Inozemtsev E.O., Grigoryev E.G., Apartsin K.A.

Irkutsk Scientific Center of Surgery and Traumatology,
Irkutsk State Medical University, Irkutsk, Russia

The significance of the problem

At the present time, an injury is a main cause of mortality among persons younger 40. After the problems with the cardiovascular system, an injury takes the second place among the causes of mortality and the first place (45 %) in working age population. The high rates of injuries cause the high social and economic influence on the society. In Russia, the financial losses after road traffic accidents (RTA) are 170 billion roubles [1, 2, 21].
The patients with abdominal injuries are related to the most severe category of patients (3.6-18.8 %). The mortality is 72.3 % after traumatic brain injury, 47.3 % after thoracoabdominal injury, 38 % – after combination with locomotor system injury [10, 13].
Investigation of this problem should include the main issues of medical care arrangement: terminology, definition of the terms, classification, the concept of traumatic disease, the uniform approaches to solving the organizational, methodical and medicodiagnostic tasks.

Transportation of patients

The levels of prehospital and early hospital mortality are higher in Russia than in the foreign countries. Only 40 % of patients are admitted to the hospital according to the statistical data. About 30 % of patients die at the accident site, the similar number – during transportation [13, 20]. Within the first 24 hours more than one-third of patients with polytrauma die as result of bleeding because of injuries to abdominal and thoracic organs.
The decrease in the prehospital mortality is possible with use of anti-shock suit Kashtan (it has been used since 1992) by emergency aid teams. It is the single measure for temporary arrest of bleeding at this stage of care. The concept of its function is based on the external pneumocompression for the lower half of the body and redistribution of blood flow to the vital organs. The effect of action of the suit is similar with transfusion of 1.5-2 liters of autoblood [11, 19, 20].
Owing to the severe condition, patients are admitted to the nearest facility (commonly, a non-specialized one). Moreover, the treatment outcomes are usually worse in the non-specialized facilities than in trauma centers. So, defects in diagnostics of injuries are identified in more than 70 % of cases. For investigation of treatment outcomes a patient should be transported to a specialized multi-profile facility. However transportation can be performed only after realization of the anti-shock measures and arrest of external and internal bleeding [11, 20].
Patients with polytrauma cannot be transported without well founded evaluation of their condition. The single absolute contraindication to transportation is agonal condition. Ongoing bleeding is a relative contraindication. For achieving hemostasis and stabilizing state, patient can be transported to the level 1 trauma center [5]. The
first day is the optimal time for transferring.
Transportation of patients is a staged high-tech process of arrangement of specific medical care. One should note that solving the problem of transportation depends on smooth coordination between all services [11, 21, 22].

Arrangement of care for patients with associated injuries: the concept of activity of trauma centers

According to the concept of trauma centers, four levels of arrangement of medical care are separated. The level 1 trauma center provides the highest level of medical care in a given region. It gives the services for population of a big city and takes a leading place in arrangement of medical care and improving its quality. It realizes the educational and scientific programs in the field of traumatology. It gives the full volume treatment for the most severe injury – from the critical care at the moment of admission to rehabilitation. It is the organizational and methodical center for trauma centers of other levels [4, 8, 19].
The level 2 trauma center provides some types of medical care for patients. It presents a type of a wide profile city hospital. It cooperates with the level 1 trauma center. It is characterized by less differentiated approach to patients. It does not have any educational or research functions in the field of trauma [4, 19].
The level 3 trauma center provides medical care in absence of the nearest level 1 and 2 trauma centers. The maximal tasks are estimation of injury severity, the critical care measures, some types of surgical treatment. Severe patients receive the procedures for stabilizing their condition and safe transportation, when the possibilities for care at the place of accident are exhausted. Transfer to a trauma center of higher level is realized in concordance with the developed protocols and agreements. The level 3 trauma center arranges the reduced educational programs for the staff [4, 19].
The level 4 trauma center is rural hospital with the task of initial estimation of severity and arrangement of primary care. It does not include the constant readiness surgical service. Transfer to a trauma center of higher level is conducted according to the developed protocols and agreements [4, 19].
The efficiency of implementation of the complex system for medical care for polytrauma is determined by the social and economic components, mainly, by means of decreasing mortality and disability [9].

The objective estimation of injury severity

The priority task is estimation of trauma severity, which is determined by severity of injuries and condition of a patient. Severity of injuries is an indicator of disorders (destruction) of the anatomic structures as result of external influence. It mainly depends on the patterns of external mechanic influence rather than on the basic state of the body. The injury severity is a feature reflecting the body response to an injury. It is determined by the basic level of health, the age and the external factors (environment). The injury severity is a concept, which combines a degree of injury to the anatomic structures as result of external impact and homeostatic disorders as response to an injury. According to the term by E.K. Gumanenko, the injury severity is a complex concept including the morphological (injury severity) and functional (condition severity) components. The English literature includes the terms anatomic score and physiologic score of the parameters, i.e. severity of injuries and condition. Currently, there is a clear tendency to parametrical estimation (indexing, estimation scores) of injury severity and its components [2].
The most common world-wide scale is Injury Severity Score (ISS) offered by Baker S.P. et al (1974). ISS is based on summing the points of injuries (Abbreviated Injury Score) in three of six standard regions: the head and the neck, the face, the chest, the abdomen, the extremities and external surface. Three highest values are raised to the square and summed. As for AIS, the injuries to each internal organ are distributed into six positions: minimal (1 point), moderate (2 points), serious (3 points), severe (4 points), critical (5 points) and life-threatening (6 points). Therefore, the instinctive estimation becomes possible, but the specific tables of severity are available for most locations of injuries [1, 2, 8, 11, 17, 19].
In the Russian Federation the scores for quantitative estimation of injury severity are common. They have been developed by the major general of medical service E.K. Gumanenko in the department of military field surgery of Military Medical Academy (Saint Petersburg). The detailed description of closed injuries after mechanical trauma and the corresponding points are presented in the scales Military Field Surgery-Injury (MFS-I) and Military Field Surgery-Gunshot Wound (MFS-GW). In contrast to ISS, the domestic scales summarize all injuries rather than only main injuries in three anatomic regions. The hospital mortality in associated injuries demonstrates the similar changes depending on the value of ISS and MFS-I [2, 17].
The scales for estimating the severity of patient’s condition or for physiological calculation usually include Glasgow Coma Scale. One should note that this scale is an exclusive, generally accepted physiological scale for estimating the cerebral function [2]. The universal scales, for example APACHE II (Acute Physiologic and Chronic Health Evaluation), can be successfully used for associated injury. At the same time, APACHE and its simplified version SAPS (Simplified Acute Physiology Score) did not become popular in the Russian medicine, because they require the values of blood arterial gases or bicarbonates of venous blood serum and levels of Na+ and K+. The dynamic estimation of these values is not available in each medical facility [5, 11].
Revised Trauma Score (RTS) is a specific score for injury. It is based on the estimation of consciousness (GCS), respiratory rate and systolic arterial pressure. The value of RTS allows assigning a patient to a group of certain probability of survival [2].
The scales Military Field Surgery-State at Admission (MFS-SA) and Military Field Surgery-State of Hospital Patient (MFS-SHP) deserve attention. Their undeniable advantages are the use of the parameters available for estimation such as skin color, patterns of breathing, intestinal noises and the simple laboratory values, which are available in the system of Russian healthcare. Depending on the scoring, the patient’s condition is estimated according to the corresponding probability of lethal outcome and/or complications [2, 17].
The variety of systems for estimating the severity of the patient’s condition indicates the great complexity and significance of this issue and the absence of the uniform opinion. The international scores modified by V.V. Agadzhanyan and used for estimating severity of condition are convenient.

The mortality risk factors and their control: Damage Control

The main cause of death in the hospital is massive blood loss and decompensated irreversible shock. Also the outcomes are influenced by patient’s age, injury severity and time of stabilization of fractures of long bones. The mortality in polytrauma is directly related to the patient’s age and injury severity. At the moment of admission, such important indices as arterial pressure and HR, CGS, injury severity (ISS) and injury mechanism (AIS) show the intensity of severe disorders and exercise a significant influence on the outcomes of treatment and on mortality [2, 6, 8, 12].
The highest hospital mortality is observed in patients with concurrent dominating injuries (72 %). The second place is taken by patients with spine-spinal cord injury (27.8 %). The main cause of mortality is spinal cord edema. Also the unfavorable predictive factor is combination of spinal and thoracic injuries. The mortality in patients with thoracic, abdominal and traumatic brain injuries is almost similar (16.6-17.7 %). In the late period of traumatic disease the main cause of death is infectious complications caused by secondary immune deficiency and multiple organ dysfunction. As result, both early and late complications of polytrauma are to be prevented [12, 13].
The damage control concept (control of injuries, staged surgical correction) is a salvation measure for patients with abdominal injuries at the decompensation stage. Damage control is a systematized three-staged approach in the treatment of severe abdominal injury. The first stage is oriented to arresting bleeding and decontamination by means of the simplest measures: splenectomy, liver wound suturing, packing, vascular ligation, intestinal damage suturing, resection of part of the intestine without application of anastomosis, suturing the injured magistral vessels. The requirement for using damage control concept is mainly associated with presence of intense metabolic disorders as result of shock. The use of damage control concept allows rapid arresting hemorrhage and performing the control for the patient’s condition. The adequate correction of shock is important, because of high risk of complications in patients with massive bleeding with the primary mechanism including acidosis, hypothermia, coagulopathy. The use of techniques of hardware autohemotransfusion gives 2.5-fold reduction of time of shock correction and 6.5-fold decrease in the volume of donor blood, as well as reducing the mortality after acute blood loss from 16 to 4 %.
The next stage is correction of homeostasis disorders in conditions of the ICU. At the same time, additional diagnostics of injuries is conducted. The third stage is relaparotomy, comprehensive correction of injuries, reconstruction of injured organs and systems. If recurrent decompensation develops during the third stage, a patient can be returned to the previous stage.
The indications for use of damage control include massive blood loss in combination with hypothermia and coagulopathy; presence of bleeding without possibility for single-moment correction; impossibility of conventional closure of a surgical wound. The errors of staged correction are the increase in duration and the volume of primary care, an attempt of single-moment correction of injuries in conditions of decompensated shock, non-adequate (insufficient or excessive) amount of tampons used in programmed packing. The third stage is associated with danger of planned (recurrent) intervention before stabilizing the patient’s condition. All errors of staged correction lead to death, i.e. they are important [4, 7, 8, 10, 13, 16, 19].
The experience with staged correction of injuries in decompensated patients demonstrate the following features of such treatment: minimization of surgical aggression, compensation of insufficient material resources, acknowledgment of the dominating role of critical care measures as compared with surgical reconstruction. The advantages of such treatment include the possibility for recurrent estimation of the features of injuries for choice of optimal reconstructive treatment at the third stage; level downing the lack of experience in team of doctors giving the care for patients in severe condition at the first stage; correction of homeostasis can be continued at the second and third stages in the optimized conditions [7, 10, 16].
One should note the versatility of damage control concept. It can be used not only for abdominal injury, but also for injuries to the thoracic organs, associated injury, traumatic brain injury and spinal injury [7, 14, 19].
The significant progress in treatment of polytrauma can be achieved with the clear organizational algorithm. The experience shows that diagnostic and tactical errors are possible in more than half of cases of polytrauma treatment. As result, it is more appropriate to render medical care in conditions of a big multi-profile facility with sufficient experience in treatment of such group of patients [3, 4, 12, 16, 18].
An example of the level 1 trauma center providing the specific care for patients with polytrauma is Regional Clinical Center of Miners’ Health Protection (Leninsk-Kuznetsky). On the basis of this facility, the efficient system for arrangement of the organizational and medicodiagnostic measures for increasing efficiency of polytrauma treatment has been developed [3, 4, 10]. The accumulated experience is thoroughly presented in the pages of Polytrauma journal having the 10-year experience.


Arrangement of medical care for patients with polytrauma is one of the actual sections of the modern medicine. This section requires the multidisciplinary approach. Arrangement of medical care requires the efforts of many specialists: emergency service physicians, surgeons, traumatologists, anesthesiologists. The process of medical care should be guided by a physician with the highest experience in treating such group of patients. Some key issues should be reviewed during solving this problem: transportation, estimation of injury severity and, the main one, who should treat a patient with associated injury and which techniques should be used.


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