RU2353289C1 - Method of estimating possibility to perform emergency surgical interventions upon life-saving operation in acuity of associated multitrauma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery and traumatological orthopaedics. The following significant factors are explored as a single set: systolic arterial pressure (SAP); heart rate (HR); hemogram values in a peripheral blood channel: erythrocytes (RBC), haemoglobin (HGB), hematocrit (HCT); PH of arterial blood; arterial blood oxygenation (pO₂), arterial blood carbonisation (pCO₂); sodium and potassium blood content. Each value is scored 0 to 4 under the table "Estimated scale parameters of relative state stabilisation" set forth in the description. Total score 0 to 5 indicate rather stable state making it possible to perform emergency surgical intervention, while scores 5 and higher show unstable state wherein emergency surgical intervention is not indicated.

EFFECT: method provides reliable choice of surgical intervention tactics, as well as allows reducing lethality by 5,6%, reducing hospital stay time by 7,8%, improving quality of medical and social rehabilitation.

8 tbl, 2 ex

Description

The present invention relates to medicine, namely to surgery and traumatology, orthopedics.

The provision of adequate medical care to victims of combined trauma is one of the most difficult problems of emergency surgery.

The features of this group of patients are: the extreme severity of the condition at the time of admission, the impossibility of a detailed examination and the provision of surgical care in full, as a result - high mortality - from 18 to 50% [1, 2, 3, 4].

The approach to the treatment of patients with combined trauma underwent significant changes during the second half of the 20th century - from passive, expectant to active surgical (the “all at once” principle), but when using these approaches to treatment, it was not possible to achieve a noticeable decrease in mortality and improve treatment outcomes .

Recent decades have been introducing into clinical tactics a more balanced, well-grounded approach to the treatment of patients with combined trauma, based on the principle of dynamic damage control [1, 2, 3, 4], which allowed to significantly improve treatment results.

Special medical literature published in recent years [1, 2, 3, 4] defines the dynamic control of injuries as a system for providing step-by-step surgical care to victims with combined trauma, depending on the patient’s condition.

The need to apply the principle of dynamic damage control arises only in victims with such a combined injury, in which there is one or more injuries that pose a direct threat to life (operations are indicated according to vital indications); and one or more serious injuries that do not pose a direct threat to life and emergency operations are indicated, the refusal or delay in the performance of which leads to the development of vital complications and death within a few days.

The condition for the possibility of performing emergency surgical interventions in this group of patients with combined trauma is the relative stabilization of the state, which can be achieved after performing operations for health reasons and adequate intensive care (replenishing the volume of circulating blood (BCC), blood loss, oxygen deficiency of tissues, etc.

But until now, criteria have not been developed for relative stabilization of the state, allowing without the threat of deterioration of the patient's condition to perform emergency surgery.

Many developed scales for determining the severity of the condition (TRISS, ASCOT, APACHE 2, 3, 4, the predictive equation of Tsybin, VPH-SP, VPH-SG, VPH-SS, etc.) [1, 2, 3, 4], evaluating the state of the victim cannot answer a fundamental question, which often determines the possibility of survival, when it is possible to perform an operation according to emergency indications after completing life-saving operations, because the need to make a decision on performing an emergency operation often arises before it is possible to take into account all the parameters for assessing the state of nogo on the above scale. This is due to the fact that they perform mechanical ventilation, the patient is in a state of drug sedation, supported by hemodynamics by vasopressors, in conditions of intensive infusion therapy, which distorts the results of laboratory tests.

There is a method of determining the patient's condition at the time of admission to the medical institution "VPH-SP" [2], developed at the Department of Military Field Surgery of the Military Medical Academy named after S.M. Kirova, St. Petersburg, which includes 12 clinical parameters (table 1)

On this scale:

- up to 12 points scored, the state is considered satisfactory,

- from 13 to 20 points - moderate;

- from 21 to 31 - heavy;

- from 32 to 45 - extremely difficult;

- more than 45 points - critical.

Disadvantages: among the 12 parameters of the “VPH-SP” scale, there are 5 (2. The nature of external respiration; 4. Speech contact; 5. Reaction to pain; 6. Corneal or pupillary reflex; 7. The size of the pupils), which cannot be taken into account when the patient is undergoing intensive therapy (mechanical ventilation; massive multicomponent infusion therapy, drug sedation, using vasopressors), therefore, the “VPH-SP” scale cannot be used to determine the relative stabilization of the condition.

For the closest analogue, a method for determining the severity of the condition of the victim "VPH-SG" [2], developed at the Department of Military Field Surgery of the Military Medical Academy named after. S.M. Kirova, St. Petersburg, which includes 16 clinical and laboratory parameters (table 2).

Table 2.
Assessment of the severity of the condition of the wounded during the treatment of "VPH-SG." Symptoms Value Rating one State of consciousness Clear
stun one
3 2 Nature of external respiration normal one frequent (> 25 in 1 min) 6 pathological 9 3 Auscultatory vesicular one weakened 3 wet wheezing 6 four Heart rate no arrhythmia one have arrhythmia 6 5 Heart Rate (bpm) 60-80 one 81-100 3 101-140 5 <60 or> 140 7 not determined 9 6 Systolic blood pressure (mmHg) > 100 one 81-100 four 61-80 8 60 and < 9 7 Noises of intestinal motility distinct one weakened 3 are absent 5 8 Daily diuresis (ml) 500-1500 one > 1500 2 <500 5 9 Body temperature (° C) <37 one 37-38 2 > 38 3 10 Red blood cells (× 10 ¹² / L) > 3.0 one 3.0-2.6 2 2.5 and < four eleven White blood cell count (× 10 ⁹ / L) 8 and < one 8.1-10.0 2 10.1-15.0 3 > 15.0 four 12 Band Leukocytes (%) <10 one 11-20 2 > 20 four 13 Total protein (g / l) > 60 one <60 3 fourteen Urea Nitrogen (mmol / L) <4.0 one > 4.0 3 fifteen Red blood cells <10 one > 10 3 16 Urine protein no protein one <0.03 2 > 0.03 3

On this scale:

- from 16 to 22 points scored, the condition is considered satisfactory,

- from 23 to 32 points - moderate;

- from 33 to 40 - heavy;

- from 41 to 50 - extremely difficult;

- more than 50 points - critical.

Disadvantages of the “VPH-SG” scale, which includes 5 parameters (1, state of consciousness, 2, nature of external respiration, 7, noise of intestinal motility, 8, daily diuresis, 9, body temperature), which cannot be determined when the patient is undergoing intensive care (Mechanical ventilation; massive multicomponent infusion therapy, drug sedation, vasopressors are used), make it impossible to use the “VPH-SG” scale to determine the relative stabilization of the condition for an objective determination of the possibility of performing emergency surgery Sgiach interventions after completing operations for health in the acute period associated trauma.

Therefore, the task was to develop criteria for assessing the relative stabilization of the state, which would objectively and reliably assess the condition of the victim in the acute period of such a combined injury, in which there are one or more injuries that pose a direct threat to life (operations are indicated for life indications, otherwise fatal come within a few minutes or hours after receipt); and one or more severe injuries that do not pose a direct threat to life (emergency operations are indicated, failure or delay of which leads to the development of vital complications and death within a few days), independent of the characteristics of the intensive care of the injury (artificial ventilation, volume and quality of intensive care, drug sedation, the use of vasopressors).

SUMMARY OF THE INVENTION

The essence of the invention is the identification of significant indicators, taking into account their total points.

Significant indicators include 10 hemodynamic and homeostasis parameters that are independent of the characteristics of the intensive care of the injury (mechanical ventilation, volume and quality of intensive care, drug sedation, the use of vasopressors), including: systolic blood pressure; heart rate (heart rate); hemogram indicators (red blood cells, hemoglobin, hematocrit in the peripheral bloodstream); arterial pH; oxygen saturation of arterial blood (pO ₂ ); carbon dioxide saturation of arterial blood (pCO ₂ ); the content of sodium and potassium in arterial blood.

Depending on the degree of deviation from the norm, a criterion is assigned a value from 0 to 4 points and, with a score of 0 to 5, the patient’s condition is determined as relatively stable with the possibility of emergency surgery, and if the value of the sum of points above 5 is determined as an unstable state in which emergency surgery is not indicated.

Table 3.
Units of measurement of the parameters of the scale of relative state stabilization in patients with combined trauma. Indicators of the relative stabilization scale. Units of measurement of indicators. one. Systolic Blood Pressure (SBP) mmHg. (excluding the administration of subrenal doses of vasopressors) 2. Heart Rate (HR) in 1 min 3. Oxygen saturation of arterial blood (pO ₂ ) mmHg. four. Carbon Saturation of Arterial Blood (pCO ₂ ) mmHg. 5. blood pH 7.350-7.450 6. Blood Potassium (K) mmol / liter 7. Blood Sodium (Na) mmol / liter 8. Hemogram indicators Red blood cells (RBC) 1 × 10 ² ml 9. Hemoglobin (HGB) g / l 10. Hematocrit (HCT) %

The assessment of the parameters of the relative stabilization scale is presented in table 4.

Table 4.
Estimation of the parameters of the relative stabilization scale Points +4 +3 +2 +1 0 +1 +2 +3 +4 Indicators one GARDEN - - - - 90-81 80-71 70-50 ≥49 2 Heart rate ≥180 140-179 110-139 - 70-109 - 50-69 40-54 ≥39 3 PO ₂ ≥140 139-130 120-129 110-119 80-109 - 79-70 - 69-60 four pCO ₂ ≥40 - 39-35 45-40 46-50 51-55 56-60 61-65 66-70 5 blood pH ≥7.7 7.6-7.69 - 7.5-7.59 7.33-7.49 7.25-7.32 7.15-7.24 ≤7.15 6 To blood 5.6-6.0 5.1-5.5 3,50-5,00 3.4-3.1 ≤3.0 7 Na blood ≥180 160-179 155-159 150-154 130.0-149.0 120-129 111-119 ≤110 8 Indicators
hemograms Rbc 2.8-3.1 2.3-2.7 2.2-1.9 18, -1.5 ≥1.4 9 Hgb 75-80 74- 63- 58-50 ≤50 10 10 64 59 HCT ≥45 41-45 - - 25-20 19-15 - ≤14

The method was tested for 3 years on over 60 patients. The reliability of using the method was p≤0.05.

The technical result of the invention is to ensure the reliability of the choice of tactics of surgical intervention, decrease in mortality by 5.6%: reduce the number of days in hospital by 7.8%, improve the quality of medical and social rehabilitation.

Example 1

Injured at the age of 38 years. I. B No. 7654.

Date of receipt 02.23.2007. Time - 03.10.

Diagnosis: combined trauma, leading damage - trauma of the musculoskeletal system (OA): unstable damage to the anterior and posterior pelvic rings, massive retroperitoneal hematoma - 1500 ml, closed fracture of the diaphysis of the right thigh, hip hematoma - 800-1000 ml, dislocation of the left shoulder, fracture of the left clavicle; TSTM: a brain contusion with a focus of brain contusion in the fronto-basal region on the right, a scalped head wound with ongoing bleeding; blunt chest injury, multiple fractures of the ribs on the left, complicated by small hemo - pneumothorax, bruised left lung; blunt abdominal injury, bruise of the left kidney, macrohematuria; traumatic shock of 3 degrees, the total acute blood loss of 3000 ml, NISS-36 points.

5 minutes after admission, temporary hemostasis was performed by suturing bleeding vessels and a pressure bandage on a scalped head wound.

40 minutes after admission, operations for vital signs are started:

- surgical stabilization of the pelvic ring with an external fixation device (ANF);

- surgical stabilization of a fracture of the femur with an external fixation device (ANF);

During and after the completion of operations for vital signs, intensive therapy was carried out:

- artificial ventilation of the lungs with the device RO-6 breathing mixture enriched with oxygen;

- the volume of infusion therapy in the intensive care room and emergency operating room was: 2000 crystalloids, 2000 ml of colloids, 3 doses of red blood cells, 5 doses of FFP, in the amount of about 6000 ml,

- after replenishing the volume of circulating blood, the introduction of subrenal doses of vasopressors (dopamine) has begun

- performed intravenous analgesia (fentanyl).

Table 5. Indicators of the parameters of the scale of relative stabilization of the state within 1 hour after admission of the victim with combined trauma.

GARDEN Heart rate NPV pH pCO ₂ pO ₂ Na TO Hgb Rbc HCT Moment of receipt 40 minutes after admission 60 mm. Hg
▼ 127 in 1
mine
that ▲ 25 in 1 minute ▲ 7,469 37,2 74.1 ▼ 134.0 4.05 73 ▼ 2.43 ▼ 22.1 2 points 2 0 2 2 0 0 0 one 0

The sum of the points evaluating the parameters of the scale of relative stabilization of the state amounted to 7 points - the state is unstable, operations according to emergency indications are not shown.

After 3 hours 40 minutes, a relative stabilization of the state occurred, after which operations were performed according to emergency indications. The total score, evaluating the parameters of the scale of relative stabilization of the state, amounted to 3 points - the condition is relatively stable, operations have begun according to emergency indications - drainage of the pleural cavity on the left due to small hemo-, pneumothorax;

- PHO head wounds, suturing.

Table 6.
Indicators of the parameters of the scale of relative stabilization of the state after 3 hours 40 minutes after the receipt of the victim with combined trauma. GARDEN Heart rate NPV pH pCO ₂ pO ₂ Na TO Hgb Rbc HCT 3 hours 40 minutes after admission 105 mmHg
Art. 104 in 1
a minute 18 in 1
a minute 7,420 37,2 104.2 137.7 4.06 73 2,8 21.9 0 0 0 2 0 0 0 one 0 0

After completing operations according to emergency indications that did not worsen the condition of the victim, the patient was transferred to the intensive care unit, where intensive therapy and dynamic monitoring were continued.

The dynamics of the course of the injury:

- 02/23/07, 3 p.m., during the follow-up ultrasound, small hemoperitoneum was detected, diagnostic laparoscopy was performed at 3.30 p.m., no abdominal organs were found to be damaged, retroperitoneal hematoma was confirmed, and drainage into the abdominal cavity was established.

- 02.24.07, in connection with the stabilization of the state, the ventilation is off;

- 02/25/07 on the control chest radiograph suspected atelectasis of the left lung, a CT scan of the chest was performed in dynamics, a rehabilitation bronchoscopy was performed, the patient was again examined by a thoracic surgeon,

- 02/26/07 - CT in the dynamics of the chest: hemopneumothorax remains on the left, there is bilateral pneumonia, RDSV or a pulmonary form of fat embolism is suspected, is transferred again to mechanical ventilation, there is a moderate posthemorrhagic pneumonia;

- 2.03.07 g. - stabilization of the state, transferred to the specialized department;

- March 4, 07 — a blocked osteosynthesis of the right femur was performed;

- March 11, 07 - extracortical pelvic osteosynthesis with anterior access, pubic articulation, sacroiliac joint with plates was performed, osteosynthesis was inconsistent, secondary displacement of the pelvic fragments;

- March 20, 07 - pelvic ring resynthesis, reinforcement of metal structures;

- 1.04.07, plastic sores on the sacrum and gluteal region;

- April 15, 07 - was discharged for outpatient treatment in satisfactory condition. Spent 43 bed days.

Example 2

Affected for 37 years. I. B No. 15592. Date April 15, 2007. Time is 10.21.

The mechanism of injury: accident (pedestrian), hit by a car.

Diagnosis: concomitant injury; leading damage - blunt trauma to the abdomen: rupture of the spleen, retroperitoneal rupture of the bladder, massive hemoperitoneum - 1500 ml; blunt chest injury, left-sided hemopneumothorax without signs of acute respiratory failure (ONE), left lung bruise, heart bruise; CCMT, mild brain injury; rupture of the pubic joint, bruised wound of the forearm; shock 3 degrees, total blood loss of about 50% of the BCC. NISS-41 point

30 minutes after admission, the operation was started for health reasons:

- laparotomy, splenectomy, hemostasis, reinfusion of blood poured into the abdominal cavity, drainage of the abdominal cavity.

During and after the completion of operations for vital signs, intensive therapy was carried out:

- artificial ventilation of the lungs with the device RO-6, a respiratory mixture enriched with oxygen;

- the volume of infusion therapy was: colloids - 3900 ml; crystalloids - 5150 ml; erythrocyte mass - 1620 ml; SZP - 1730; total - 12380 ml.

- after replenishing the volume of circulating blood, the introduction of subrenal doses of vasopressors (dopamine) has begun

- performed intravenous analgesia (fentanyl).

Table 7.
The indicators of the parameters of the scale of relative stabilization of the state within 1 hour after admission of the victim with combined trauma. GARDEN Heart rate NPV pH pCO ₂ PO ₂ Na TO Hgb Rbc HCT Moment of receipt 40 minutes after admission 55 ▼ 121 ▲ 24 ▲ 7,470 ▲ 45,2 ▲ 63.6 ▼ 133.7 5,4 ▲ 57 ▼ 2.23 ▼ 17.9 ▼ 2 points 2 0 2 four 0 one 2 2

The total score, evaluating the parameters of the scale of relative stabilization of the state was 13 points, the state is unstable, emergency surgery is contraindicated.

After 7 hours 10 minutes after admission, relative stabilization of the state was achieved, after which operations according to emergency indications were performed. The sum of points evaluating the parameters of the scale of relative stabilization of the state was 4 points, the condition is relatively stable, operations have begun on emergency indications

- drainage of the pleural cavity on the left,

- pelvic osteosynthesis ANF,

- GKO wounds of the forearm;

- suturing the rupture of the bladder, drainage of the cellular spaces of the pelvis, the imposition of epicystostomy.

Table number 8.
Indicators of the parameters of the scale of relative stabilization of the state after 7 hours 10 minutes after the receipt of the victim with combined trauma. GARDEN Heart rate NPV pH pCO ₂ PO ₂ Na TO Hgb Rbc HCT 7 hours 10 minutes after admission 110 104 19 7,410 39.0 105,2 137.0 4.86 79 2.94 17.9 0 0 0 2 0 0 0 0 0 2

After completing operations according to emergency indications that did not worsen the condition of the victim, the patient was transferred to the intensive care unit, where intensive therapy and dynamic monitoring were continued.

The dynamics of the course of traumatic disease:

- 04/27/2007, the condition is serious, bilateral pneumonia, septic state, CT in dynamics: bilateral pneumonia, there is no free fluid in the abdominal cavity and pelvis; the severity of the condition is due to bilateral pneumonia and urinary phlegmon of the pelvis.

- 04/27/2007 - 05/06/2007 - stabilization of the purulent process, pelvic inflammatory phlegmon was performed, pelvic wound closure, drainage, remounting of the ANF on the pelvic ring.

- 05/09/2007 - stabilization of the state, normalization of temperature.

- May 18, 2007, was discharged for outpatient treatment in satisfactory condition.

Spent in a hospital 33 days

Bibliography

1. Agadzhanyan V.V. Politrauma. Problems and practical issues. Materials of the international conference "New technologies in military field surgery and surgery for peacetime damage." St. Petersburg 2006 p. 14-18.

2. Gumanenko E.K. with co-authors. Field Surgery. Textbook. St. Petersburg 2005 p. 413-428.

3. S. A. Seleznev, S. F. Bagnenko, Yu. B. Shapot, A. A. Kurygin. Traumatic disease and its complications. A Manual for Physicians 2004, from 24-57.

4. Sokolov V.A. et al. Multiple and combined damage. A Practical Guide for Physicians 2006 Moscow, from 45-49; from 124-146.

Claims (1)

The method for determining the possibility of performing emergency surgical interventions after the completion of vital signs in the acute period of combined trauma, including the identification of indicators, characterized in that the complex reveals the following significant indicators: systolic blood pressure (SBP); heart rate (heart rate); hemogram values in the peripheral bloodstream: red blood cells (RBC), hemoglobin (HGB), hematocrit (HCT); Arterial blood pressure; arterial oxygen saturation (pO ₂ ), carbon dioxide saturation of arterial blood (pCO ₂ ); the content of sodium and potassium in arterial blood, each indicator is assigned values from 0 to 4 points according to the table “Assessment of the parameters of the scale of relative stabilization of the state” described in the description, and with the sum of points from 0 to 5, the patient’s condition is determined as stable with the possibility of emergency surgical intervention, and when the value of the total score is above 5 - as an unstable condition in which emergency surgical intervention is not shown.