The damage control resuscitation strategy is aimed at combating the components of the “lethal triad” - coagulopathy, hypothermia and acidosis, which arise against the background of traumatic blood loss and contribute to its continuation. Developing hypoperfusion leads to a decrease in oxygen delivery, a transition to anaerobic metabolism, lactate accumulation, and metabolic acidosis. Anaerobic metabolism limits endogenous heat production, increasing hypothermia. A vicious pathogenetic circle arises. Core body temperature less than 35 °C is an independent predictor of death in severe trauma (R.S. Martin et al., 2005).

The main components of the damage control resuscitation strategy are:

1) permissible (intentional) hypotension with limiting the volume of infusion until reliable hemostasis is formed;

2) hemostatic resuscitation strategy, including the earliest possible use of blood components as primary infusion therapy and the prescription of hemostatic pharmacological agents;

3) surgical damage control.

A hypotensive resuscitation strategy (taking into account suboptimal end-organ perfusion requirements) involves delaying or limiting the volume of colloid and crystalloid infusion until reliable hemostasis is achieved and is aimed at preventing dilutional coagulopathy. Thus, the study showed that a mean arterial pressure (MAP) of 40 mmHg. for 2 hours, led to the development of fatal hypoperfusion, and conversely, hypertension, when SBP was more than 80% above normal, led to the development of fatal rebleeding (T. Li et al., 2011). Another study noted that systolic blood pressure (BPsyst.) at 80 mm Hg. in comparison with the group of patients with ADsyst. > 100 mmHg provided effective control of bleeding. Therefore, in patients with active bleeding, it is recommended to maintain target blood pressure. less than 100 mm Hg. The effectiveness of this approach has also been confirmed by a number of other studies (R.P. Dutton et al., 2012), although it is still a subject of debate. Recommendations for acceptable hypotension are included in US military medical doctrine (T. J. Hodgetts et al., 2007) and in the 8th edition of Advanced Trauma Life Support (ATLS, 2008). Acceptable hypotension is contraindicated in TBI due to the need to maintain cerebral perfusion pressure.

Hemostatic resuscitation strategy is aimed at rapid and aggressive treatment of acute post-traumatic coagulopathy and is recognized as an important factor in improving treatment outcome (E. Kirkman et al., 2008). It includes the use of fresh frozen plasma, platelets, cryoprecipitate, fibrinogen, recombinant factor VIIa, tranexamic acid, prothrombin complex concentrate, and replenishment of calcium deficiency. To monitor the state of the hemostatic system, it is not sufficient to use only publicly available diagnostic tests (prothrombin time, activated partial thromboplastin time) due to their low sensitivity and the duration of obtaining results, but the “bedside” thromboelastography technique is recommended.

The decision on the need for massive blood transfusion is based on clinical assessment (visually massive bleeding; bilateral proximal traumatic amputations of the extremities; bleeding in the torso and unilateral proximal traumatic amputations), as well as the presence of clinical signs such as a decrease in body temperature below 35 ° C, blood pressure . less than 90 mm Hg. and laboratory changes (INR > 1.5; base deficiency (BE > -6); hemoglobin< 110 г/л). При этом необходимо отметить, что лабораторные данные не являются обязательным требованием для активации протокола массивной трансфузии (J. Mark et al., 2011). В случае использования протокола массивной гемотрансфузии рекомендуется соблюдение соотношения свежезамороженной плазмы и эритроцитарной массы 1: 1, которое способствует снижению летальности (M.A. Borgman, 2007; J.C. Duchesne et al., 2008), а также трансфузия тромбоцитов в соотношении 1: 1 с препаратами крови (O.L. Gunter et al., 2008; J.B. Holcomb et al., 2008) или по крайней мере одной дозы тромбоцитов на каждые пять доз эритроцитарной массы. Не рекомендуют применение эритроцитарной массы со сроком хранения более двух недель, так как это связано с увеличением частоты инфекционных осложнений и полиорганной недостаточности.

Correction of metabolic acidosis requires restoration of normal organ perfusion and only occasionally the use of buffer solutions (Boyd J.H. et al., 2008).

Surgical damage control is an important component of anti-shock therapy and involves the primary restoration of normal physiological parameters, rather than anatomical integrity: stopping bleeding, primary surgical treatment of wounds, prevention of compartment syndrome, primary (usually extrafocal) metal osteosynthesis of bone fractures. Restorative and reconstructive operations are carried out after the patient has restored normal physiological parameters (Shapiro M.B. et al., 2000).

Thus, the formation and ongoing development of the “damage control” strategy when providing intensive care to patients with polytrauma allows us to influence the components of the “lethal triad” and is the basis for improving treatment results and increasing the survival rate of patients both in peacetime and during military operations ( Holcomb J.B., 2007; Jansen J.O. et al., 2009).

dentists are more at risk of progression of atherosclerosis in the implanted area. It is necessary to take into account the prognostic factor of depressive symptoms when assessing the possibility of atherosclerotic changes in patients who have undergone coronary artery bypass grafting.

An important role in myocardial diseases is played by oxygen deficiency, which leads to limitation of aerobic energy production due to disruption of the energy-synthesizing function of the mitochondrial respiratory chain. As a result, accumulation of reactive oxygen species occurs, depletion of endogenous antioxidants and activation of lipid peroxidation of cell membranes. Some of the most promising drugs from the group of antioxidants are 3-hydroxypyridine derivatives that can penetrate the blood-brain barrier. Therapy of cognitive impairment that develops as a result of anxiety-depressive and neurological disorders caused by atherosclerosis and arterial hypertension in patients with chronic cerebrovascular accidents requires the use of drugs with vasoactive, psychostimulating and nootropic properties.

Thus, with this in mind, the use of antidepressants, especially selective serotonin reuptake inhibitors, in combination with antihypoxants in patients with cardiovascular disease suffering from depression has become more common among these patients. Combination therapy with the antidepressant Deprivox and the antihypoxant Mexiprim is relevant in patients with anxiety and depression due to cardiovascular pathology.

UDC 616-001-089.16

YARESHKO V.G., MIKHEEV Y.A., OTARASHVILI KN. State Institution "Zaporozhye Medical Academy of Postgraduate Education of the Ministry of Health of Ukraine"

DAMAGE CONTROL CONCEPT IN TRAUMA (surgeon's view)

A little history, or everything new is well forgotten old

Recent NATO military experience has revived the use of tourniquets, and new, easy-to-apply tourniquets (even self-applied one-handed tourniquets) have gained popularity in the world of civilian medicine. For some time, the wise idea expressed by Walter B. Cannon in 1918 about the inadvisability of restoring normal blood pressure (BP) until the bleeding has been stopped was forgotten. Aggressive prehospital and preoperative fluid therapy has replaced the standard of care

help. Obviously, lack of blood circulation (oxygen) for a few minutes will lead to cell death, first in the brain and then in other vital organs. To achieve a compromise between maintaining sufficient perfusion and blurring of blood clots from the injured area, leading to more bleeding after normalization of blood pressure, new approaches to prehospital care have been introduced, such as hypotensive resuscitation, low-volume resuscitation (or limited-volume resuscitation), controlled hypotension, and even concepts such as scoop and run (as opposed to the previous stay and play). In urban settings, the “grab and run” policy of getting the patient to the nearest trauma center as quickly as possible is most popular, and a Canadian study found that, paradoxically, having a physician on the scene of an injury worsens the prognosis, likely by -due to the fact that doctors tend to perform more invasive interventions, thereby delaying evacuation.

The experience of recent years, especially of the American military in Iraq and Afghanistan, has shown that in case of injury, transfusion of whole blood is more effective than red blood cells alone. The current policy followed in mobile army surgical (MASH) and military hospitals is to use fresh whole blood (FWB) when available or, alternatively, equal doses of red blood cells, fresh frozen plasma and platelets in a 4:1:1 ratio, among others. The advantages of this ratio are a decrease in the volume of infusion of other solutions, as a result, the likelihood of complications caused by massive infusion of crystalloids is reduced. Crystalloids do not transport oxygen and do not have clotting factors. A similar approach is gradually spreading to civil practice.

Tamponade of liver injuries was first described by James Pringle (made famous by the Pringle maneuver, famous among surgeons) in 1908. He did place packing around the liver in 4 patients, one of whom survived the initial operation but died 4 days later from a pulmonary embolism. During the section, bleeding from the liver (as well as from the right kidney, which he also tamponed) was stopped. William Halsted used a similar technique, but to prevent the tampons from firmly adhering to the liver tissue, he placed rubberized sheets between them. In this way he prevented recurrent bleeding after removal of tampons. In addition, it should be noted that gauze tamponade of the liver in case of extensive damage and serious condition of the victims was used during the Great Patriotic War by Soviet surgeons, and in the guidelines of the Ministry of Health

VA of the USSR from 1984, compiled at the Research Institute of Emergency Medicine named after. N.V. Sklifosovsky, contains instructions on the use of temporary abdominal tamponade and cessation of surgical procedures in order to stabilize hemodynamics in patients with severe abdominal trauma. The positive side of the concept is a survival rate of up to 70%, the negative side is postoperative complications associated mainly with temporary closure of the abdominal cavity. In any case, tamponade was forgotten for about 70 years, and attempts to reduce the volume of surgery for any injury amounted to “loss of surgical courage...” In 1983, Harlan Stone et al showed that this approach actually saves lives.

In the 80s of the last century, the concept of immediate total care (ETC) was proposed, which allowed simultaneous surgical treatment in the first 24 hours after injury of all injuries, both abdominal and orthopedic. The ETS concept has become the gold standard for providing care to victims of polytrauma. It was used universally in all groups of victims, regardless of the severity of the injuries. However, in the late 1980s, with the development of trauma surgery, it turned out to be ineffective in patients with critical injuries. Prolonged surgical intervention in patients with polytrauma, especially with thoracic, abdominal and craniocerebral injuries, with unstable hemodynamic parameters, led to death both during these operations and on the 5-7th day from severe complications that developed - respiratory adult distress syndrome, multiple organ failure, pneumonia and sepsis. In foreign literature, this period is called the era of borderline states - the borderline era. To assess borderline conditions, in 1990 the Go-Nover school of polytraumas proposed a damage control system. The term damage control comes from the Navy (do not stop a damaged ship, which will become easy prey for the enemy, but plug the hole in any way possible and head to the nearest shipyard for full repair) and was transferred to the surgery of Mike Rotondo and Bill Schwab of Philadelphia . This principle involves dividing surgical care for severe injuries into two or more stages, when the trauma and duration of emergency surgery exceed the functional capabilities of the body, and the immediate and final restoration of damaged structures will lead either to the death of the victim or to severe postoperative complications. A comparative description of ETS and damage control tactics carried out by G. Taeger et al. showed that when

damage control surgical blood loss is 10 times less, the traumatic impact of the operation and postoperative complications are significantly reduced.

The use of damage control probably represents the greatest advance in damage surgery in the last 50 years.

Application of damage control tactics at the stages of medical evacuation

In the medical support of modern combat operations, increased demands are placed on the pre-hospital stage, within which first medical aid is considered the optimal pre-evacuation preparation. However, a significant proportion of seriously wounded patients with ongoing internal bleeding and other life-threatening consequences that cannot be eliminated by first aid measures die before reaching the operating table.

One of the directions for reducing mortality among the wounded is bringing surgical care closer to the battlefield, which was developed as a result of the use of multi-stage surgical treatment tactics at the stages of medical evacuation. A key factor in reducing the risk of complications after injury is shortening the duration of surgery to stop the natural physiological deterioration caused by the injury.

The tactics of multi-stage surgical treatment (or damage control surgery) is aimed at preventing the development of an unfavorable outcome by reducing the scope of the first surgical intervention (a shortened emergency surgical procedure is performed) and shifting the final restoration of damaged organs and structures until the vital functions of the body are stabilized.

In the standard version, damage control tactics are carried out on the wounded at the time of admission to the surgeon.

Damage control tactics are implemented in 3 stages. The first stage is a primary emergency operation in a reduced volume; Stage 2 - intensive therapy until the vital functions of the body are stabilized; Stage 3 - repeated surgical intervention to correct all damage.

Damage control tactics for life-saving reasons, based on the severity of the general condition of the wounded who will not tolerate the full scope of emergency surgical intervention, should be used in multidisciplinary military hospitals when providing specialized surgical care to the seriously wounded.

However, currently the goals and scope of application of damage control tactics have expanded. Indications for its use are established in the seriously wounded and with compensated physical

logical indicators in case of organizational or tactical impossibility of complying with the standards of surgical care (mass influx of wounded, shortage of medical personnel, lack of necessary specialists, shortage of operating tables, blood products, etc.). This option for using damage control for medical and tactical indications implies, among other things, performing a reduced surgical intervention at one stage of medical evacuation (when providing qualified surgical care), followed by urgent evacuation and final surgical treatment at another stage of medical evacuation (when providing specialized surgical care). Thus, at present, damage control tactics are used not only as a last resort measure in the surgical treatment of seriously wounded people, but also as a strategy for providing surgical care for wounds and trauma in war. In this aspect, damage control tactics allow you to save time to save the wounded and rationally use the forces and means of the medical service.

Indications for the use of damage control tactics in the wounded

1. Vital, related to the extent of damage and the complexity of the required surgical intervention.

A. Inability to stop bleeding directly:

Damage to the main vessels of the neck in a hard-to-reach location (internal carotid artery and internal jugular vein at the base of the skull, vertebral artery);

Damage to large vessels of the mediastinum and multiple injuries to the vessels of the chest wall;

Severe damage to the liver and vessels of the retroperitoneal space (retrohepatic inferior vena cava, abdominal aorta and its visceral branches);

Damage to large vessels of the small pelvis (including ruptured intrapelvic hematomas);

Unstable fractures of the posterior half-ring of the pelvic bones.

B. Presence of severe combined and multiple injuries:

Combined multiple injuries of the neck, chest, abdomen, pelvis and damage to the great vessels;

Combined injuries with competing sources of bleeding;

Injuries requiring complex reconstructive interventions (plasty of the trachea and larynx, pancreaticoduodenectomy, prosthetics of the great vessels).

2. Life-related, related to the severity of the condition and complications that have developed.

A. Physiological indications:

Unstable hemodynamics requiring inotropic support (systolic blood pressure< 70 мм рт.ст.);

Severe metabolic acidosis (pH< 7,2, ВЕ < -10);

Increased serum lactate (> 5 mmol/l);

Hypothermia (body temperature< 35 °C);

Electrical instability of the myocardium.

B. Increased treatment requirements:

Massive blood transfusions (more than 3.0 l or more than 10 doses of erythroconcentrate or erythrocyte suspension);

Long-term surgery (more than 90 minutes).

B. Occurrence of intraoperative complications:

Generalized fibrinolysis;

Inability to close the laparotomy wound due to intestinal paresis and peritonitis.

3. Medical and tactical indications.

A. Mass influx of wounded.

B. Insufficient qualifications of the surgeon to perform complex or highly specialized reconstructive surgery.

B. Limited forces and means of the medical service.

Stages and elements of damage control tactics

The objectives of the 1st stage of damage control tactics are:

Temporary or permanent stop of bleeding;

Temporary or permanent elimination of external respiration disorders;

Prevention of further contamination and infection of body cavities and tissues with the contents of hollow organs (intestinal contents, bile, urine, saliva);

Temporary sealing of cavities, temporary closure of wounds and therapeutic and transport immobilization of fractures of the pelvic bones and limbs.

Stopping bleeding is done:

Ligation of secondary or restoration with a side suture of the main damaged blood vessels;

Application of soft clamps to the vascular pedicles of parenchymal organs (kidneys, spleen) or their removal if destroyed;

Temporary prosthetics of damaged great vessels;

Application of a hemostatic tourniquet (for separation and destruction of limbs);

Tight tamponade of the bleeding area of ​​injury (nasal cavity, mouth, nasopharynx, sites of multiple rib fractures, liver wounds, retroperitoneal space and pelvic tissues, muscle masses of the gluteal and lumbar regions). It should be remembered that tamponade can be of a resuscitation nature (manual

compression of the abdominal aorta under the diaphragm or digital compression of the hepatoduodenal ligament) and performed in order to achieve long-term hemostasis (packing wounds of the liver, retroperitoneum, large muscle masses);

The use of various balloon catheters (for wounds of the heart, liver, large cavitary vessels), which can be used either by introducing a balloon into the wound canal with subsequent inflation, or endovascularly;

Application of a Ganz frame or a rod apparatus (for unstable fractures of the bones of the posterior semi-ring of the pelvis with ongoing intra-pelvic bleeding).

The technique of performing all these methods has its own characteristics.

Temporary elimination of external respiration disorders in seriously wounded patients is carried out by tracheal intubation and conicotomy. Extensive damage to the trachea can be temporarily eliminated by introducing an endotracheal tube (or tracheostomy cannula) through the wound (atypical tracheostomy), and large bronchi - by hardware resection of a lobe or the entire lung.

Prevention of further contamination and infection of cavities and tissues with the contents of hollow organs is achieved as follows:

Suturing small wounds of hollow organs (esophagus, small intestine, colon, bladder) with a continuous single-row suture;

Hardware obstructive resection of destroyed areas of hollow organs without restoring their integrity or imposing stomas;

Application of temporary suspended stomas (in case of damage to the common bile duct, pancreatic duct, gallbladder, ureter, esophagus) or delimiting the area of ​​damage with tampons with drainage directly to the wound of these structures.

Temporary sealing of cavities and closure of wounds is carried out:

Thoracotomy wound - with a single continuous suture through all layers of the chest wall;

Laparotomy wound - by applying single-row interrupted sutures to the skin, bringing together the abdominal skin with linen tweezers, bringing the edges of the wound together with subcutaneous Kirschner needles, and suturing a sterile plastic bag to the edges of the wound. When sealing a laparotomy wound, it is very important to install a wide-lumen drainage tube into the pelvic cavity to control hemostasis, and to prevent compartment syndrome of the abdominal cavity, not to suture the aponeurosis;

Bleeding wounds of soft tissues - by applying rare skin sutures over tampons inserted into the wound canal (according to A. Beer).

For fractures of the extremities, the 1st stage of damage control tactics ends with external fixation of bone fractures with rods or simplified

using special pin devices in the mode of medical and transport immobilization. The duration of the 1st stage should not exceed 90 minutes.

Simultaneously with surgical interventions, intensive therapy is carried out, which continues at the next stages of damage control tactics.

Objectives of the 2nd stage of damage control tactics:

Replenishment of circulating blood volume (CBV); correction of coagulopathy;

Elimination of acidosis;

Correction of water and electrolyte disorders;

Long-term artificial ventilation;

Preventive antibacterial therapy;

Warming the wounded.

Replenishment of blood volume must be carried out with large-volume infusions and transfusions, including through the systemic circulation (intra-aortic). Particular importance should be given to blood reinfusion in those wounded in the chest and abdomen. Correction of coagulopathy is carried out by transfusion of fresh frozen plasma, cryo-precipitate, platelet mass, administration of large doses of protease inhibitors and glucocorticoids. With massive reinfusions, it is necessary to promptly inactivate excess heparin by administering protamine sulfate. All wounded people should be warmed using available methods (by wrapping them in a blanket, heating pads, warming infusion media). Central hemodynamics are supported by inotropic drugs (dopamine, adrenaline). Preventive antibacterial therapy is carried out with cephalosporins of the II-III generations in combination with aminoglycosides and metronidazole. During intensive therapy, monitoring of basic vital parameters (pulse, blood pressure, blood saturation, number of red blood cells and hemoglobin, coagulogram parameters and blood biochemistry) should be carried out. In the postoperative period, pain relief is multi-level (long-term blockade with local anesthetics in combination with central analgesia). Energy supply is carried out through mixed, and in some cases, complete parenteral nutrition. The duration of the 2nd stage of damage control tactics (when treating the wounded in an extremely serious unstable condition) averages 1-1.5 days. The criteria for stabilizing the condition of the wounded are: systolic blood pressure > 100 mm Hg, heart rate< 100 уд/мин, гематокрит >0.30 l/l. After achieving these indicators, the 3rd stage of the damage control tactics is performed.

The task of the 3rd stage of damage control tactics is the final surgical correction of all damage.

Priority surgical interventions are:

Final restoration of large vessels of the cavities, pelvis and extremities;

Repeated revision of tamponed areas with final stop of bleeding or replacement of tampons using hemostatic drugs (hemostatic sponges or films);

Reconstructive interventions on hollow organs (suturing, resection, restoration of continuity, ostomy, probe decompression);

Sanitation and drainage of cavities and cellular spaces (thoracic and abdominal cavities, paravesical and pararectal spaces, etc.);

Primary or secondary surgical treatment of gunshot wounds.

In this case, the timing of repeated operations can be determined by the time of transportation of the wounded, stabilization of the general condition or the development of complications and other emergency situations (secondary bleeding, abdominal compartment syndrome, uncompensated ischemia of the limbs, progressive peritonitis, etc.).

A feature of the 3rd stage of damage control surgical tactics in patients wounded in the abdomen is not only the performance of reconstructive operations, but also subsequent (according to indications) repeated sanitary relaparotomies. Final reduction and fixation of fractures of the pelvic bones and limbs after primary reduction

This intervention can be performed from 3-7 to 15 days, and stabilizing operations on the spine are performed as planned - against the background of compensation for the condition of the wounded.

1. Damage control tactics are used to save the lives of seriously wounded people who are unable to endure the full extent of surgical intervention due to the severity of the injury. When resources are limited, damage control tactics can be used according to medical and tactical indications.

2. The meaning of damage control tactics is the use of abbreviated simple and quick emergency interventions (1st stage) with delayed implementation of reconstructive operations after stabilization of the condition (3rd stage). The second stage of damage control tactics includes resuscitation and intensive care measures and evacuation of the wounded.

3. Tight tamponade, ligation or temporary prosthetics of blood vessels, provision of external respiration, sealing of hollow organs, therapeutic and transport immobilization of fractures - the main content of the 1st stage of damage control tactics.

4. The transition to the 3rd stage of damage control tactics is possible only after the wounded person’s condition has stabilized.

5. An objective assessment of the severity of the injury helps to identify a group of wounded people who need to use damage control tactics. ■

The steady increase in injuries observed in recent years is increasingly accompanied by combined and multiple injuries to the victims’ organs and systems, which makes it impossible for them to perform large reconstructive operations in one stage. Success in the treatment of such patients is largely determined not only by the availability of experienced specialists and conditions for providing specialized care, but also by the use of a number of new approaches developed on the basis of modern achievements in surgery, anesthesiology and resuscitation. Improving care for victims with polytrauma is the most pressing task of modern traumatology, since it is the cause of mortality in young and middle-aged people. Serious injuries to long tubular bones occur in 70% of patients with polytrauma, which further aggravates the general condition and complicates treatment. On the other hand, these fractures do not pose an immediate threat to life, and their treatment can be divided into two or more stages using simple techniques that are safe for the victim at the first stage, and complex restorative, surgical treatment in subsequent stages, carried out in conditions of complete or partial compensation for the patient's condition with minimal risk to his life.

In the 80s, the concept of immediate total care was proposed - ETC (early total care), which allowed simultaneous surgical treatment in the first 24 hours after injury of all injuries, both abdominal and orthopedic. The ETS concept has become the gold standard for providing care to victims of polytrauma. It was used universally in all groups of victims, regardless of the severity of the injuries. After osteosynthesis, patients became mobile, which reduced the number of pulmonary complications, pain impulses from the fracture zone stopped, bleeding stopped, which reduced the duration of shock. This concept also had an economic effect, as it shortened treatment times. However, in the late 1980s, with the development of trauma surgery, it turned out to be ineffective in patients with critical injuries.

Long-term surgical intervention in patients with polytrauma, especially with thoracic, abdominal and craniocerebral injuries, with unstable hemodynamic parameters, led to death, both during these operations and on the 5-7th day, from severe complications that developed - Adult RDS, multiple organ failure, pneumonia and sepsis. In foreign literature, this period is called the era of borderline states - the borderline era. To assess borderline states in 1990. The Honover school of polytraumas proposed a damage control system. This principle involves dividing surgical care for severe injuries into two or more stages, when the trauma and duration of emergency surgery exceed the functional capabilities of the body, and the immediate and final restoration of damaged structures will lead either to the death of the victim or to severe postoperative complications. A comparative description of the tactics of ETS and DCS, carried out by G. Taeger et al., showed that with DCS, surgical blood loss is 10 times less, the traumatic effect of the operation and postoperative complications are significantly reduced.

According to P. Harwood et al., when using the damage control protocol, adult RDS and sepsis develop less frequently than when providing assistance according to the ETC principle. The term damage control surgery was proposed in 1993 by M. Rotondo et al. for surgery of abdominal injuries and consisted of three stages. The first stage is to stop bleeding and bacterial contamination of the abdominal cavity. The second is intensive anti-shock therapy in the intensive care unit, aimed at stabilizing the vital functions of the body (replenishment of circulating blood volume, correction of coagulopathy, warming the victim, hemodynamic support, ventilation support, elimination of acidosis). The third stage is final surgical treatment. In 2001, J. Johnson et al. expanded the concept of damage control, highlighting the fourth stage - ground zero, which implies the provision of pre-hospital medical care (the fastest possible transportation to a medical facility, the simplest measures to stop bleeding, prevention of hypothermia, preparation for massive transfusion therapy). This tactic significantly improved the outcomes of severe polytraumas and made it possible to save the life and health of victims who were previously considered hopeless. Separate protocols were allocated damage control for abdominal, thoracic, craniocerebral, spinal and orthopedic injuries, which received the appropriate designations - DCS (damage control surgery - damage control control of damage to the musculoskeletal system).

The main pathophysiological prerequisites for damage control tactics in severe polytrauma are metabolic acidosis, pH level less than 7.2, hypothermia, the victim’s body temperature less than 340C, hypotension, systolic blood pressure less than 90 mmHg. Art., coagulopathy, activated partial thromboplastin time more than 60 s. This triad defines the physiological limit of the body, at which even the most technically successful operation is doomed to failure. For successful application of damage control in practice, it is necessary to carefully evaluate three factors: 1) the severity of the initial injury, the first hit, 2) the biological constitution of the patient, age, body weight, concomitant diseases, 3) the number of necessary operations, taking into account their duration and probable blood loss (the second hit). Danger second strike stable and borderline implementation of any type of osteosynthesis urgently did not lead to a deterioration in the general condition. In the unstable group, at the first stage only low-traumatic operations and conservative methods are used. In the critical group, at the first stage only conservative fixation methods are used. Stable functional osteosynthesis in these groups is performed at the second stage, after stabilization of the general condition, on days 4-14 after injury.

Thus, the action of a traumatologist when applying damage control tactics in the case of severe polytrauma is as follows: priority is given to operations on the organs of the abdominal cavity, pelvis, chest, and brain. These operations are divided into two and sometimes three phases. First, after minimal stabilization (blood pressure at 90 mm Hg, pulse 120 per minute), chest drainage and laparotomy with tamponing or clamping of bleeding vessels or organs are performed according to indications. The damaged intestine is removed and isolated from the free abdominal cavity. The wound is closed with a continuous suture, only the skin. After stabilization, after 24-36 hours the laparotomy wound is reopened and the second phase of surgical treatment is carried out with final suturing of the wound. Depending on the severity of the condition, in unstable and critically ill patients with damage to long tubular bones, in the first phase, fixation is performed with an external fixation device (AFD), skeletal traction, or a plaster splint. For open fractures, victims in critical condition only need to wash the wound with antiseptics, remove visible foreign bodies, and apply an antiseptic bandage. Surgical treatment is also carried out after 24-36 hours. Immersion osteosynthesis for closed fractures is postponed for 6-8 days.

Based on the above, we propose an algorithm for the treatment of fractures of long tubular bones in polytrauma. abdominal and thoracic cavities), DCO (damage control orthopedics - characterized by systemic inflammation in combination with microvascular damage, increasing interstitial edema, especially of the lungs, and multiple organ failure. This explains the fact when a victim with a severe injury who has undergone several operations, blood loss was compensated by transfusion of donor blood, the acid-base and electrolyte balance was restored, however, after 1-2 days, severe complications with a fatal outcome develop.The concept of damage control in orthopedics is used for fractures of the femur, pelvis with disruption of the anterior and posterior half-rings, multiple fractures of long tubular bones, avulsions of the femur and tibia. Great importance is attached to the following: damage to which areas is combined with injury to the musculoskeletal system. Most of all, the unfavorable outcome and development of complications are influenced by closed chest injury and traumatic brain injury. For the effective use of damage control, depending on the severity of injury and general condition, patients with polytrauma were divided into four groups: stable, borderline, unstable, critical. The severity of the injuries received was determined using a score for the severity of polytrauma according to AIS and ISS, the severity of traumatic brain injury according to the Glasgow scale (CGS), as well as indicators of systolic blood pressure, heart rate (HR), respiratory rate (RR), hemoglobin level, hematocrit .

Thus, damage control is a tactic for treating victims with polytrauma who are in an unstable or critical condition. Damage control orthopedics applies to patients whose condition severity according to ISS is more than 20 points in combination with trauma to the skull, chest, or abdominal cavity. Treatment consists of two stages: Stage I - for victims in critical condition, in the first 24 hours from the moment of injury, a minimum of trauma care is performed, after surgery on the brain and abdominal organs; Stage II - 6-8 days after the injury, after complete stabilization, final osteosynthesis is performed.

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Every year, up to 800 patients with multiple and combined fractures of extremity bones who require hospitalization for emergency reasons pass through the emergency department of the Trauma Center of the Republican Clinical Hospital in Kazan. Of these, victims with severe polytrauma account for 12-15%. All patients with severe polytrauma were delivered to the Center's emergency department with symptoms of traumatic shock, often in a comatose state. The article presents the immediate results of providing specialized care to 180 patients with severe multiple fractures of the extremity bones, delivered to the emergency department of the Trauma Center of the Republican Clinical Hospital. The main directions and stages of treatment and diagnostic measures for patients with severe polytrauma are determined, depending on the type and severity of injuries, the severity of the patients’ condition. The most justified and gentle method of surgical treatment of multiple fractures of extremity bones at the first stage of specialized care is the method of transosseous osteosynthesis with external fixation devices. In all cases, positive treatment results were achieved.

external fixator

transosseous osteosynthesis

multiple fractures of the limbs

polytrauma

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11. Sokolov V.A. “Damage Control” - a modern concept for the treatment of victims with critical polytrauma // Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. – 2005. - No. 1. – P. 81-84.

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Introduction. Emergency situations accompanied by explosions, fires, destruction, with a high risk of thermomechanical damage, are the cause of the appearance of those affected with polytrauma, more than half of whom are in serious condition.

The Republic of Tatarstan in general, and the city of Kazan in particular, are territories with a high concentration of risk factors for emergency situations of this nature. These are industries that use hydrocarbons and other highly flammable and detonating substances, product pipelines, and transport routes.

Road traffic accidents (RTAs) are an endless source of people affected by polytrauma. In general, in the Republic of Tatarstan their number reaches 10-12 thousand people per year.

In industrialized countries, injury is the leading cause of death for people under 40 years of age. In the age group from 1 year to 34 years, injury is the main cause of death, and among adolescents and young men this figure is 80%. Combined mechanical injuries are one of the leading causes of mortality in the population of the Russian Federation under the age of 39-44 years. A special place is occupied by road traffic accidents, the mortality rate of which reaches 60%.

Patients with severe polytrauma represent a special category of patients with severe and complex injuries to the musculoskeletal system. The features of such injuries include shock and acute massive blood loss, which accompany most severe multiple fractures of the bones of the extremities and associated injuries, as well as the development of early severe complications from the blood coagulation system, cardiovascular, respiratory and other body systems, often leading to death . The clinical picture and severity of the patients' condition are significantly aggravated by the frequent combination of fractures of the limbs with severe traumatic brain injury, severe trauma to the chest and abdomen.

Currently, the problem of treating severe polytrauma is the focus of attention of most orthopedic traumatologists in our country and abroad.

Mortality in severe polytrauma reaches 40% and higher. The main causes of death in the first hours after severe polytrauma are shock and acute massive blood loss, and later - severe brain disorders and associated complications. Among the early complications of polytrauma, complications from the blood coagulation system come first. The incidence of deep vein thrombosis of the lower extremities, according to the literature, is 60-80%, pulmonary embolism is noted in 2-10% of cases. Another severe complication of multiple fractures of the bones of the extremities, as well as associated injuries, is the development of fat embolism syndrome, which is not inferior in frequency to venous thromboembolic complications.

Among the late complications of multiple injuries to the skeletal bones, often leading to permanent disability and decreased quality of life, it is necessary to note the delayed consolidation of fractures, the formation of false joints, the development of persistent contractures and deforming arthrosis of the joints of the extremities. The rate of disability reaches 25-45%.

The emergence of an important independent functional component - the syndrome of mutual aggravation of injuries in case of combined injury, significantly increases the overall severity of injuries, causing the inevitability of death. The choice of timing and volume of surgical interventions is important for a favorable outcome in the treatment of victims with concomitant injuries.

Treatment of limb bone fractures in severe polytrauma is one of the most pressing problems of modern traumatology and orthopedics. Surgical treatment is currently the main treatment for multiple fractures of extremity bones and combinations of fractures with severe traumatic brain injury and damage to internal organs. At the same time, most traumatologists adhere to the concept of early surgical treatment of fractures. In recent decades, the concept of organizing the treatment process and providing highly qualified care to patients with severe polytrauma, taking into account the principle of damage control when they are admitted to the emergency department of specialized hospitals of multidisciplinary clinics, has become increasingly relevant.

Materials and research methods. Every year, on average, up to 5,700 patients who require hospitalization for emergency and urgent reasons pass through the emergency department of the Trauma Center of the Republican Clinical Hospital of Kazan (level I trauma center), of which about 760-800 are patients with multiple bone fractures and associated injuries. Of this number, victims with severe polytrauma (severe multiple fractures of the bones of the extremities, combined injuries - bone fractures in combination with severe traumatic brain injury, injuries to the chest and abdomen) account for 12-15%. In most cases, these are patients with severe combined traumatic brain injury (extremity bone fractures, severe or moderate brain contusions, intracranial hematomas). Patients with severe monolocal and multiple fractures of the bones of the extremities in combination with mild traumatic brain injury, injuries to the chest and abdominal organs make up about 35-40% of the total number of victims with polytrauma. At the same time, every year the number of people in need of emergency, highly qualified assistance is progressively increasing.

All victims with severe polytrauma were taken to the emergency department of the Center with symptoms of traumatic (usually grade III-IV) shock. Patients with severe concomitant traumatic brain injury had varying degrees of profound loss of consciousness. All this required the adoption of emergency measures to provide specialized medical care. When patients are admitted in a state of severe traumatic shock, anti-shock measures come first. The entire complex of therapeutic and diagnostic measures is carried out against the background of anti-shock therapy. Emergency assistance to victims is provided in the shock operating room of the emergency department.

We have identified the main directions and stages of treatment and diagnostic measures for patients with severe polytrauma upon their admission to the emergency department of the trauma center: accuracy and timeliness of diagnosis of all types of injuries, including a full clinical and x-ray examination; timeliness and adequacy of the provision of specialized, including highly qualified care, choice of treatment method, method of repositioning and fixation of fractures; timeliness and correctness of the implementation of medical manipulations and surgical aids; continuity in patient treatment (damage control principle). It should be noted here that the sequence of care, the implementation of a set of treatment measures, including surgical procedures, should be carried out in accordance with the type and severity of injuries that determine the possible development of a traumatic disease.

In case of fractures of the bones of the extremities in combination with injuries to internal organs, intracranial hematomas, surgical interventions for emergency indications are performed by two or more operating teams in the shock operating room of the emergency department. Surgical reduction and stabilization of fractures is an essential component of anti-shock therapy and prevention of complications of traumatic disease. An indispensable condition for providing assistance is the accuracy of surgical manipulations and minimizing the time of surgical intervention.

In case of severe combined injuries in patients in critical condition, the provision of specialized surgical care should be kept to a minimum (damage control principle). At the first stage of treatment, simultaneously with anti-shock therapy, surgical interventions on vital organs are performed (removal of intracranial hematomas, stopping external and internal bleeding). Surgical interventions for fractures of the bones of the extremities are performed in a delayed manner after the victims have been removed from a state of severe shock and the main physiological parameters have been normalized. An attempt to surgically reduce extremity fractures in patients with severe polytrauma who are in critical condition can lead to worsening shock with possible death. At this stage of treatment, it is necessary to limit oneself to complete immobilization (splinting) of the injured limbs.

In case of severe monolocal and multiple fractures of the bones of the extremities without the threat of bleeding, surgical interventions are performed after removing the victims from shock and stabilizing blood pressure. Surgical reduction of fractures and stabilization of bone fragments is the most important measure aimed at eliminating shockogenic foci and preventing the possible development of fat embolism syndrome and disorders of the blood coagulation system. The most justified method of treatment when patients are admitted to a hospital at the stage of the admission and diagnostic department is transosseous osteosynthesis with external fixation devices. In case of open fractures, according to emergency indications, primary surgical treatment and transosseous osteosynthesis under visual control are performed. For closed fractures of the bones of the extremities, surgical interventions are performed according to urgent indications. Surgical reduction is achieved on an orthopedic operating table; closed transosseous osteosynthesis with external fixation devices is used.

In case of threatening or developed fat embolism, surgical interventions are performed according to emergency indications in order to stabilize bone fragments. Closed transosseous osteosynthesis with external fixation devices is used.

When patients are admitted with fractures of the limb bones against the background of severe polytrauma, depending on the type and severity of the injuries, the condition of the patients, for emergency (urgent) indications, transosseous osteosynthesis according to Ilizarov is used as the most gentle method of surgical treatment. We have developed and successfully used original clinically and biomechanically substantiated configurations of external fixation devices based on the method of G.A. Ilizarov, as well as methods of surgical treatment of fractures. Simultaneous closed reduction on the orthopedic operating table is achieved in the shortest possible time (5-10 minutes). Anesthesia - anesthesia or central segmental blockade, depending on the type of damage.

As a rule, the device is mounted from 2-3 arc or ring supports of the Ilizarov kit with brackets that are connected to each other using threaded rods. Shants bone screw rods are inserted into the fragments above and below the fracture site, which are fixed in brackets on the supports of the device. Large intermediate fragments in comminuted and double fractures are also fixed with Shants screws or pins with stops. By moving the supports along the Shants screw rods, fracture reposition is achieved. Once fracture reposition is achieved, the device is switched to stable fixation mode.

By improving the condition of patients with a view to their early activation, in a number of cases (as a rule, with fractures of the femur and shin bones), it is possible to replace the external fixation apparatus with various modern submersible structures - the principle of damage control in traumatology. In the process of repeated surgical intervention, the external fixation device is sequentially dismantled without disturbing the previously achieved fracture reposition. For fractures of long tubular bones, osteosynthesis with locking pins is used. For peri- and intra-articular fractures, as a rule, various special plates are used to ensure stable osteosynthesis. Additional external immobilization of the limbs is not used. This contributes to the onset of early active movements in the joints, as well as the loading of damaged limbs, which is the prevention of the possible development of persistent joint contractures, as well as a condition for restoring the function of damaged limbs.

In Fig. 1 (a, b, c) shows radiographs upon admission to the emergency department of the trauma center of patient L., born in 1971, case history No. 14536, who was treated at the traumatology clinic from 15.05. to 06/14/2010. Delivered by ambulance on an emergency basis on 05/15/2010. The circumstances of the injury are unknown, found by passers-by on the sidewalk near his home. Upon admission, the condition was assessed as extremely serious. Examined by an on-duty team consisting of traumatologists, a neurosurgeon, a surgeon, and a resuscitator in a shock operating room in the emergency department. Dz: Severe combined injury. Open craniocerebral injury, moderate brain contusion, open fracture of the temporal bone pyramid, otohemorrhage on the right. Open fracture of the lower jaw on the right. Closed fracture of the surgical neck of the right shoulder with slight displacement of the fragments. Closed fracture of the proximal left femur with displaced fragments, closed intra-articular fracture of the distal epimetaphysis of the left femur with displaced fragments. Closed fracture of the left calcaneus with displacement of fragments. Shock III degree.

Upon admission, resuscitation measures were started. Clinical and radiological examination against the background of resuscitation therapy. The damaged limbs are splinted. After initial resuscitation and diagnostic measures, the patient was hospitalized in the intensive care unit. Upon normalization of the general condition and main clinical and laboratory parameters, on May 18, 2014, he was transferred to the specialized traumatology department. After a comprehensive examination, operations were performed: 05/25/2014 - primary delayed treatment of the mandibular fracture, splinting. 06/01/2014 - open reduction of a fracture of the proximal part of the left femur, osteosynthesis with a locking pin. Transosseous osteosynthesis using an external fixation device for an intra-articular fracture of the distal epimetaphysis of the left femur. Transosseous osteosynthesis using an external fixation device for a fracture of the left calcaneus. Repositions were achieved on the operating table. Discharged with improvement on June 14, 2014.

A) b)

V)

Rice. 1. Radiographs of fractures of the bones of the lower extremities of patient L., born in 1971, clinical case 14536 with severe polytrauma (a - proximal part of the left femur, b - intra-articular fracture of the distal epimetaphysis of the left femur, c - intra-articular comminuted fracture of the left calcaneus ).

In Fig. 2 (a, b, c) shows radiographs upon admission to the emergency department of the trauma center of patient E., born in 1953, case history No. 150, who was treated at the clinic from 16.01. to 02/10/2008. Delivered by ambulance on an emergency basis from the scene of an accident on 01/16/2008. He was hit by a car. Upon admission, the condition was assessed as extremely serious. Dz: Severe polytrauma. Open polyfragmentary fracture of the bones of the left leg. Open double fracture of the bones of the right leg. Closed fracture of the middle third of the right humerus. Shock III-IV degree. Alcohol intoxication.

Upon admission, comprehensive anti-shock measures were taken. After removing the victim from shock and normalizing the main clinical and laboratory parameters, he was taken to the operating room. The operation was performed: primary surgical treatment of fractures of the bones of the right and left leg, transosseous osteosynthesis with external fixation devices. The right upper limb is fixed in a plaster splint. After 7 days, osteosynthesis of the right humerus fracture was performed using a Sternberg pin. After 4 months, due to the delayed consolidation of shin bone fractures and the formation of false joints at the level of the lower third of both tibias, the external fixation devices were dismantled and intramedullary osteosynthesis of the left and right tibias with locking pins was performed. The patient was discharged with improvement in satisfactory condition.

A) b)

V)

Rice. 2. Radiographs of patient E., born in 1953, case history No. 150 with severe multiple fractures of the limb bones (a - before surgery; b - during treatment with external fixation devices; c - stage of internal osteosynthesis of the humerus)

Treatment results and their discussion. The immediate outcomes of specialized and highly qualified treatment were assessed in 180 patients with severe polytrauma of the limb bones delivered to the emergency department of the Traumatology Center for the period 2012-2013. Fatal outcomes in the immediate period after hospitalization (in the emergency department, anesthesiology and intensive care department) were observed in 22. These were victims brought to the emergency department in an extremely serious, in some cases terminal, condition, injured as a result of a fall from a great height, or a road accident. -transport accidents. All victims were provided with specialized and highly qualified emergency assistance. Depending on the type of injury and the severity of the general condition of the patients, they underwent surgical interventions for emergency or urgent (delayed due to the extremely serious condition after complex anti-shock therapy) indications. All treated patients with severe multiple and combined fractures of the extremity bones showed positive treatment results at the time of discharge.

Thus, the algorithm for providing specialized, including highly qualified, care to victims with severe polytrauma admitted to the emergency department of a level I trauma center is determined taking into account the type and severity of injuries, the severity of the general condition of the patients, and the degree of traumatic shock.

All therapeutic and diagnostic measures were carried out according to emergency or urgent indications against the background of complex anti-shock therapy.

In case of fractures of the bones of the extremities in combination with intracranial hematomas, closed trauma to the chest and abdomen with threatening internal bleeding, evacuation of the hematoma with the elimination of compression of the brain, stopping internal bleeding using the most gentle methods come to the fore. After stopping intra-abdominal bleeding in case of severe trauma to internal organs, it is possible to perform repeated restorative surgical interventions on the abdominal organs after stopping the phenomena of traumatic shock (damage control principle). At the same time, in cases of severe traumatic shock with a threat to the life of the victims, surgical interventions on injured limbs are performed according to urgent indications in a delayed manner after recovery from shock and normalization of the main clinical and laboratory parameters. In these cases, complete immobilization of injured limbs is carried out with splints or plaster casts. Complete immobilization is also a reliable anti-shock measure that helps prevent the possible development of complications of a traumatic disease.

In case of avulsions and crushes of the limbs, at the first stage of anti-shock therapy, external bleeding is temporarily stopped by applying a tourniquet or hemostatic clamp. Primary surgical treatment with the formation of a limb stump for emergency indications is carried out after the victim has been completely recovered from shock.

In case of severe, including multiple fractures of the pelvic bones and extremities without the threat of bleeding, surgical reposition and stabilization of fractures is carried out according to urgent indications, also after stopping the phenomena of traumatic shock, normalizing the main clinical and laboratory parameters in the conditions of the shock operating room of the emergency department. At the same time, reposition and stabilization of bone fragments is the most important measure aimed at eliminating shockogenic foci and preventing the possible development of complications from impaired rheology and blood coagulation system (fat embolism syndrome, venous phlebothrombosis). The most justified and gentle method of surgical treatment when patients are admitted to hospital is transosseous osteosynthesis with external fixation devices. At the same time, in the future, it is not excluded that the external fixation device will be replaced with submersible structures in order to quickly restore the function of damaged segments of the musculoskeletal system (damage control in traumatology and orthopedics).

In all cases of providing specialized, including highly qualified, care to patients with severe polytrauma of the bones of the extremities, positive immediate treatment results were obtained.

Reviewers:

Mikusev I.E., Doctor of Medical Sciences, Professor, Professor of the Department of Traumatology and Orthopedics of the Kazan State Medical Academy of the Ministry of Health of the Russian Federation, Kazan.

Skvortsov A.P., Doctor of Medical Sciences, Associate Professor of the Department of Traumatology and Orthopedics of the Kazan State Medical Academy of the Ministry of Health of the Russian Federation, Kazan.

Bibliographic link

Pankov I.O., Sirazitdinov S.D., Asadullin Sh.G., Sirazitdinov D.T. PRINCIPLES OF PROVIDING SPECIALIZED CARE TO PATIENTS WITH SEVERE MULTIPLE FRACTURES OF LIMB BONES IN A LEVEL I TRAUMA CENTER AT THE CURRENT STAGE. DAMAGE CONTROL IN TRAUMATOLOGY // Modern problems of science and education. – 2014. – No. 3.;
URL: http://science-education.ru/ru/article/view?id=13241 (access date: 02/01/2020). We bring to your attention magazines published by the publishing house "Academy of Natural Sciences"

“© V.A. Sokolov, 2005 “DAMAGE CONTROL” – A MODERN CONCEPT FOR TREATING VICTIMS WITH CRITICAL POLYTRAUMA V.A. Sokolov Moscow Research Institute...”

© V.A. Sokolov, 2005

“DAMAGE CONTROL” – MODERN

CONCEPT OF TREATING VICTIMS WITH

CRITICAL POLYTRAUMA

V.A. Sokolov

Moscow Research Institute of Emergency Medicine

them. N.V. Sklifosovsky

Improving care for victims with polytrauma is one of the most

current tasks of modern traumatology, since polytraumas are the main cause of mortality among young and middle-aged people and contribute to the depopulation of the Russian population.

The second half of the 20th century was a period of significant advances in the treatment of severe injuries, primarily in developed Western countries. The number of cases of fatal polytraumas decreased by 2 times or more, the number of cases of permanent disability decreased by the same amount, and the treatment time was reduced by 4 times.

In the early 80s, the concept of immediate total care (ETC) was proposed, which involved surgical treatment of all injuries, both abdominal and orthopedic, in the first 24 hours.

This concept was applied universally in all groups of victims, regardless of the severity and extent of injury. The success was facilitated by the development of new methods of osteosynthesis - first, stable according to the principles of AO-ASIF, and then minimally invasive locked osteosynthesis of long bones.

After osteosynthesis, patients became mobile, pain impulses from the fracture zone stopped, and bleeding stopped. There was also an economic effect, since the treatment time was reduced several times.

However, in the late 1980s it became clear that ETC was not a universal system and was only effective in patients who were not critically injured (although they constituted the majority). Prolonged surgical procedures in the early period of nolitrauma led to death, especially with significant thoracic, abdominal and craniocerebral injuries.

The death of the victims occurred both in the first hours after the injury during these operations and on the 5-7th day - from severe complications that developed: adult respiratory distress syndrome, multiple organ failure, pneumonia, sepsis.

To improve the outcome of treatment of the most severe polytraumas, the Hannover School of Polytrauma in 1990 proposed a system of so-called “damage control”, according to which surgical treatment of injuries to both internal organs and the musculoskeletal system is divided into two stages: first day, minimal life-saving short operations are performed such as decompressive trifilation or mini-craniotomy for epi- and subdural hematomas, laparotomy with Vestnik of Traumatology and Orthopedics named after. N.N. Priorova. 2005, No. 1, pp. 81-84 by applying clamps to the pedicle of the spleen and tamponade of liver rupture, puncture epicystomy, etc., and fractures of large bones, primarily the hip, are immobilized with external fixation devices. Then the victim is given intensive therapy until hemodynamic and other indicators of homeostasis are completely stabilized, and after 1-2 days, reconstructive operations on internal organs are performed, and after 5-7 days and later, minimally invasive osteosynthesis of long bone fractures is performed. This tactic significantly improved the outcomes of severe polytraumas and made it possible to save the lives and health of victims who were previously considered hopeless. Separate “damage control” protocols were identified for abdominal, thoracic, traumatic brain, spinal and orthopedic injuries, which received appropriate abbreviations - for example, DCS (damage control surgery).

abdominal and thoracic cavity), DCO (damage control orthopedics - “damage control” of the musculoskeletal system).

The term “damage control” is still little known to most domestic traumatologists, and there are still recommendations to operate on victims with polytrauma by two or three teams of surgeons, to perform amputations in case of low blood pressure, to perform open osteosynthesis of the femur in case of extremely severe brain injury, etc. It is a misconception that surgical interventions are anti-shock measures, despite the additional trauma they cause. In fact, any operation is an aggression and, to one degree or another, worsens the patient’s condition. In a bleeding victim with polytrauma, even a small operational blood loss can be fatal.

According to the assessment of injury severity according to AIS (Abbreviated Injury Scale), currently accepted in most countries, those injuries that give a mortality rate of 25% or more are considered critical. These include, for example, intracranial hematomas with a volume of more than 80 cm3, bilateral large hemothorax, multiple ruptures of the liver with hemoperitoneum of more than 1500 ml, multiple unstable pelvic fractures with rupture of the joints and similar injuries in each of the six anatomical regions (structures) of the human body. These damages correspond to an AIS score of 5. The same situation arises if the victim simultaneously has two or more injuries with a score of 4 points according to AIS, i.e. life-threatening injuries.

The basis for the introduction of the “damage control” system was immunological studies conducted in patients with polytrauma in the 80-90s of the 20th century. According to the results of these studies, damage, i.e. tissue destruction causes a local inflammatory response (MIR) with an increase in the total concentration of proinflammatory cytokines. Cytokine levels correlate with the degree of soft tissue and bone damage. MBO activates polymorphonuclear leukocytes, which adhere to capillary endothelial cells and stimulate the release of free oxygen radicals and proteases, resulting in damage to the vessel wall, leading to interstitial edema. All these processes are known abroad as multiple organ dysfunction syndrome (MODS), and in our country as disseminated intravascular coagulation syndrome (DIC), deeply developed by academician. A.P. Vorobyov and his school. The release of pro-inflammatory cytokines and products of damaged cells forms the system. Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. 2005, No. 1, pp. 81-84 new inflammatory changes, which is facilitated by the presence of ischemic ones. dead and infected tissue. This explains the high frequency of infectious complications (primarily pneumonia) in patients with full trauma and specific complications such as adult respiratory distress syndrome, early multiple organ failure, etc.

In order to apply damage control in practice, three factors must be carefully assessed:

1) the severity of the initial injury (“the first blow” - the first hit);

2) the biological constitution of the patient (age, body weight, concomitant diseases);

3) the number of necessary trauma operations, their expected duration and traumatic nature (blood loss). These operations are a “second hit” for the seriously injured.

The underlying mechanisms of the fatal effect of the “second strike” are not fully understood, but it is clear that they are characterized by systemic inflammation in combination with microvascular damage, increasing interstitial edema, especially of the lungs, and multiple organ failure. This can explain the cases when, in seriously injured patients who have undergone several operations, the blood loss is formally compensated for by a transfusion of donor blood, the acid-base and electrolyte balance is restored, however, after 1-2 days, severe complications with a fatal outcome develop.

With advances in laboratory technology, it is becoming possible to quantify the inflammatory response to injury and surgical procedures. Markers of inflammation are cytokines (interleukins). The most reliable marker turned out to be interleukin-6, which can be used to predict the development of DIC syndrome.

The concept of “damage control” in orthopedics is used only for fractures of the femur, pelvis with damage to the anterior and posterior half-rings, multiple fractures of the long bones of the lower extremities, avulsions of the femur and tibia. Of great importance is the damage to which areas of the musculoskeletal system. Closed chest trauma and traumatic brain injury most influence the outcome of injury and the development of complications.

Severe closed chest trauma is always accompanied by damage to the lung parenchyma, which cannot in all cases be detected by X-ray examination. Fractures of the femur and tibia are accompanied by fat embolism of the pulmonary circulation, which aggravates pulmonary disorders. Boss et al. showed that intraosseous osteosynthesis of the femur with reaming of the medullary canal, performed on the first day after injury, sharply increases fat embolization, therefore, adult respiratory distress syndrome and pneumonia develop in such victims more often than in non-operated patients.

If a patient, along with fractures of the femur and tibia, has a severe traumatic brain injury, then with early osteosynthesis, cerebral perfusion is reduced and an additional stroke of the damaged brain is possible. This can explain the cases when a patient after hip osteosynthesis cannot be transferred to spontaneous breathing, whereas before the operation he was breathing on his own.

Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. 2005, No. 1, pp. 81-84 For the effective use of “damage control” it is necessary to determine the appropriate group of victims.

Clinical experience suggests that it is advisable to adhere to tactics to control the severity of damage in the following so-called “borderline” cases:

Polytrauma with ISS20 in the presence of thoracic injury with AIS2. The ISS (Injury Severity Score) is obtained by summing the AIS scores of the three most seriously damaged areas squared. For example: combined chest injury - fracture of the V-IX ribs on the right with damage to lung tissue, pneumothorax and pneumomediastinum (AIS=4);

closed supracondylar fracture of the right femur (AIS=3); closed fracture of the diaphysis of the left femur (AIS=3); closed fracture of the neck of the left shoulder (AIS=2). ISS = 42 + Z2 + Z2 = 34 points.

Polytrauma in the presence of damage to the abdominal or pelvic organs (AIS3) and shock with a blood pressure of 90 mm Hg. Art. For example: closed fractures of the ischial bones on both sides, rupture of the sacroiliac joint on the left with displacement of half of the pelvis upward (AIS=4); open fracture of the right shoulder (AIS=3);

closed fracture of the right ulna (AIS=2); shock II degree. ISS = 42 + Z2 = 25 points.

Polytrauma with ISS40 without thoracic trauma. For example: moderate brain contusion, epidural hematoma 40 cm3 (AIS=4); closed abdominal injury, splenic rupture (AIS=4); rupture of the sacroiliac joint, fracture of the pubic bone (AIS=3); closed fracture of the diaphysis of the left femur (AIS=3);

open fracture of both bones of the left leg (AIS=3). ISS = 42 + 42 + Z2 = 41 points.

Bilateral pulmonary contusion according to X-ray examination.

In addition, the following clinical options may help identify patients for whom ETC is not the best choice:

Difficulties in resuscitation and stabilization of the condition of victims when the period of unstable hemodynamics lasts more than 2 hours;

Coagulopathy with thrombocytopenia below 90x109l;

Hypothermia (T32°C);

Traumatic brain injury with a Glasgow Coma Scale score of less than 8 points or intracerebral hematoma;

Expected duration of operations is more than 6 hours;

Damage to the main artery and hemodynamic instability;

Systemic inflammatory response (interleukin-6 more than 80 pg/mm::).

The specific actions of a traumatologist when applying “damage control” tactics are as follows. When a seriously injured person is admitted, priority is still given to operations on the internal organs of the abdomen, pelvis, chest, and brain.

However, the execution of these operations is also divided into two and, in exceptional cases, three phases. In the first phase, with minimal stabilization of the victim’s condition (blood pressure at 90 mm Hg, pulse 120 per minute), drainage of the pleural cavity is performed to eliminate pneumo- or hemothorax, then laparotomy with clamping of bleeding vessels (pedicles of the spleen, kidneys) with temporary clamps (with clips), liver ruptures are tamponed, the damaged intestine is removed and Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. 2005, No. 1, pp. 81-84 isolated from the free abdominal cavity. Only the skin is closed in the wound with a continuous suture. After this, resuscitation measures continue. If the patient’s condition can be stabilized, after 24-36 hours he is taken back to the operating room, the laparotomy wound is opened and the second phase of surgical treatment is performed - splenectomy, suturing of liver wounds, intestinal wounds with complete suturing of the laparotomy wound.

Damage to the musculoskeletal system in the first phase is fixed with plaster splints, fractures of the femur and tibia - with external fixation rods.

Wounds and open fractures in extremely critically ill patients are not subjected to surgical treatment, but are only washed with antiseptics, visible foreign bodies are removed, the edges are pricked with antibiotics and covered with bandages with antiseptics. In case of traumatic avulsions of the limbs, clamps are applied to the main vessels, the wounds are treated with hydrogen peroxide and antiseptics, injected with antibiotics and bandages with antiseptics are applied. After this, intensive therapy is continued.

Surgical treatment of open fractures and amputations are also performed 24 hours after the second phase of operations for abdominal injuries, taking a break between these operations for 2-3 hours, especially if a drop in pressure was noted during laparotomy. Carrying out any simultaneous operations by two or three teams of surgeons is excluded.

Immersion osteosynthesis for closed fractures is postponed on the 6-8th day, but minimally invasive intramedullary osteosynthesis of the femur and tibia is allowed on the 3rd day in order to facilitate care for the victim and give him greater mobility.

Rare et al. proposed a relatively simple scheme reflecting the algorithm for the treatment of long bone fractures in patients with polytrauma (see below).

The use of such a flexible approach to the treatment of “major fractures” in patients with polytrauma made it possible to significantly reduce the incidence of general complications. Thus, the frequency of respiratory distress syndrome in adults decreased from 40 to 15-20%, pneumonia and sepsis - by more than 2 times. Mortality rate has decreased accordingly.

It should be said that “control of orthopedic damage” is not a fundamentally new position. An individual approach to the treatment of victims has been promoted by domestic scientists over the past 15-20 years. A great contribution to the development of this problem was made by specialists from the St. Petersburg Research Institute of Emergency Medicine named after. I.I. Dzhanelidze (Yu.N. Tsybin, Yu.B. Shapot, M.V. Grinev, S.F. Bagnenko) and the Department of Military Field Surgery of the Military Medical Academy (I.A. Eryukhin, E.K. Gumanenko), who created various treatment and tactical schemes for providing assistance to victims with combined trauma, depending on the severity of their condition. Similar developments have been carried out since 1975 at the Moscow Research Institute of Emergency Medicine named after. N.V. Sklifosovsky (V.P. Okhotsky, L.G. Klopov, V.A. Sokolov, E.I. Byalik). The merit of representatives of the Hannover School of Polytrauma, who put forward the concept of “damage control” in 1990, is that they substantiated this tactic based not only on clinical experience, but also on an in-depth study of changes in the immune system, biochemical changes, and morphological changes in the lungs , which made it possible to objectify the choice of treatment tactics depending on various combinations of injuries and the severity of the patient’s condition.

Bulletin of Traumatology and Orthopedics named after. N.N. Priorova. 2005, no. 1, pp. 81-84

–  –  –

CONCLUSIONS 1. “Damage control” is a tactic for treating life-threatening and critical polytraumas, according to which, depending on the severity of the victim’s condition, assessed by objective indicators, in the early period only those methods are used that do not cause a serious deterioration in the patient’s condition.

2. “Orthopedic injury control” includes victims with a total injury severity according to ISS of more than 20 points in the presence of serious injuries to the chest, skull, abdominal organs and retroperitoneal space.

3. “Damage control” in traumatology of the musculoskeletal system consists of two phases. In the first phase, within 24 hours from the moment of injury in victims who are in critical condition, a minimum of traumatological procedures are performed (secondarily after operations on the brain and internal organs of the abdomen) with immobilization of fractures with plaster casts and external fixation devices, after which intensive therapy. Immersion osteosynthesis is performed on the 6-8th day after injury when the patient’s condition is completely stabilized (second phase).

4. In extremely critically ill patients, operations by two or three teams of surgeons are excluded at an early stage; If the patient’s condition worsens during even a minimal operation, a break is taken between operations to continue intensive care.

L I T E R A T U R A

1. Gumanenko E.K. Objective assessment of injury severity. – St. Petersburg, 1999-109 p.

2. Eryukhin I.A., Shlyapnikov S.A. Extreme conditions of the body. – St. Petersburg, 1999. – 109 p.

3. Okhotsky V.P., Lebedev V.V., Klopov L.G. Tactics of treatment of limb fractures in Vestnik of Traumatology and Orthopedics named after. N.N. Priorova. 2005, No. 1, pp. 81-84 patients with traumatic brain injury. In the book. Proceedings of the III All-Union Congress of Traumatologists and Orthopedists. M. 1976 p. 42-45.

4. Sokolov V.A., Byalik E.I. and others. Tactics of surgical treatment of fractures of long bones of the extremities in the early period of combined trauma. Guidelines. M. 2000. 17 pp.

5. Tsibin Yu.N. Multifactorial assessment of the severity of traumatic shock. J. Bulletin of surgery. 1980, no. 9, p. 62-67.

6. Shapot Yu.B., Seleznev S.A., Remizov V.B. etc. Multiple and combined trauma, accompanied by shock. Chisinau, 1993, p. 240.

7. Boss M., Mac-Kenzie E., Riemer A. et all. ARDS, pneumonia, and morfality following thoracic injury anl a femoral fracture treated either with in tramedullary nai ling with reaming or with a plate. J.Bone Joint Surg.Am. 1997, 79-A; 799-809.

8. Eppiheimer M.J., Granger D.N. Ischemia/reperfusion-induced leukocyte-endothelal interferences in post capillary venules. Shok. 1997; 8: 16-26.

9. Greene R. Lung alterations in thoracic trauma. J Thorac Imag 1987; 2:1-8.

10. Guerrero-Lopez F, Vazguez-Mata G, Alcazar PP, Fernandez-Mondejar E, Aguayo-Hoyas E, Linde-Valverde LM. Evaluation of the utility of computed tomography in the initial assessment of the critical care patent with chest trauma. Crit Care Med 2000; 28: 1370-5.

11. Hauser CJ, Zhou X, Joshi P, Cuchens MA, Kregor P, Devidas M, et al. The immune microenvironment of human fracture/soft-tissue hematomas and its relationship to systemic immunity. J Trauma 1997; 42: 895-903.

12. McLntyre TM, Modur V, Prescott SM, Zimmermann GA. Molecular mechanisms of early inflammation. Throm Haemost 1997; 77: 302-9.

13. Pape HC, van Griensven M, Rice J, et all. Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: determination of the clinical relevance of biochemical markers. J Trauma 2001; 50: 989-1000.

14. Perl M, Gebhard F, Knoferl MW, Bachtn M, Gross HJ, Kinzl L, et all. The pattern of preformed cytokines in tissue frequently affected by blunt trauma. Shock 2003; 19: 299Rotondo MF, Schwab CW, MC gonigal et all. “Damade contol” an approach for improved survival in exsanguinafing penetrafing abdominal injuries. J Trauma. 1993; 35: 375-382.

16. Przkova R, Bosch U, Zelle et all. Damage control orthopedics: a case report. J of Trauma 2002: 53, no. 4, 765-769.

17. Scalea TM, Boswekk SA, Scott ID et all. External fixation as a bridge to intramedullary

nailing for patients with multiple injuries: damage control orthopedics. J Trauma 2000; 48:

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