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Главная > № 4 (2021) > Гуманенко

SEVERE COMBINED TRAUMA AND POLYTRAUMA: DEFINITION, CLASSIFICATION, CLINICAL CHARACTERISTICS, TREATMENT OUTCOMES 

Gumanenko E.K., Zavrazhnov A.A., Suprun A.Yu., Khromov A.A.

St. Petersburg State Pediatric Medical University, Kirov Military Medical Academy, Saint Petersburg, Russia

“Severe concomitant injury” and “polytrauma” are now common terms for defining the most severe injuries, in which, as a result of extreme exposure to a person, severe injuries occur in several areas of the body. These injuries are accompanied by life-threatening consequences of trauma: asphyxia, external or internal ongoing bleeding, cardiac tamponade, cerebral compression, tension or open pneumothorax. In response to severe trauma and its consequences, the body of the injured person urgently implements a genetically generated protective program aimed at counteracting the rapidly developing post-traumatic pathological processes. Clinically, this interaction is manifested by an acute violation of vital functions in the form of traumatic shock, traumatic cerebral coma, acute respiratory failure or acute heart failure due to heart contusion.
To save the lives of such victims, emergency medical care is required, aimed at eliminating the life-threatening consequences of injuries and restoring vital functions. These activities should begin at the site of the injury and continue during the transportation of victims to a level I or II trauma center during the "golden hour". In a level I trauma center, within the first 6 hours, the full volume of specialized resuscitation care and the full volume of multidisciplinary specialized surgical care should be provided. These provisions are an axiom for specialists of trauma centers, since they are approved by law by the relevant "Procedures for the provision of medical care." At the same time, on the problem of determining polytrauma and the classification of severe concomitant injuries, various opinions remain among surgeons and traumatologists who professionally work in the space of this severe traumatic pathology and have been studying this problem for a long time. The current situation was an objective reason for initiating a discussion on the pages of a popular Russian journal among specialists and scientific researchers, which regularly covers the state of the problem under discussion.
Objective - to present and discuss the modern therapeutic and tactical characteristics of severe combined injuries for the formation of a conciliatory interdisciplinary definition of the concept of "polytrauma" and the creation of a unified classification of severe combined injuries for surgeons and traumatologists.
Tasks: 1) presentation of the evolution of the problem of determining polytrauma and classification of severe concomitant injuries; 2) objective substantiation of the main provisions of their own concept; 3) a proposal for discussion of their own options for the definition of "polytrauma" and the classification of severe concomitant injuries.

MATERIALS AND RESEARCH METHODS

A representative clinical and statistical analysis of the results of treatment of 331 victims with severe concomitant injuries and polytrauma was carried out. The study was carried out in accordance with the principles of the Declaration of Helsinki of the World Medical Association - Ethical Principles for Medical Research Involving Hyman Subjects (2013) and the Rules for Clinical Practice in the Russian Federation approved by the Order of the Ministry of Health of the Russian Federation of June 19, 2003, No. 266.
The victims of this sample were provided with specialized resuscitation care, emergency multidisciplinary specialized surgical care. High-tech treatment of traumatic illness was carried out in the period from 2012 to 2017 in trauma centers of the first level of large hospitals in St. Petersburg: Elizavetinskaya Hospital and the clinic of Kirov Medical Military Academy. Inclusion criteria were: 1) damage to several areas of the body, 2) the presence of one or more severe injuries with AIS (version 1998) ≥ 3 and Military Field Surgery-Injury (Gunshot Wound) scale ≥ 1, 3) delivery time to the trauma center ≤ 1 hour. The exclusion criterion was age > 60 years. The average age of the victims was 37.4 ± 0.8 years. The severity of injuries was assessed according to ISS, NISS, Military Field Surgery-Injury (Gunshot Wound) scale; the severity of the condition of the victims - according to Military Field Surgery-State Upon Admission scale. Information about patients was entered into an electronic database.
To solve the research problems, we used the methods of statistical data processing from the system of medical and biological programs STATISTICA 10.0 for WINDOWS. The first program is an assessment of the mathematical expectation, variance, median, mode, skewness, kurtosis, graphical representation of distributions (Basic Statistics and Tables module). The second is analysis of variance (ANOVA / MANOVA module). The third is correlation analysis (Basic Statistics and Tables module). The fourth is the analysis of contingency tables (Table and Banner module). The fifth one is discriminant analysis (Discriminant Analysis module).

RESULTS AND DISCUSSION

Evolution of the problem of classification of severe injuries and definition of polytrauma

 For the first time in our country, the idea of polytrauma as a major scientific problem was voiced at the IIIrd All-Union Congress of Traumatologists and Orthopedists in 1976. By the decision of the Congress, the definitions and classification of mechanical injuries proposed by A.V. Kaplan, V.F. Pozharsky and V.M. Lirtsman were approved. The classification was based on the division of all mechanical injuries into four types: isolated, multiple, concomitant and combined ones, and the concept of "polytrauma" was considered equivalent in meaning to the concepts of "multiple" or "combined" injury. To assess the severity of polytrauma, three criteria were proposed: the frequency of traumatic shock, mortality and the frequency of performing urgent surgical interventions [1]. After the congress in 1978-1990, the largest discussion was on the pages of the most popular at that time journals "Orthopedics, Traumatology and Prosthetics", "Surgery" and "Bulletin of Surgery named after I.I. Grekov ". The leading traumatologist-orthopedists and surgeons of the country took part in the discussion: A.B. Rusakov, S.S. Tkachenko, G.D. Nikitin, E.G. Gryaznukhin, I.I. Deryabin, Yu.G. Shaposhnikov, V.F. Trubnikov, V.A. Sokolov, I.A. Eryukhin and others. The main subjects of discussion were: 1) the definition of the "focus of injury" as the main structural unit of the classification of injuries, 2) the definition and classification of multiple injuries. The discussion did not make any fundamental changes in the classification of injuries by A.V. Kaplan and others, but it contributed to: 1) a more precise definition of the concepts: "isolated", "multiple" and "combined injury", 2) agreement between traumatologists and surgeons on dividing the human body into 7 areas when making a classification of injuries: the head, neck, chest, abdomen, pelvis, spine, limbs. From this point of view, injuries with one focus of damage began to be considered isolated, injuries with several foci within one area of ​​the body were considered as multiple, and injuries that had several foci of damage in different areas of the body were combined. These definitions and classification of injuries proved to be resistant to subsequent attempts to modify them, became a recognized methodology for systematizing injuries and the basis for constructing diagnoses, strategies and tactics for treating this severe traumatic pathology. With this approach to the problem, there was no place for the concept of "polytrauma" as a nosological category in this classification [2].
International discussion of topical issues of polytrauma took place for the first time in 1982 at a large-scale congress "Advances in the treatment of multiple trauma patients" in Baltimore (USA). With regard to the definition of the concept of "polytrauma" and the possibilities of its grades in severity, the proposals of six leading world-class luminaries in this problem were discussed: N. Tscherne (Hannover, Germany), G. Heberer (Munich, Germany), S. Olerud (Uppsala, Sweden), M. Allgower (Basel, Switzerland), R. Roy-Camille (Paris, France) and B. Claudi (Dallas, USA). From the definitions presented, it followed that polytrauma includes the most severe injuries that have at least three pathognomonic signs. The first is severe injuries to several areas of the body, one of which is life-threatening. The second is severe injuries to several internal organs or complex fractures of several long bones or a combination of severe injuries to internal organs and complex fractures of long bones. The third is traumatic shock, traumatic cerebral coma or acute respiratory failure as manifestations of acute disturbance of vital functions. To assess the severity of injuries, N. Tscherne suggested using the PTS scale, G. Heberer - the SAT system, B. C1audi - the Schweiberer method [3].
At the beginning of the 21st century, two important events took place in the healthcare of the Russian Federation that significantly influenced the formation of a new attitude of leading surgeons and traumatologists of the country to the concept of "polytrauma" as the medical nosological category. Firstly, this is the implementation of a new model of national health care in the compulsory health insurance system. Secondly, the introduction into regional health care of a new system of organization of emergency specialized multidisciplinary medical care for victims with "severe trauma accompanied by shock" [4]. The new system combined specialized prehospital medical care and regional trauma centers of levels I and II to provide emergency specialized multidisciplinary medical care to such victims in the shortest possible time. The efficiency of the system was ensured by the regulated routing of this category of victims. When implementing such system, the term "polytrauma" was proposed to denote the contingent of victims with the most severe concomitant, multiple injuries and shock, which needs specialized resuscitation care and emergency multidisciplinary specialized surgical care. It was these victims who had to be sent to level I trauma centers, where the necessary forces and means for the provision of emergency specialized multidisciplinary medical care were concentrated.
The subsequent evolution of the definition of "polytrauma" consisted in detailing and objectifying the severity of injuries and the severity of the condition of the victims. Based on the results of a prospective expert study conducted by expert surgeons and expert traumatologists from the United States, Germany and the Netherlands, a consensus decision was formulated on the definition of "polytrauma". It was recommended to classify this category of severe injuries as the most severe damages with severe injuries (AIS > 2 points) in at least two areas of the body and with a total severity of injuries according to ISS of more than 17 points [5]. Later, the "Berlin definition of polytrauma" included not only anatomical, but also functional parameters, as well as the age of the victims [6]. Ultimately, the “New Berlin definition of polytrauma” was proposed, in which: 1) there are two or more severe injuries, each of which is assessed on AIS  ≥ 3 points; 2) there are violations of vital body functions, manifested by one or more of the listed symptoms: hypotension (systolic blood pressure ≤ 90 mm Hg), cerebral coma (GCS ≤ 8), acidosis (BE ≤ 6.0 mmol / l), hypocoagulation (APTT ≥ 40 sec., INR ≥ 1.4); 3) the age of the victims ≥ 70 years [7]. It should be noted that this European definition of "polytrauma" has many supporters in Russia [8].

Substantiation of the main provisions of the own concept of definition of polytrauma and classification of severe concomitant injuries

 When formulating the concept of definition of polytrauma and classification of severe concomitant injuries, the authors proceeded from five fundamental provisions. The first - severe concomitant injuries and polytrauma are a single type of severe injuries in which severe and mild injuries occur in several (≥ 2 out of 7) areas of the body and are accompanied by an acute violation of the vital functions of the injured person's body. The second - polytrauma is a particular type of severe concomitant injuries, which is distinguished by the greatest severity of the injury. The third - severe concomitant injuries differ in the total severity of injuries, the number of damaged areas of the body and the number of severe injuries localized in different areas of the body. The fourth - polytrauma includes severe concomitant injuries with two or more severe injuries (AIS severity ≥ 3 each). The fifth position is based on an objective fact stating that with such an approach to the definition of severe concomitant injuries and polytrauma, the range of this category of victims turns out to be very large and varied in severity, nature and localization of injuries, according to the severity of the condition of the victims, according to the therapeutic strategy and tactics of treating injuries of individual areas of the body, as well as treatment outcomes. Therefore, it is expedient to divide all victims with severe concomitant injuries into several categories, objectively and substantiated from a therapeutic and tactical standpoint.
To systematize the studied victims with severe concomitant injuries, a traditional approach was used, in which lethality was chosen as a classifying criterion, divided into three levels: 1st − 0, 2nd − from 0 to 50 %, and 3rd − more than 50 %. In accordance with the mortality rate, all victims with severe associated injuries were divided into three groups. The first - a group with a favorable prognosis, in which there was no mortality; it corresponds to victims with the least severity of severe concomitant injuries and is designated as “victims with severe concomitant injuries”. The second - a group with a positive prognosis, in which the mortality rate did not exceed 50 %; it corresponds to the following gradation of severe concomitant injuries in terms of severity and is designated as “victims with polytrauma”. The third is a group with a poor prognosis. In this group, the mortality rate exceeded 50 %. Therefore, it was assigned the maximum gradation of severe concomitant injuries, and it was designated as “victims with extremely severe polytrauma”. To prove the objectivity and therapeutic and tactical justification of such approach to the definition and classification of severe concomitant injuries, a comparative clinical and statistical analysis of the selected groups of victims was carried out according to signs characterizing the severity and localization of injuries, the severity of the condition of the victims, the content of the main measures of specialized resuscitation care and emergency multidisciplinary specialized surgical help, features of the course of traumatic illness and the immediate outcome of treatment (tables 1-5).

Table 1. Characteristics of the victims by localization and severity of damage

Number of Damaged areas of the body and severity of damage	Research array groups			Total n = 331
	Severe combined injuries n = 96	Polytrauma n = 147	Extremely severe polytrauma n = 88
Number of damaged areas of the body
N (M ± m)	2.7 ± 0.1	3.3 ± 0.1	4.1 ± 0.2	3.4 ± 0.1
P < 0.0001 for groups 1 and 3, 2 and 3
Severity of damage according to ISS
ISS (M ± m)	16.2 ± 0.1	21.6 ± 0.2	36.9 ± 0.9	24.1 ± 0.5
P < 0.0001 for all groups
Number of injuries, severity according to AIS	1, AIS = 4	2, AIS = 3	3, AIS =3	-
ISS (Min → Max)	11 → 17	18 → 35	36 → 75	11 → 75
Severity of damage according to NISS
NISS (M ± m)	17.0 ± 0.4	27.4 ± 0.5	45.8 ± 0.9	29.3 ± 0.7
P < 0.0001 for all groups
Number of injuries, severity according to AIS	1, AIS = 4	3, AIS = 3	3, AIS = 3	-
NISS (Min → Max)	12 → 18	19 → 40	41 → 75	12 → 75
Severity of damage according to Military Field Surgery-Damage
MFS-D (M ± m)	1.9 ± 0.06	7.8 ± 0.3	24.0 ± 1.0	10.4 ± 0.5
P < 0.0001 for all groups
MFS-D (Min → Max)	1.0 → 3.0	3.1 → 15.0	15.1 → 72.1	1.0 → 72.1

Table 2. Characteristics of the victims by severity of damage

Severity of condition of victims	Research array groups						Total n = 331
	Severe combined injuries n = 96		Polytrauma n = 147		Extremely severe polytrauma n = 88
Severity of condition of victims on Military Field Surgery-State on Admission scale
MFS-SA (M ± m)	22.8 ± 0.1		27.0 ± 0.3		46.0 ± 0.5		29.4 ± 0.5
P < 0.0001 for all groups
MFS-SA (Min → Max)	21 → 29		24 → 38		35 → 78		21 → 78
Severity of condition of victims according to clinical syndromes
Clinical syndromes	Abs.	%	Abs.	%	Abs.	%	Abs.	%
Traumatic shock	77	80.2	115	78.2	29	33.0	221	66.8
Traumatic brain coma	0	0	9	6,1	51	57.9	60	18.1
ARDS	17	17.7	15	10.2	7	8.0	39	11.8
AHF	2	2.1	8	5.5	1	1.1	11	3.3
Total	96	100.0	147	100.0	88	100.0	331	100.0
Pearson's criterion χ2 = 136.6; crit. value = 26.12 at p = 0.001; Ccoup. = 0.535

Table 3. Characteristics of the victims according to the need and content of specialized resuscitation care

Content of specialized resuscitation care	Research array groups						Total n = 331
	Severe combined injuries n = 96		Polytrauma n = 147		Extremely severe polytrauma n = 88
	Abs.	%	Abs.	%	Abs.	%	Abs.	%
Intravenous (intraarterial) infusions
IT	47	49.0	21	14.3	9	10.2	77	23.3
ITT	49	51.0	126	85.7	79	89.8	254	76.7
Total	96	100.0	147	100.0	88	100.0	331	100.0
Pearson's criterion χ2 = 136.6; crit. value = 13.82 at p = 0.001; Ccoup. = 0.535
Inotropic support
Not performed	87	90.6	65	44.2	14	15.9	166	50.2
Was performed	9	9.4	82	55.8	74	84.1	165	49.8
Total	96	100.0	147	100.0	88	100.0	331	100.0
Pearson's criterion χ2 = 72.1; crit. value = 25.61 at p = 0.001; Ccoup. = 0.423
Respiratory support
Not performed	87	90.6	49	33.3	0	0	136	41.1
Was performed	9	9.4	98	66.7	88	100.0	195	58.9
ALV < 3 days	9	9.4	61	41.5	31	35.2	101	30.5
ALV > 3 days	0	0	37	25.2	57	64.8	94	28.4
Total	96	100.0	147	100.0	88	100.0	331	100.0
Pearson's criterion χ2 = 39.0; crit. value = 13.82 at p = 0.001; Ccoup. = 0.415
Duration of ALV (M ± m)	1.7 ± 0.9		5.0 ± 0.6		6.7 ± 0.7		4.5 ± 0.8
P > 0.05
Duration of treatment in ICU (M ± m)	6.5 ± 0.6		11.1 ± 1.2		15.3 ± 1.5		7.8 ± 0.7
P < 0.005 for groups 1 and 3, P < 0,01 for 1 and 2, 2  and 3

Table 4, Characteristics of the victims by need and content multidisciplinary specialized surgical care

Need for and content of multi-profile specialized surgical care	Research array groups						Total n = 331
	Severe combined injuries n = 96		Polytrauma n=147		Extremely severe polytrauma n = 88
	Abs.	%	Abs.	%	Abs.	%	Abs.	%
Not provided	0	0	2	1.4	14	4.5	16	4.8
Was provided:	96	100.0	145	98.6	84	95.5	315	95.2
emergency	80	83.3	146	99.3	84	95.5	310	93.7
planned	38	39.6	68	46.3	18	20.5	124	37.5
Total	96	100.0	147	100.0	88	100.0	331	100.0
Pearson's criterion χ2 = 8.7; crit. value = 9.21 at p = 0.01; Ccoup. = 0.170
Types of surgical interventions for victims
Emergency	11	9.3	88	30.1	65	37.4	164	28.1
Urgent	16	13.6	52	17.8	47	27.0	115	19.7
Delayed	53	44.9	84	28.8	44	25.3	181	31.0
Planned	38	32.2	68	23.3	18	10.3	124	21.2
Total of operations	118	100.0	292	100.0	174	100.0	584	100.0
Pearson's criterion χ2 = 71,7; crit. value.= 25,59 at p = 0.001; Ccoup. = 0.431
Total victims	96	100.0	147	100.0	88	100.0	331	100.0
Number of operations for 1 victim	1.2		2.0		2.0		1.8

Table 5. Characteristics of the victims according to the type of course of the traumatic disease and the nearest outcome

Complications of traumatic illness	Research array groups						Total n = 331
	Severe combined injuries n = 96		Polytrauma n = 147		Extremely severe polytrauma n = 88
	Abs.	%	Abs.	%	Abs.	%	Abs.	%
Type of course of traumatic illness
No complications	91	94.9	94	64.0	27	30.7	212	64.0
Complications of traumatic illness:	5	5.1	55	36.0	61	69.3	119	36.0
non-infectious	1	0.9	9	4.7	6	6.8	14	4.3
infectious	4	4.2	46	31.3	55	62.5	105	31.7
Total	96	100.0	147	100.0	88	100.0	331	100.0
Pearson's criterion χ2 = 81.9; crit. value = 22.46 at p = 0.001; Ccoup. = 0.445
Duration of treatment of survivors (M ± m)	22.4 ± 2.1		36.4 ± 4.5		55.7 ± 6.9		34.6 ± 1.7
P < 0.005 for all groups
The nearest outcome of treatment
Survived	96	100.0	131	89.1	37	42.1	264	79.8
Deceased	0	0	16	10.9	51	57.9	67	20.2
Total	96	100.0	147	100.0	88	100.0	331	100.0
Lethality, %	0		10.9		57.9		20.2
Pearson's criterion χ2 = 108.6; crit. value = 13.82 at p = 0.001; Ccoup. = 0.487
The term of the fatal outcome (M ± m)	-		17.5 ± 0.4		6.6 ± 0.9		9.2 ± 1.4
P < 0.005 for 2  and 3

The table 1 shows that the identified groups of victims significantly differ in the number of injured areas of the body: in severe concomitant injuries, 2-3 body regions are most often damaged, in polytrauma - 3, and in extremely severe polytrauma - 4. All identified groups of victims differ significantly in terms of the overall severity of injuries, objectively assessed by ISS, NISS and Military Field Surgery-Injury (Gunshot Wound) scale. At the same time, the number of severe injuries (AIS ≥ 3) in severe concomitant injuries was equal to one when assessing the total severity of the injury both according to ISS and NISS. The number of severe injuries (AIS ≥ 3) in polytrauma was two when assessing the total severity of injury according to ISS and three according to NISS. The number of severe injuries (AIS ≥ 3) in extremely severe polytraumas according to both ISS and NISS turned out to be three, since the rest of the severe injuries are not taken into account by these methods, which is their significant disadvantage.
This disadvantage is clearly confirmed by a relative comparison of groups according to severity indices. Thus, the coefficient of the relative difference in the total severity of injury between the compared groups: polytrauma/severe combined injuries, extremely severe polytrauma/polytrauma and extremely severe polytrauma/severe combined injuries - according to ISS index was 1.3, respectively; 1.7 and 2.3; for NISS - 1.6; 1.7 and 2.7; and on Military Field Surgery-Injury (Gunshot Wound) scale - 4.1; 3.1 and 12.6. This difference is explained by the fact that ISS index, like NISS index, is the square of the true injury severity value calculated on AIS scale and cannot characterize the true injury severity. When assessing the overall severity of injuries according to the Military Field Surgery-Injury (Gunshot Wound) scale, the true scores of each injury are summed up, associated with a dense linear relationship with the mortality rate. This methodology of the scale forms different ranges of severity and different specific contributions to the lethality of mild (0.01-0.9) and severe (1.0-75.0 points) injuries. Therefore, it makes no sense to count the number of severe injuries when assessing the total severity of injury on Military Field Surgery-Injury (Gunshot Wound) scale due to the absolute dominance of the scores of severe injuries over the scores of non-severe injuries, a large gradation of their severity and a large number of severe injuries in one victim when evaluating them using this method.
The selected groups significantly differ in the dominant damage with a moderate correlation: Pearson χ² criterion = 168.4, its critical value = 32.91 with p = 0.001; contingency factor = 0.580. In severe concomitant injuries, the most often dominant is limb injury - 61 injured (63.5 %) and chest injury - 19 (19.8 %), less often head injuries dominate - 8 patients (8.3 %), abdominal injuries - 4 (4, 2 %) and the spine -4 (4.2 %). In polytrauma, in most cases, the dominant is injury to the limbs -40 (27.2 %), the pelvis - 34 (23.1 %) and chest - 26 (17.7 %), less often abdominal injuries dominate - 16 (10.9 %), head - 16 (10.9 %), spine - 9 (6.1 %) and neck - 5 (3.4 %). Extremely severe polytrauma is characterized by the dominance of damage to areas with vital organs: head - 51 patients (57.9 %), chest - 14 (15.9 %) and abdomen - 10 (11.4 %), less often pelvic injuries are dominant - 5 (5.7 %), spine - 4 (4.5 %) and neck - 2 (2.3 %).
The data in the table 1 objectively prove two points. Firstly, for the definition and classification of severe concomitant injuries, an objective sign is damage to several areas of the body and their number: 2-3 - for severe concomitant injuries, 3 - for polytrauma, and 4 - for extremely severe polytrauma. Secondly, for the definition and classification of severe concomitant injuries, the objective sign is the number of severe injuries assessed on AIS ≥ 3 points: 1 - for severe concomitant injuries, 2-3 - for polytrauma and ≥ 3 -  for extremely severe polytrauma.
Currently, the severity of the condition of victims with severe concomitant injuries and polytrauma is assessed using objective methods (SAPS, Military Field Surgery-State Upon Admission scale, TS, etc.), as well as the formation and severity of clinical syndromes specific to severe concomitant injuries and polytrauma. Such syndromes are traumatic shock, traumatic cerebral coma, acute respiratory failure (ARF) and acute heart failure (AHF) with heart contusions. In this article, an objective assessment of the severity of the condition of the victims upon admission to the trauma center is presented according to Military Field Surgery-State Upon Admission scale, and the clinical assessment of the severity of the condition - according to clinical syndromes (Table 2).
From Table 2 it follows that the group of severe concomitant injuries includes victims with a subcompensated (21-30 points) level of severity of the condition: from 21 to 29 points. In the overwhelming majority of the victims, a severe condition was manifested by traumatic shock, mainly Ist degree (71.6 %), less often - ARF and AHF with heart contusions. Polytrauma is characterized by subcompensated and decompensated (> 30 points) severity levels: from 21 to 38 points. In most cases, a serious condition was also manifested by traumatic shock, but mainly of II-III degree (54.4 %), less often - ARF, traumatic cerebral coma and AHF with heart contusions. Extremely severe polytrauma is characterized mainly by a decompensated level of severity of the condition: from 35 to 78 points. In most of the victims of this group, the severe condition was manifested by traumatic cerebral coma (57.9 %), less often - ARF and AHF with cardiac tamponade. For all the signs characterizing the severity of the condition, the identified groups of victims have a moderate correlation and differ with a high degree of reliability.
The main reasons for the serious condition of 220 studied victims were life-threatening consequences of injuries (66.5 %). It is for their elimination that the activities of specialized resuscitation care and urgent measures of multidisciplinary specialized surgical care are urgently carried out. In general, with all types of severe concomitant injuries, the following types of life-threatening consequences of injuries developed: in 5 victims - asphyxia (1.5 %), in 47 - external bleeding (14.2 %), in 80 - internal bleeding (24.2 %) , in 60 - compression and dislocation of the brain (18.1 %), in 27 - tense pneumothorax (8.2 %) and in 1 - cardiac tamponade (0.3 %).
In severe concomitant injuries, the life-threatening consequences of injuries (33.3 %) were the cause of the serious condition in 32 victims. Most often (in 15 cases) it was external bleeding with injuries to the arteries of the extremities (15.6 %), in 7 cases - internal bleeding with injuries to the parenchymal organs of the abdomen and multiple unstable fractures of the pelvic bones (7.3 %), and a serious condition manifested itself traumatic shock. In 9 victims, the cause of the serious condition was tension pneumothorax with bronchial ruptures (9.4 %), in 1 - combined asphyxia as a result of open craniofacial trauma (1 %), which manifested ARF.
The victims with polytrauma were characterized by a high level of life-threatening consequences of injuries - they developed in 100 victims (68.0 %). In 53 cases, it was internal bleeding with injuries to the abdominal and chest organs, unstable fractures of the pelvis (36.1 %), in 23 cases - external bleeding with injuries to the arteries of the extremities (15.6 %), while the severity of the condition was manifested by traumatic shock degrees II and III. In 11 cases, acute respiratory disorders in the form of tense pneumothorax in severe chest injuries (7.5 %) were the cause of acute disturbance of vital functions, in 4 - dislocation and aspiration asphyxia in severe craniocerebral trauma (2.7 %). In 9 victims, the cause of a serious condition was severe brain damage due to its compression and dislocation (6.1 %), manifested by the clinical picture of traumatic cerebral coma.
The severe and extremely severe condition of all the victims as a clinical manifestation of acute disturbance of vital functions was a characteristic sign of extremely severe polytrauma. In all cases, it was caused by the life-threatening consequences of trauma. Moreover, the main ones were due to damage to vital organs. In 51 victims, the cause of acute disturbance of vital functions and an associated extremely serious condition was severe brain damage with contusion, compression and dislocation, and axonal brain damage (57.9 %) manifested by traumatic cerebral coma. In 20 cases, the cause of severe and extremely severe conditions was intra-abdominal, intrapleural and intrapelvic bleeding (22.7 %), and in 9 cases - external arterial bleeding (10.3 %). In 7 victims, the cause of acute disturbance of vital functions and serious condition was tense pneumothorax as a result of bronchial rupture (8.0 %), and in 1 - cardiac tamponade (1.1 %) due to penetrating into the heart cavity of the myocardium of the right ventricle by an acute fragment of broken ribs. The identified three groups of victims significantly differ in the frequency and types of life-threatening consequences of injuries with a moderate correlation: Pearson χ² criterion = 212.7; its critical value = 25.59 at p = 0.001. Contingency coefficient = 0.625.
The data in the table 2 objectively prove the following two propositions. The third position - for the definition and classification of severe concomitant injuries, an objective sign is the serious condition of the victims, manifested clinically by traumatic shock (66.8 %), traumatic cerebral coma (18.1 %), ARF (11.8 %) or AHF with heart contusions (3.3 %) and assessed objectively on Military Field Surgery-State Upon Admission scale > 20 points. The fourth position - the main causes of a serious condition in all types of severe concomitant injuries are life-threatening consequences of injuries: asphyxia (1.5 %), external (14.2 %) or internal (24.2 %) bleeding, compression and dislocation of the brain (18.1 %), tension pneumothorax (8.2 %) or cardiac tamponade (0.3 %).
A distinctive feature of severe concomitant injuries and polytrauma is the need for all victims of this category in emergency specialized multidisciplinary medical care. It includes specialized resuscitation care (Table 3) in intensive care units (ICU) and emergency multidisciplinary specialized surgical care (Table 4) in operating units for anti-shock measures at level I trauma centers.
From Table 3 it follows that the need for the victims with severe concomitant injuries and polytraumas in specialized intensive care was 100.0%. The content of specialized resuscitation care was: objective systemic monitoring of the severity of the condition of the victims on Military Field Surgery-State Upon Admission scale and Military Field Surgery-Condition Monitoring scale - in the process of intensive care in ICU, diagnosis of dysfunction or insufficiency of life support systems and their directional correction. In the provision of specialized resuscitation care, there were three main activities. The first is replenishment of the circulating blood volume and restoration of its rheological properties, prevention of disseminated intravascular coagulation in all victims. Its implementation was carried out through continuous multicomponent infusion therapy (IT), and in 76.7 %  − infusion-transfusion therapy (ITT) through large veins, as well as through the abdominal aorta (6.3 %) with traumatic shock of the IIIrd degree or terminal state. The second - maintaining the proper volume of blood circulation, contractile function of the myocardium and a safe level of blood pressure by continuous drip injection of inotropic or vasoactive drugs; it was carried out for 49.8 % of patients. The third - respiratory therapy to maintain the safe oxygen tension in arterial blood, which was provided by artificial lung ventilation (ALV) and assisted lung ventilation in various modes - 58.9 % of victims. The average period of treatment for victims in ICU was 8 days: the minimum - for victims with severe concomitant injuries, the maximum - for victims with extremely severe polytraumas. For all the signs that characterize the need and content of specialized resuscitation care, the selected groups of victims have a moderate correlation and differ with a high degree of reliability.
Table 4 shows that the overwhelming majority of the studied victims required emergency multidisciplinary specialized surgical care - 93.7 %: with severe concomitant injuries - 83.3 %, with polytrauma - 99.3 %, with extremely severe polytrauma - 95.5 %. It should be noted that in the second and third groups, emergency operations were not performed only for patients in terminal state. The volume of emergency multidisciplinary specialized surgical care in operating rooms for anti-shock measures was complete, i.e. in the acute period of traumatic illness, all necessary surgical interventions were performed on all areas of the body by a multidisciplinary surgical team. Urgent operations accounted for 28.1 % of all performed surgical interventions, emergency - 19.7 % and delayed - 31.0 %. The largest proportion of urgent and emergency operations was typical for extremely severe multiple trauma and polytrauma, the smallest - for severe concomitant injuries. The gradation of the proportion of delayed operations was inverse, which is explained by the predominance of injuries to the musculoskeletal system in patients with severe concomitant injuries.
An important surgical technology that made it possible to implement the strategy “Full volume of emergency multidisciplinary specialized surgical care in the acute period of traumatic disease” was the tactics of programmed multistage surgical treatment [9]. In case of extremely severe abdominal injuries, the tactics of programmed multi-stage surgical treatment (Damage control surgery) was used in 7 cases (2.1 %). In 39 patients with unstable multiple fractures of the pelvic bones (11.8 %), in 17 patients with unstable fractures of the spine (5.1 %) and in 167 patients with all types of fractures of long bones (50.5 %), the tactics of programmed multistage surgical treatment was used (Damage control orthopedics). In the subsequent periods of traumatic illness, all patients underwent expensive treatment for MODS, infectious complications of injuries, and rehabilitation treatment, during which 124 (21.2 %) patients underwent high-tech planned surgical interventions on all areas of the body. In general, 1 patient with severe concomitant injury underwent 1.2 surgical interventions. This indicator was 2.0 for polytrauma and extremely severe polytrauma. All three groups differ with a high degree of reliability according to the given features.
The research results presented in tables 3 and 4 prove another important point. The fifth position - for the definition and classification of severe concomitant injuries, an objective sign is the need for specialized resuscitation care and multidisciplinary specialized surgical care, high-tech treatment of complications of traumatic illness and high-tech rehabilitation treatment in level I trauma centers.
Important indicators characterizing various types of severe concomitant injuries are the frequency, nature and severity of complications of traumatic illness, the duration of inpatient treatment and mortality (Table 5).
It follows from Table 5 that for all types of severe concomitant injuries, a complicated course of traumatic illness was noted in 36 % of cases, and three groups of severe concomitant injuries distinguished in the frequency of complications with a high degree of reliability. Thus, the minimum number of complications was characteristic of severe concomitant injuries - they developed in 6 out of 96 victims (5.1 %). In polytrauma, the frequency of complications was significantly higher - they developed in 36 % of victims: 9 patients with non-infectious complications (fat embolism, thromboembolism, edema and dislocation of the brain, etc.), 55 patients with infectious complications (local, visceral and generalized forms of wound infection). The maximum incidence of complications was typical for extremely severe polytrauma - 69.3 %, mainly due to various forms of generalized infection in the form of sepsis, severe sepsis and septic shock. The identified groups of severe concomitant injuries also differ with a high degree of certainty in mortality and the timing of treatment for survivors. In the group of severe concomitant injuries, there is no lethality, and the period of treatment for the victims is minimal - 22 days. In patients with polytrauma, the mortality rate is low - 10.9 %, the duration of inpatient treatment is 36 days. Patients with extremely severe polytrauma are characterized by the highest mortality rate - 57.9%, and the maximum duration of treatment was 56 days.
The research results presented in Table 5 prove the last point. The sixth position - for the definition and classification of severe concomitant injuries, objective signs are: the incidence of complications of traumatic illness, the duration of inpatient treatment of victims and mortality.

FINAL RESULTS

Scientific and professional discussion of the problem of severe associated injuries has a half-century history. During this time, there has been an evolution of pathogenetic and therapeutic-tactical concepts, definitions and classification of mechanical injuries, strategies for treating severe concomitant injuries in general, and tactics for treating injuries of individual areas of the body. This article is a call to scientific researchers and practitioners on this issue to discuss two important issues that form the methodological basis of the modern treatment strategy for this complex interdisciplinary traumatic pathology - the definition of the concept of "polytrauma" and the classification of severe concomitant injuries.
To discuss the questions posed, the results of the clinical and statistical analysis of the representative sample of 331 cases of severe concomitant injuries are presented. The provision of emergency specialized multidisciplinary medical care to patients and the subsequent treatment of traumatic illness was carried out in level I trauma centers in St. Petersburg according to the canons of the outstanding experience of the department and clinic of Kirov Military Medical Academy by multidisciplinary teams consisting of current and former employees. A feature of emergency specialized multidisciplinary medical care was the implementation of the strategy "The full volume of emergency multidisciplinary specialized surgical care in the acute period of traumatic illness." The possibility of its safe implementation was ensured by objective monitoring of the severity of the condition of patients on Military Field Surgery-State Upon Admission scale and Military Field Surgery-Condition Monitoring scale in the course of intensive therapy, using the tactics of programmed multi-stage surgical treatment (damage control) and minimally invasive surgical technologies.

CONCLUSION:

         1. Severe concomitant injuries are defined as severe injuries, in which multiple injuries, one of which is severe (AIS ≥ 3), have occurred in multiple areas of the body; the total severity of injuries is 11-75 according to ISS, 12-75 according to the NISS, 1.0-75 points on Military Field Surgery-Injury (Gunshot Wound) scale, 21-78 points on Military Field Surgery-State Upon Admission scale.
          2. Severe concomitant injuries are accompanied by acute impairment of vital functions, which is characterized by a severe condition, assessed objectively Military Field Surgery-State Upon Admission scale ≥ 21 points and manifested by traumatic shock (66.8 %), traumatic cerebral coma (18.1 %), ARF (11.8 %) and AHF with heart contusions (3.3 %).
3. The main causes of a serious condition in severe concomitant injuries are life-threatening consequences of injuries: asphyxia (1.5 %), external (14.2 %) or internal (24.2 %) bleeding, compression and dislocation of the brain (18.1 %), tension pneumothorax (8.2 %) or cardiac tamponade (0.3 %).
         4. All victims with severe concomitant injuries need specialized multidisciplinary medical care: 100.0 % - in specialized intensive care, 93.7 % - in emergency multidisciplinary specialized surgical care, 36 % - in high-tech treatment of traumatic disease and 37.5 % - in high-tech restorative surgical treatment.
5. For the formation of a rational strategy for the treatment of victims, severe concomitant injuries should be classified into three types that significantly differ in all studied parameters: I - “severe concomitant injuries”, II -“polytrauma” and III - “extremely severe polytrauma”.
6. Polytrauma is the most severe type of severe concomitant injuries, in which two or more severe injuries (AIS ≥ 3) have occurred in three or more areas of the body, the total severity of injuries is 18-75 according to ISS, 19-75 according to NISS, 3.1-75 points according to  Military Field Surgery-Injury (Gunshot Wound) scale, 24-78 points according to Military Field Surgery-State Upon Admission scale.

DEFINITION OF THE CONCEPT OF "POLYTRAUMA"

Polytrauma is the most serious trauma, in which several severe injuries occur in several areas of the body, as well as acute disruption of vital functions, and for which the victims need specialized foot-profile medical care in level I trauma centers.

REFERENCES:

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