laparotomy.Conclusion. A patient with severe concomitant trauma needs urgent full body scan with subsequent X-ray CT, staging treatment based on the principal «Damage control», early fixation of pelvic fractures with the use of external fixation devices and subsequent minimally invasive osteosynthesis, and optimal external fixation device which allows adequate access in case of surgery.

Types of Acute Lung Injury and Fat Embolism

Objective: to enhance the efficiency of diagnosing acute lung injury (ALI) and fat embolism (FE). Subjects and methods: Forty-seven patients with severe concomitant trauma (SCT), divided into three groups by the severity of shock and injury, were examined. The parameters of the scales rating ALI severity, lipid metabolism, hemostatic system, and hemodynamic monitoring were analyzed. Results. Three types of acute lung injury were identified in FE depending on clinical laboratory parameters: the patients having a shockogenicity index of less than 14 scores had significantly activated coagulation hemostasis and suppressed fibrinolytic system. Those with a shockogenicity index of 15 to 22 scores developed hemostatic disorders as activated coagulation hemostasis throughout the study and considerably activated fibrinolytic system, the levels of atherogenic very low density lipoproteins (LVDL) and triglycerides increased. The patients with a shockogenicity index of more than 23 scores developed hemostatic disorders, such as pronounced activation of the blood coagulation system and suppression of the fibrinolytic system. The manifestation of ALI increased with the elevated concentrations of LVDL and triglycerides, hypercoagulation by hemo-viscosimetric parameters and reduced platelets, lower oxygenation index, and decreased oxygen consumption. Conclusion. A scheme of development of the types of ALI and FE has been proposed. Key words: severe injury, acute lung injury, fat embolism, types of diagnosis.

Diagnostic and Predictive Markers of Acute Lung Injury in Severe Concomitant Trauma

Objective: to define the diagnostic and predictive value of the markers of fat embolism as a cause of acute lung injury (ALI) in severe concomitant trauma. Subjects and methods: 34 patients with severe concomitant trauma were examined. A dynamic study was undertaken to examine by biochemical tests and hemoviscosimetry and lipid metabolism (very low-density lipoproteins (VLDL) and triglycerides (TG)). The Murray scale was used to evaluate the severity of ALI. The authors calculated the trauma shock genicity index in accordance with the recommendations developed by the Dzhanelidze Research Institute of Emergency Care (Saint Petersburg) and the patients’ condition by the TRISS scale. Results. In all the groups, patients with severe concomitant trauma develop ALI whose severity correlates with the severity of a trauma. In the group of patients with a shock genicity index of more than 14 scores, the most significant severe hemostatic disorders develop, which are retained within 9 days. In the same group, the levels of VLDL and TG increased within the first 3 days after trauma. Conclusion. In patients with severe concomitant trauma, the parameters of the hemostatic vascular platelet link and the elevated serum VLDL and TG levels are of diagnostic and predictive value in the development of ALI and fat embolism. Key words: fat embolism, severe concomitant trauma, acute lung injury, hemostasis, lipid metabolism.