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Chikaev V.F., Akhtyamov I.F., Ziatdinov B.G., Galyautdinov F.Sh.

Kazan State Medical University,
Kazan City Clinical Hospital No.7, Kazan, Russia

ORGANIZATIONAL ASPECTS OF THE ANTI-SHOCK UNIT OF THE ADMISSION DEPARTMENT IN HOSPITALIZATION OF PATIENTS WITH POLYTRAUMA

Associated injury is one of the most complex problems of modern medicine. Hospital mortality is still high (17.5 %). It achieves 72 % in patients with concurrent and dominating injuries [1].
The logistic factor plays the important role in decreasing mortality and complications in polytrauma: admission timing, timeliness of diagnostic and medical procedures depending on the patterns of injuries [2, 3, 4].
The key to success at the stages of diagnostics and selecting treatment techniques is the first hours of admission, because “the golden hour” is a real chance of survival in patients with polytrauma. According to Agadzhanyan V.V. et al (2015), the highest amount of diagnostic errors (80.2 %) is observed in acute period of traumatic disease.  

The study objective – to analyze and estimate the features of functioning of the anti-shock unit of the admission and diagnosis department (ADD) in the multi-profile emergency hospitals.

MATERIALS AND METHODS

The complex study of the features of organization of diagnostics and medical care for patients in the anti-shock unit of the admission department of the multi-profile hospital was conducted.
During the last three years, the emergency medicine center of Kazan City Clinical Hospital No.7 accepted 75,062 patients (age of 16-93) (the table).

Table 1. Structure of patients admitted to the admission department of City Clinical Hospital No.7

Unit

Admitted

Outpatients care

Total

%

Traumatology

12972

21559 (62.4 %)

34531

46

Neurosurgery

4923

18988 (79.4 %)

23911

31.8

Maxillofacial unit

4988

11632 (70 %)

16620

22.2

Total

22883

52179

75062

100

One of the factors of intensive activity of ADD in the modern multi-profile trauma centers is the high amount of patients who require for admission. Trauma patients had the higher requirement for outpatient (69.5 %) and inhospital (46 %) care.
For the period of 2012-2017, the retrospective analysis was carried out with compliance of the ethical standards of diagnostics and treatment of 343 patients with associated injury. The patients were selected with continuous sampling.
Associated injury was mainly identified in the patients of working age (18-50) – 77.4 %. The combination of two anatomic regions was identified in 88.3 %, three anatomic regions – in 11.7 %. There were more men than women: 237 (69 %) and 106 (31 %) correspondingly. The associated traumatic brain injury was identified in 191 (55.6 %) patients. Thoracic injuries were in 108 (31.49 %) patients. The locomotor system trauma was in 172 (50.1 %) patients, including 110 (64 %) with lower extremities damages and 62 (36 %) with upper extremities damages. Pelvic injuries were in 57 (16.5 %) patients, spinal trauma – in 61 (17.7 %). Abdominal injury was in 41 (11.9 %) patients.
The severity of damages was estimated with Military Field Surgery-Injury (Mechanical Injury) Score [5]. Mild injury was found in 56 (16.3 %), middle severity injury – in 81 (23.8 %), severe injury – in 194 (56.5 %), very severe injury – in 10 (2.9 %) patients.
Primary estimation of blood loss was carried out with combination of the techniques: empirically, with consideration of severity of injuries and fractures, and the hemodynamic value of shock index, as well as with results of the instrumental diagnostic methods (CT, ultrasonic examination).
At the moment of admission to ADD, the card was made. This card included the report on route scheduling and description of medicodiagnostic procedures. For analyzing the efficiency of the developed algorithm we studied the time of initiation of diagnostic search and blood testing at the moment of admission.
The statistical analysis of the study was conducted with the variance analysis with calculation of mean arithmetic (M) and error of mean (m), Basic, Statistica.

RESULTS AND DISCUSSION

As we indicated above, the time factor is the important task of medical care for patients with associated injury. The time of ambulance transportation varied from 10 to 40 minutes (31 ± 8 on average). Almost all patients with associated injury were admitted with shock state. ISS was > 24 in 80 % of the patients with shock of degrees 2-3. Intensive diagnostics and therapy was the priority at the first stage during medical care in the anti-shock unit of ADD. The main task is rapid identification of a life threatening injury. The direct connection between the clinic and the emergency call service dispatcher gives timely information on admission of critically ill patients. The patients are admitted to the anti-shock unit for primary diagnostics performed by the multidisciplinary team (intensivist, surgeon, neurosurgeon). Rapid diagnostics was carried out with use of the high tech equipment: RCT, ultrasound investigation, X-ray, endoscopic video equipment. Whole body CT was used for identification of severe associated injury. Body scanning takes about 5 ± 1.2 minutes. The main life threatening injuries are identified within the short time. We think that adequate estimation of results is one of the main aspects of diagnostics. Hyperdiagnostics is dangerous like hypodiagnostics. The patient’s condition can be worsened after unjustified extension of surgical intervention.
Blood loss is one of the pathogenetic aspects in associated injury. Bleeding duration is important for acute massive blood loss. Objective estimation of severity of the patients’ condition, and clinicolaboratory diagnostics are essential factors. Intensive diagnostics allows rapid estimating the causes of blood loss, life threatening conditions and selecting the treatment techniques. Arrest of “empty heart” must be prevented in severe bleeding, and macrocirculation system is refilled with crystalloids and colloids.
Within the first minutes after admission to the anti-shock unit, the vascular approach was made, infusion therapy was initiated, blood group and Rh factor were estimated, and blood phenotype was estimated in the laboratory. The initial rate of solution introduction was jet or fast drop, depending on AP. Infusion included two or three veins including central vein. For unstable hemodynamics and AP < 80 mm Hg, infusion therapy was conducted with introduction of the vasopressor (noradrenaline) with the syringe intravenous dosing device (0.1 µg/kg/min). The efficiency criterion of infusion therapy was maintenance of circulating blood volume, cardiac output and AP at the safe levels (AP syst. > 80-90 mm Hg). Qualitative and timely replacement of blood loss is one of the important parts of resuscitation procedures in treatment of polytrauma.
The primary estimation of blood loss was conducted with the complex measures: empirically, with consideration of severity of injuries and fractures, with the hemodynamic value of shock index, as well as with results of the instrumental diagnostic methods (CT, ultrasound investigation). According to our data, the hemoconcentration values (hemoglobin, red blood cells, hematocrit) do not show the true blood loss within the first hours. Blood loss diagnostics also includes such important aspect as estimation of concurrent diseases (cardiovascular pathology, chronic diseases) causing anemia and unstable hemodynamics. The time of pretreatment of blood components before transfusion is significantly reduced by the confirmed duty list of blood group testing in the anti-unit of ADD. So, the time of blood group and phenotype testing reduced to 40 ± 5 minutes. Transfusion of blood components was carried out for blood loss > 30 % of CBV.
Continuous intensive care, beginning from the anti-shock unit, is continued in the intensive care unit. It is the basic management in our clinic. The card in made in ADD. It includes the routing schedule and description of medical diagnostic measures.
The developed algorithm significantly reduces the time of specialized medical care in the clinic. The time of initiation of diagnostic search reduced from 15.3 ± 3.2 minutes to 4.8 ± 2.6 minutes. Damage control is the treatment standard for patients with shock of degrees 2-3, ISS > 18 and Military Field Surgery-Mechanical Injury Score > 12 [5]. A maximally safe approach should be used for patients with severe mechanical injury and polytrauma, because displacement can cause the devastating consequences and disordering the compensatory capabilities of the body.
A combination of bleedings from two regions can be critical. Early diagnostics of internal organ damages in patients with polytrauma is a foundation for successful treatment [6]. Videolaparoscopy was the most informative technique for diagnostics of such injuries. Laparocentesis was conducted for extremely severe conditions and doubtful data, when pneumoperitoneum was contraindicated. (n = 4).
The external fixation device was used for unstable fractures of the pelvic ring. During abdominal organ damages diagnostics, the configuration of the device was realized with consideration of a possibility for adequate approach during laparotomy.
Possible diaphragm damage should be considered in presence of chest injury and intensifying symptoms of respiratory insufficiency. Associated diaphragm injury was observed in 8 cases. Diaphragm rupture diagnostics can be difficult since abdominal organs prolapse into the pleural cavity sometimes happens after a long period after injury. In one case, a diaphragm injury was identified only on 10th day of the treatment.
Respiratory support and pleural cavity draining are conducted in ADD, if multiple costal fractures complicated by hemothorax present. The time of primary diagnostics was reduced by the multidisciplinary team (intensivist, surgeon, traumatologist, neurosurgeon) using the accepted algorithm with reducing time of initiation of diagnostic search and whole body CT within 5 ± 2 minutes in ADD. Reducing time of blood group testing promoted the timely and qualitative replacement of blood loss. Low traumatic technology and staged treatment with damage control reduced the mortality by 2 %.

Figure 1. The diagnostic algorithm for patients with associated injury in the anti-shock unit of the admission and diagnosis department


We present a clinical case. The patient V., age of 22. Catatrauma: falling from height of 9th floor. The patient was admitted 40 minutes after the injury. Whole body CT within 7 minutes. Complex diagnostics was conducted simultaneously with intensive care within the first minutes after admission to the anti-shock unit of the diagnostic department (Fig. 2). Shock index was 1.5. Blood loss was higher than 30 % of CBV. ISS was higher than 35, Military Field Surgery-Mechanical Injury Score [6] > 12 (extremely severe trauma).

Figure 2. X-ray picture of pelvis and leg fractures


Blood loss. Blood group and Rh factor testing, intensive infusion therapy, transfusion of packed red blood cells and fresh frozen plasma were initiated in the anti-shock unit of ADD. 839 ml of packed red blood cells and 810 ml of fresh frozen plasma were transfused. Pleural cavity draining was conducted to the left, and diagnostic laparoscopy was carried out: retroperitoneal hematoma, bursting of right lobe of the liver without signs of bleeding; sanitation and draining of abdominal cavity. Diagnosis: “Associated injury. Closed chest injury, closed fractures of the ribs 1‒3, 5, 6, 7, 10, 11 to the left, pneumothorax, pneumomediastinum, subcutaneous emphysema, fracture of L5 transverse processes, fracture of lateral masses of sacrum along the entire length, fracture of sacral vertebral bodies, fracture of iliac bone with transition to the roof and articular surface of acetabulum, fracture of pubic bone to the right, fracture of ischial bone to the left. Opened fractures of calcaneal bones, closed fracture of both legs. Closed abdominal injury, rupture of liver right lobe, intraabdominal bleeding, retroperitoneal hematoma.
The pelvic and leg bones were fixed with the external fixation devices (Fig. 3). Tibialis post and Tibialis ant. contusion. Arterial thrombosis appeared on the following day. Arteriotomy was conducted. The clots were removed with the probe Fogarti. Arterial patency was performed. Foot gangrene was prevented. Bleeding with liver rupture appeared on the second day. Laparotomy and liver rupture suturing were performed.

Figure 3. Appearance of the patient after installment of the external fixing devices


Therefore, fast diagnostics, low traumatic fracture fixation within the first hours, timely intensive replacement of blood loss with anti-shock unit at the first stage saved the patient’s life. 

CONCLUSION

1. The feature of functioning of the admission department of the multi-profile city hospital is intensive activity relating to high amount of patients, and within the recent years – with necessity for high volume of outpatient care.
2. The organizational factor of diagnostics and intensive care is very important at the first stage of qualified care for patients with associated injury in the anti-shock unit of ADD.
3. Low traumatic technology and damage control concept for patients with associated injury reduced the mortality by 2 %.

REFERENCES:

1.  Agadzhanyan VV, Kravtsov SA, Shatalin AV, Levchenko TV. In-hospital mortality in polytrauma and the main directions of its reduction. Polytrauma. 2015; 1: 6-15. Russian (Агаджанян В.В., Кравцов С.А., Шаталин А.В., Левченко Т.В. Госпитальная летальность при политравме и основные направления ее снижения // Политравма. 2015. № 1. С. 6-15)
2.  Milyukov AYu. Tactical features consistent with differentiated medical care to victims with injuries of the pelvis in the prehospital and transportation. Genius of Orthopedics. 2012; 4: 24-28. Russian (Милюков А.Ю. Тактические особенности последовательной дифференцированной медицинской помощи пострадавшим с повреждениями таза на догоспитальном этапе и при транспортировке // Гений ортопедии. 2012. № 4. С. 24-28)
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