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PRIMARY ASSESSMENT OF SEVERITY OF CONDITION AS THE BASIS FOR CHOOSING A STRATEGY OF DIAGNOSTIC AND THERAPEUTIC TACTICS IN PATIENTS WITH COMBINED TRAUMA
Amarantov D.G., Zarivchatsky M.F., Kholodar A.A., Ladeyshchikov V.M., Denisov A.S., Belokrylov N.M., Shchekolova N.B., Tokarev A.E.
Perm State Medical University named after Academician E. A. Wagner, Perm, Russia
Injuries
present one of the three main causes of mortality in the population of the
Russian Federation, and it ranks first among the working-age population,
accounting for 45 % of all mortality [1, 2]. The frequency of concomitant
injury in the general structure of injuries is 40–60 %, and the mortality rate
is 35–80 %. Persistent disability with concomitant injury reaches 15–20 %
[1-3].
A special place is occupied by combined injuries
to the organs of the thoracic and abdominal cavities and extremities, which are
characterized by the severity of the victim's condition and present great
difficulties for diagnosis and treatment [1].
Modern medical and diagnostic techniques are
widely introduced into the practice of health care facilities at various
levels. Computed tomography, video endoscopy, modern methods of treating
injuries to the bones of the extremities can now be presented in the arsenal of
a small regional hospital. At the same time, high mortality rates and a large
number of complications, according to many authors, are associated with the
lack of generally accepted rational surgical tactics [4, 5].
Many tactical issues are widely discussed [6].
However, usually outside the boundaries of discussion is the question of the
very first decision that a doctor makes when examining a patient with
concomitant trauma delivered to the emergency department. At this moment, the doctor
is faced with a dilemma - either immediately deliver the patient into the
operating room and continue examination and treatment there, or to examine the
victim in the emergency room (first of all, to perform computed tomography
(CT)) and only then to carry out treatment in the operating room. Both of these
approaches have advantages and disadvantages.
A delay in transportation to the operating room
can be tragic for the patient, and the immediate rise of the patient to the
operating room makes it possible to immediately respond to a life-threatening
situation − to drain the pneumothorax, perform laparotomy for intra-abdominal bleeding, etc.
However, in the operating room, it is impossible to perform CT and, without
resorting to invasive diagnostic methods, to exclude damage to the abdominal
organs, intracranial hematomas, and to identify injuries that, in the future,
can dramatically worsen the patient's condition, for example, a two-stage
rupture of the spleen. In its turn, a detailed examination (primarily CT) in
the admission department makes it possible to draw up a rational plan of
treatment and examination, and often avoid laparoscopy. However, if
complications of concomitant trauma, such as bleeding, tension pneumothorax,
etc., suddenly appear in the emergency room, the time necessary to save the
patient's life may be lost.
Often, the choice between emergency
transportation to the operating room and examination in the emergency room is
obvious, but in some cases it can be difficult to make this decision. A
significant role in such a situation is played by the subjective opinion of the
doctor, his experience and qualifications. One cannot but take into account how
great the temptation is to perform a CT scan on a patient before surgery. In
this regard, we believe that the subjective approach should be excluded from
the process of making such a decision.
In our opinion, the decision on the place of the
beginning of the provision of assistance to the patient should be made already
at the stage of the initial examination, that is, within the first minutes from
the patient's admission to the emergency department until the results of
analyzes and instrumental examination methods are received. This work is
devoted to the creation of an algorithm for making a decision on the choice of
the primary place of care for a patient with concomitant trauma.
Objective - to improve the results of treatment of
patients with combined trauma by developing diagnostic and therapeutic tactics
based on the initial assessment of the severity of the victim's condition.
MATERIALS AND METHODS
The design of this study was as follows. The object of the study was 269
victims with concomitant trauma, hospitalized at City Clinical Hospital No. 4
in Perm in the department of traumatology, thoracic surgery and general surgery
in the period from 2015 to 2021. All patients were examined immediately after
admission using the developed algorithm for choosing diagnostic and therapeutic
tactics based on the initial assessment of the severity of the victim's
condition.
According to the results of using the algorithm, the victims were divided
into two groups:
• a group of patients "operating room", immediately transported
to the operating room, who had a particularly high probability of performing an
urgent surgical intervention;
• a group of patients "admission unit", in whom during the
initial examination no indications were found for performing an urgent
operation, therefore their examination (primarily CT) and treatment was started
in the admission unit.
After the end of the treatment, the final diagnoses and treatment results
of patients of both clinical groups were analyzed and it was determined how
effectively it was possible with the help of the created algorithm to identify
the patients requiring urgent surgical treatment into the “operating room” group.
The age of 269 (100%) victims varied from 14 to 80 years. The average age
of the patients was 35.4 ± 10.1 years. Of these, there were 189 (70.26 %)
patients of working age. Among 269 patients (100 %), 167 were men (62.08 %),
102 (37.92 %) - women. The male to female ratio was 2.64:1.
The causes of concomitant injury were distributed as follows: road
traffic accident - 125 (46.47 %), falling from a height - 36 (13.38 %),
household injury - 95 (35.32 %), of which 43 (15.99 %) of cases, the cause was
a criminal injury. In 4 (1.49 %) cases, the circumstances of the injury could
not be established.
Most of the patients (260 (96.65 %) people) were delivered by the
ambulance service or disaster medicine service, while 9 (3.35 %) people were
delivered by passing transport.
149 (55.39 %) patients had limb fractures. Pneumothorax and hemothorax
were found in 70 (26.02 %). Rib fractures were found in 107 (39.78 %) patients,
lung contusion - 41 (15.24 %), and heart contusion - 18 (6.69 %). Among the
complications of abdominal trauma, hemoperitoneum was found in 38 (15.24 %)
patients, and peritonitis caused by rupture of hollow organs - in 12 (15.24 %).
Traumatic brain injury was detected in 140 (52.04 %) patients, a spinal
fracture - in 19 (7.06 %), and a pelvic fracture - in 32 (11.9 %).
Clinical, laboratory, radiological, radiation (ultrasound, computed
tomography) and minimally invasive video endoscopic (fibrobronchoscopy,
thoracoscopy, laparoscopy) examination methods were used for diagnostics.
During the operations, general surgical instruments and standard
endoscopic equipment were used. Anesthesia with endotracheal anesthesia was
used when performing laparoscopy, laparotomy and thoracotomy, as well as when
applying external fixation devices and performing osteosynthesis. Local
anesthesia was used when performing thoracoscopy and primary surgical treatment
of wounds. According to indications, endobronchial anesthesia was also used
during thoracoscopy.
Statistical
analysis. The statistical data were processed using the Excel and Stat Soft
Statistica 6.0 programs. Quantitative indicators were assessed by means of
arithmetic mean values (M) and standard deviations (σ), qualitative - in
absolute values with percentages (%). The assessment of the reliability of the
results was carried out using the Student's criteria (t), Z. Critical level of
significance was taken equal to 0.05. Differences were assessed as statistically
significant at p < 0.05.
This 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 Human Subjects
(2013) and the Rules for Clinical Practice in the Russian Federation (June
19, 2003). The Ethics Committee of Perm State Medical University approved the
study.
RESULTS
In the treatment, we used the algorithm developed by us for choosing the diagnostic and therapeutic tactics based on the initial assessment of the severity of the victim's condition (Fig. 1). When creating the algorithm, we proceeded from the belief that the decision to transport the victim to the operating room or to conduct an examination (primarily CT) in the admission department should be made in the first 2-3 minutes after the patient is admitted to the hospital, before receiving the test results and conducting X-ray and ultrasound research. When creating the algorithm, we used our own clinical observations and criteria of Military Field Surgery-State upon Admission scale.
Figure 1. Algorithm
for choosing diagnostic and treatment tactics based on primary assessment of
the severity of the victim's condition
|
A patient with combined trauma |
|||
|
Is there one of the signs? ALV |
|||
|
↓ |
↓ |
||
|
Yes |
No |
||
|
↓ |
↓ |
||
|
Transportation of the patient to the operating room |
Estimation of severity of condition according to Military Field Surgery-State on Admission |
||
|
↓ |
↓ |
||
|
← |
32 points and more |
31 points and less |
|
|
|
|
↓ |
|
|
Computed tomography, examination in the admission department |
|||
The primary clinical examination of a patient with associated trauma was
performed by a thoracic surgeon and a traumatologist, who consistently
ascertained signs that are indications for transportation to the operating
room. The first stage of the algorithm was to identify signs of
life-threatening complications requiring urgent surgical treatment: external
and internal bleeding, pneumothorax, peritonitis.
These signs included the presence of a patient on mechanical ventilation,
the absence of pulse; pulse rate less than 60 or more than 140 beats in a
minute; systolic blood pressure less than 90 mm Hg. After determining the ratio
of the pulse to systolic blood pressure in the patient, the Algover shock index
was calculated. At a value of more than 0.8, the victim was diagnosed with
shock, and he or she was transported to the operating room while carrying out
anti-shock measures. Gray skin and wide pupils also favored immediate
transportation to the operating room.
If a patient has external bleeding and temporarily stopped external
bleeding from the great vessels, he or she was also immediately transported to
the operating room.
A patient was also transported to the operating room with tachypnea more
than 30 respiratory movements per minute, the presence of a pathological type
of breathing, and oxygen saturation (SpO2) (with oxygen inhalation)
less than 90.
A clinical examination of the chest reveals signs of lung damage and
intrapleural catastrophe, requiring the patient to be transferred into the
operating room, such as flotation of the chest wall, subcutaneous emphysema,
total and subtotal dulling of percussion sound over one or two halves of the
chest, total tympanic sound over half of the chest, one- or bilateral sharp
weakening or absence of breathing sounds on auscultation.
We consider the dullness of the percussion sound in the sloping places of
the abdomen and the presence of positive peritoneal symptoms to be unambiguous
indications for the immediate transportation of the patient to the operating
room.
We refrain from further examination in the admission department in the
presence of open limb fractures in combination with extensive soft tissue
wounds, as well as their combination with signs of acute limb ischemia.
If necessary, the anesthesiologist-resuscitator was involved in the
treatment of a patient in the emergency department. Intensive therapy measures
began immediately, and, according to indications, resuscitation measures, and a
patient was immediately transported to the operating room.
For the listed categories of victims, further assistance and examination
was carried out in the operating room. In the absence of indications for
immediate surgery on the operating table, patients must undergo radiography of
the chest, abdomen in lateroposition, pelvis and injured limbs, ultrasound of
the abdominal cavity and retroperitoneal space. According to indications,
additional radiography of the spine, additional radiographs of the extremities,
ultrasound of the pleural cavities and the heart are performed.
For the rest of the victims, the second stage of the algorithm is
performed: a general blood test is performed and the severity of the condition
is assessed using the Military Field Surgery-State upon Admission scale (Fig. 2).
Figure 2. The
scale for assessing the severity of the condition of the wounded (injured)
according to Military Field Surgery-State on Admission after arrival to a
medical facility
|
|
Symptoms |
Significance of symptoms |
Assessment of symptoms in points |
|
1. |
Skin surface |
Normal |
1 |
|
2. |
Pattern of external respiration |
Normal |
1 |
|
3. |
Auscultatory changes in the lungs |
Distinct breathing |
1 |
|
4. |
Voice contact |
Normal |
1 |
|
5. |
Pain response |
Persistent |
1 |
|
6. |
Pupillary or corneal reflex |
Persistent |
1 |
|
7. |
Pupil size |
Normal |
1 |
|
8. |
Pulse pattern |
No arrhythmia |
1 |
|
9. |
Heart rate |
60–80 |
1 |
|
10. |
MAP, mm Hg |
101–140 |
1 |
|
11. |
Approximate blood loss, ml |
< 500 |
1 |
|
12. |
Intestinal peristalsis noises |
Clear |
1 |
The criteria for assessing severity in points on this scale are as follows:
satisfactory condition - 12 points, moderate condition - 13-20 points, severe condition
- 21-31 points, extremely severe - 32-45 points and terminal condition - more
than 45 points. Patients in extremely serious and terminal condition are
transported to the operating room, the rest of the patients, the severity of
whose condition is estimated at 31 or less points, are examined in the
admission department. It should be noted that, as a rule, patients in extremely
serious and terminal condition are detected at the previous stage of the
algorithm and immediately transported to the operating room.
The main study performed for patients in the emergency department is CT
of the head, chest, abdomen, pelvis and extremities. This study allows you to
accurately diagnose most injuries and form a rational tactics for further
treatment.
According to the results of using the algorithm, the victims were divided
into two groups: a group of patients for whom examination and treatment was
started in the admission department ("admission unit") and a group of
patients who were immediately taken to the operating room ("operating
room"). There were 158 (58.74 %) victims in the “admission unit” group,
and 111 (41.26 %) patients in the “operating room” group. The analysis revealed
that already at the first stage of the algorithm application (search for
symptoms of life-threatening complications), the overwhelming number of victims
of the "operating room" group was identified - 98 (88.29 %) people.
At the second stage of using the algorithm when calculating points on the Military Field Surgery-State upon Admission
scale, only 13 (13.27 %) patients in the "operating room" group were
additionally identified.
From this we can conclude that the dominant stage in the decision-making
process on assigning a patient to a particular clinical group is the first
stage of the algorithm, which is aimed at finding signs of life-threatening
complications requiring urgent surgical treatment. The first stage consists of
examinations that do not require any long time. The second stage of the
algorithm, based on the use of the Military Field Surgery-State upon Admission scale, makes it possible to additionally identify
patients in need of surgical treatment, the indications for which are not so
obvious. However, it is possible to assess the Military Field Surgery-State upon Admission
scale only after detecting a general blood test, which still requires a little
additional time.
Table 1 shows the injuries that occurred in the victims. We analyzed the
number of life-threatening complications of concomitant trauma in both groups
of patients. Pneumothorax was found in 6 (3.8 %) of 158 (100 %) patients in the
“admission unit” group and in 22 (19.82 %) of 111 (100 %) patients in the
“operating room” group. Hemothorax was detected in 17 (10.76 %) patients in the
“admission unit” group and in 25 (22.52 %) patients in the “operating room”
group. As we can see, the number of victims with pneumothorax and hemothorax in
the “operating room” group is statistically significant (p = 0.000 and p =
0.014, respectively).
Table 1. Injuries in victims with associated trauma (n = 269)
|
Damage types |
Patient groups |
p |
|
|
surgery room |
admission unit |
||
|
Chest contusion |
47 (42.34 %)* |
107 (67.72 %) |
0.000 |
|
Rib fractures |
57 (51.35 %)* |
51 (32.28 %) |
0.003 |
|
Sternum fracture |
5 (4.5 %) |
2 (1.27 %) |
0.212 |
|
Lung contusion |
21 (18.92 %) |
20 (12.66 %) |
0.217 |
|
Heart contusion |
13 (11.71 %)* |
5 (3.16 %) |
0.012 |
|
Hemothorax and hemopneumothorax |
25 (22.52 %)* |
17 (10.76 %) |
0.014 |
|
Pneumothorax |
22 (19.82 %)* |
6 (3.8 %) |
0.000 |
|
Intraabdominal bleeding |
33 (29.73 %)* |
5 (3.16 %) |
0.000 |
|
Contusion of the anterior abdominal wall |
17 (15.32 %)* |
43 (27.22 %) |
0.031 |
|
Hollow organ rupture, peritonitis |
11 (9.9 %)* |
1 (0.63 %) |
0.000 |
|
Kidney contusion |
4 (3.6 %) |
5 (3.16 %) |
0.883 |
|
Foot fracture |
8 (7.21 %)* |
15 (9.49 %) |
0.662 |
|
Leg fracture |
13 (11.71 %) |
31 (19.62 %) |
0.119 |
|
Hip fracture |
22 (19.82 %) |
22 (13.92 %) |
0.262 |
|
Forearm fracture |
22 (19.82 %) |
20 (12.65 %) |
0.154 |
|
Fracture of shoulder and shoulder girdle |
23 (20.72 %) |
20 (12.65 %) |
0.108 |
|
Hand fracture |
5 (4.5 %) |
7 (4.43 %) |
0.785 |
|
Pelvic fracture |
15 (13.51 %) |
17 (10.76 %) |
0.621 |
|
Spine fracture |
8 (7.2 %) |
11 (6.96 %) |
0.868 |
|
Traumatic brain injury |
46 (41.44 %)* |
94 (59.49 %) |
0.005 |
|
Total number of patients |
111 (100 %)* |
158 (100 %) |
0.614 |
Note: * – p < 0.05 compared with group II. Statistical analysis method – Z criterion.
Intra-abdominal bleeding took place in 5 (3.16 %) patients in the “admission
unit” group and in 33 (29.73 %) patients in the “operating room” group. This
complication significantly predominates in the "operating room" group
(p = 0.000).
Hollow organ rupture and peritonitis were detected in 11 (9.9 %) patients
of the "operating room" group. In the “admission unit” group, we
observed such a complication in 1 (0.63 %) victim. Thus, there is a
statistically significant predominance of victims with peritonitis in the
"operating room" group (p = 0.000).
The statistically significant prevalence of such formidable complications
of concomitant trauma as intra-abdominal and intrapleural bleeding,
pneumothorax and peritonitis in the group of patients who were immediately
taken from the admission department to the operating room indicates the diagnostic
efficiency of the proposed algorithm.
At the same time, among the manifestations of concomitant trauma, which
in themselves do not pose an unambiguous threat to the patient's life, such
patterns are not traced. Thus, hip fractures were found in 22 (13.92 %)
patients in the “admission unit” group and in 22 (19.82 %) injured in the
“operating room” group. Shin fractures were found in 31 (19.62 %) patients in
the “admission unit” group and in 13 (11.71 %) injured in the “operating room”
group. There were no statistically significant differences between the groups
in the number of patients with hip and leg fractures (p = 0.262 and p = 0.119,
respectively).
Fractures of the shoulder and shoulder girdle were found in 20 (12.65 %)
patients in the “admission unit” group and in 22 (19.82 %) patients in the
“operating room” group. Forearm fractures were found in 20 (12.65 %) patients
in the “admission unit” group and in 22 (19.82 %) patients in the “operating
room” group. Thus, there was no significant difference between the groups in
the number of patients with fractures of the shoulder and shoulder girdle and
patients with fractures of the forearm (p = 0.108 and p = 0.154, respectively).
There were no statistically significant differences among patients with
fractures of the bones of the hand, spine and pelvis (p = 0.785, p = 0.868, p =
0.621, respectively).
94 (59.49 %) patients with traumatic brain injury were identified in the
“admission unit” group, and 46 (41.44 %) in the “operating room” group. Thus,
patients with traumatic brain injury statistically significantly predominate in
the “admission unit” group (p = 0.005).
Getting such patients into the “admission unit” group allows patients with
craniocerebral trauma to perform the CT scan they need immediately after
admission. The proposed algorithm makes it possible to differentiate patients,
the severity of whose condition is largely due to craniocerebral trauma, from
victims, the severity of whose condition is caused by life-threatening injuries
to the chest and abdomen.
Table 2 shows the structure and frequency of operations in patients with
concomitant injury in both groups. When analyzing the data, the prevalence of
open operations in patients of the "operating room" group is clearly
determined. Thus, laparotomies were performed in 24 (21.62 %) patients in the
“operating room” group, which is significantly more than 5 (3.16 %) in patients
in the “admission unit” group (p = 0.000).
Table 2. Operations performed for patients with associated trauma (n = 269)
|
Surgery type |
Number of patients |
p |
|
|
surgery room |
admission unit |
||
|
Laparoscopy |
32 (28.83 %)* |
22 (13.92 %) |
0.004 |
|
Laparotomy |
24 (21.62 %)* |
5 (3.16 %) |
0.000 |
|
Thoracoscopy and pleural drainage |
44 (39.64 %)* |
22 (13.92 %) |
0.000 |
|
Thoracotomy |
1 (0.9 %) |
0 (0 %) |
0.860 |
|
Primary surgical preparation of wounds |
27 (24.32 %) |
47 (29.75 %) |
0.399 |
|
External fixation apparatus |
17 (15.32 %) |
20 (12.66 %) |
0.657 |
|
Osteosynthesis upon admission |
6 (5.4 %) |
6 (3.8 %) |
0.754 |
|
Delayed osteosynthesis |
24 (21.62 %) |
48 (30.38 %) |
0.145 |
|
Skeletal traction |
1 (0.9 %)* |
15 (9.49 %) |
0.008 |
|
Craniotomy |
1 (0.9 %) |
1 (0.63 %) |
0.640 |
|
Number of patients |
111 (100 %) |
158 (100 %) |
|
Note: * – p < 0.05 compared with group II. Statistical analysis method – Z criterion.
Thoracoscopy with drainage of the pleural cavity was performed in 44
(39.64 %) patients in the “operating room” group and in 22 (13.92 %) patients
in the “admission unit” group. The reliable predominance of minimally invasive
thoracic operations aimed at eliminating life-threatening intrapleural
complications in the operating room group indicates the correct separation of
patient flows at the stage of admission to the hospital (p = 0.000).
There is also a significant
predominance of the number of laparoscopies in the "operating room"
group (32 (28.83 %)) compared with the " admission unit" group (22
(13.92%)) (p = 0.004). At the current stage in the development of endoscopic
technology, laparoscopy is not only a diagnostic, but also a highly effective
medical procedure, which in many cases allows stopping intra-abdominal
bleeding, suturing a diaphragm rupture, etc.
The treatment ended with recovery in 230 (85.5 %)
patients, while 39 (14.5 %) patients were fatal. Among 158 (100 %) patients of
the " admission unit"
group, 152 (96.2 %) patients recovered, 6 (3.8 %) died. Among 111 (100 %)
victims of the "operating room" group, 78 (70.27 %) people recovered,
33 (29.73 %) died.
We assessed the severity of the patients' condition on
admission using the Military
Field Surgery-State upon Admission scale. It was revealed that 6 (2 %) patients were
hospitalized in a terminal state, and 18 (6 %) patients were in an extremely
serious condition. All of these patients were from the operating room group.
DISCUSSION
According to researchers, to date, no clear and
universal system for assessing the severity of the condition of patients with
concomitant trauma has been developed [1]. There are no reliable methods and
criteria that allow to adequately assess the condition of the victim, highlight
the dominant and life-threatening injuries and determine the order of their
elimination [5]. The authors of the studies believe that it is especially
important to single out a group of patients requiring urgent surgery as soon as
possible after admission to the hospital [7]. The need to quickly isolate such
a group is due to the fact that in 80 % of the dead, death occurs within the
first 3-6 hours after concomitant injury [3, 8].
The algorithm developed by us makes it possible to
isolate the majority of this group of patients as soon as possible even before
receiving analyzes and before the start of instrumental diagnostics methods. In
our study, using this algorithm, it was possible to identify 91 (75.83 %) out
of 120 (100 %) life-threatening complications of concomitant trauma, requiring
urgent surgical treatment (pneumothorax, hemothorax, intra-abdominal bleeding,
peritonitis) in the first minutes after admission of the victim to the
hospital. This made it possible to immediately transport the victims to the
operating room and reduce the time from the moment of injury to the moment of
the start of surgical treatment.
In particular, immediately after admission, 11 of 12
victims with rupture of the hollow organ and peritonitis were transported to
the operating room. The only patient with a similar complication who was left
to be examined in the emergency department had a small rupture of the small
intestine with a minimal amount of exudate in the abdominal cavity, which was
detected by CT. At the same time, the patient did not have a clinic of peritonitis,
and the abdominal pains were moderate. Patients underwent laparoscopy, which
revealed a small amount of turbid exudate, and laparotomy, during which the
bowel defect was discovered and sutured.
It is at the earliest possible beginning of therapeutic
measures, according to modern authors, that the main reserves are concentrated
in reducing the lethality caused by concomitant trauma [7]. The main task of
the doctor with such a complication of concomitant trauma as pneumothorax is to
eliminate it and expand the lung as soon as possible [3].
In our study, pneumothorax was suspected on admission,
and patients were transported to the operating room in 22 (78.57 %) of 28 (100 %)
cases of this complication. In the remaining 6 (21.22 %) cases, we encountered small
parietal and apical pneumothorax without pronounced respiratory failure, which
were detected by CT and were effectively cured.
According to all researchers, one of the main mistakes
in the treatment of concomitant trauma is continuing bleeding diagnosed with a
great delay [5, 8].
In our study, intra-abdominal bleeding in 33 (86.84 %)
out of 38 (100 %) cases was detected during the application of the proposed
algorithm and immediately taken to the operating room. In the remaining 5
(13.16 %) cases of intra-abdominal bleeding, which were in the victims of the
" admission unit"
group, there was a small amount of blood loss. In 2 cases, it was during the CT
scan that it was possible to reveal an extensive subcapsular rupture of the
spleen, for which the patients were operated before the onset of massive
intra-abdominal bleeding. In 1 case, the bleeding from the rupture of the liver
in the area of the round ligament of the liver was stopped by laparoscopy.
Speaking of intrapleural bleeding, it should be noted
that a significantly greater number of hemothoraxes was detected in 25 (22.52 %)
of 111 (100 %) patients in the "operating room" group as compared to 17
(10.76 %) of 158 (100%) victims in the “admission
unit” group (p = 0.014). However, a fairly large number of intrapleural
bleeding, which was left for examination in the admission department, requires
a separate explanation. In all 17 cases, we dealt with a stopped small-volume
bleeding that does not directly threaten the patient's life. In one case, it
was a small hemothorax with a volume of no more than 200 ml, which was lysed
during conservative treatment. In the remaining 16 cases, these were small
medium hemothorax with stopped bleeding. After CT, the patients underwent
thoracoscopy with drainage of the pleural cavity, after which additional
hemostasis was not required.
Thus, using the algorithm developed by us, it was
possible to effectively identify and start surgical treatment as early as
possible in all patients with life-threatening internal bleeding.
According to various authors, hospital mortality in
associated trauma varies within a very wide range from 13.34 to 37.7 % [7, 8,
9]. According to M.Sh. Khubutia et al., mortality in patients with concomitant
injury was 14.1 % [8]. G.M. Maidarov et al. analyzed mortality in concomitant
injury in three neighboring large cities of the Russian Federation. Mortality
in polytrauma in patients in the cities of Ulan-Ude, Irkutsk and Barnaul was
37.7 %, 35.4 % and 30.2 %, respectively. In our study, the mortality rate was
14.5 %. Although the team of authors considers this indicator to be quite high,
it remains below most of the data presented in the literature.
CONCLUSION:
1. The developed algorithm for determining the diagnostic and therapeutic
tactics on the basis of the initial assessment of the severity of the victim's
condition is easily feasible and objective.
2. Patients with pneumothorax, hemothorax, intra-abdominal bleeding and
peritonitis (p = 0.000, p = 0.014, p = 0.000 and p = 0.000, respectively)
prevailed in the group of victims transported to the operating room as compared
to the group examined in the admission unit. The statistically significant
predominance of the number of life-threatening complications of concomitant
trauma in the group of victims immediately transported to the operating room
testifies to the high prognostic efficiency of the proposed algorithm.
3. There were no significant differences between clinical groups in the
number of patients with fractures of the hip, lower leg, shoulder, shoulder
girdle and forearm (p = 0.262, p = 0.119, p = 0.108 and p = 0.154,
respectively). The absence between the groups of a significant difference in
the number of injuries that do not directly threaten the victim's life
indicates that the proposed algorithm clearly differentiates patients with
injuries requiring immediate surgical treatment from patients whose surgical
treatment can be performed after thorough diagnosis and preoperative
preparation without deterioration of the general condition of the victim.
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