Diagnostic and Diagnostic and emergency care emergency care for polytraumafor polytrauma

Prepared by:Prepared by: C.m.s., assistant professor C.m.s., assistant professor

of outpatient therapy of outpatient therapy and emergency medical and emergency medical

emergency KGMUemergency KGMUA.R. AlpyssovaA.R. Alpyssova

The purpose of the lectureThe purpose of the lecture

After completing the lecture, students should focus on After completing the lecture, students should focus on issues of diagnosis and emergency treatment in case of issues of diagnosis and emergency treatment in case of polytrauma in the amount of the first medical care polytrauma in the amount of the first medical care (doctor's line crews), and depending on the patient - in (doctor's line crews), and depending on the patient - in the amount of specialized care (intensive the amount of specialized care (intensive care team, intensive care team).care team, intensive care team).

The plan of the lectureThe plan of the lecture

Multiple injuries: definition, the syndrome of Multiple injuries: definition, the syndrome of mutual weights, the concept of traumatic disease, the mutual weights, the concept of traumatic disease, the clinical criteria for systemic inflammatory response clinical criteria for systemic inflammatory response syndrome (SIRS).syndrome (SIRS).

Combined, multiple and combined injuries: Combined, multiple and combined injuries: major symptoms, classification, assessment of severity major symptoms, classification, assessment of severity of the condition and screening of patients of the condition and screening of patients with polytrauma.with polytrauma.

Algorithm of UMC team in providing assistance to Algorithm of UMC team in providing assistance to victims with combined and multiple trauma.victims with combined and multiple trauma.

Traumatic shock: definition, classification, first aidTraumatic shock: definition, classification, first aid

POLYTRAUMAPOLYTRAUMA Polytrauma Polytrauma - is a complex pathological process - is a complex pathological process

caused damage to several anatomical areas or segments caused damage to several anatomical areas or segments of the extremities with severe manifestation of the of the extremities with severe manifestation of the syndrome of mutual weights, which includes the syndrome of mutual weights, which includes the simultaneous beginning and development of simultaneous beginning and development of several pathological conditions characterized by profound several pathological conditions characterized by profound disturbances of all kinds of metabolic changes in the central disturbances of all kinds of metabolic changes in the central nervous system (CNS), cardiovascular, respiratory, nervous system (CNS), cardiovascular, respiratory, and pituitary-adrenal systems.and pituitary-adrenal systems.

Syndrome of mutual weightsSyndrome of mutual weights Syndrome of mutual weights Syndrome of mutual weights - is a statement - is a statement

of pathophysiological disorders of the crisis of the vital of pathophysiological disorders of the crisis of the vital functions that are in the hospital for two or more damage functions that are in the hospital for two or more damage to the anatomical and functional areas of apparent state of to the anatomical and functional areas of apparent state of shock.shock.

On the severity of polytrauma show fatality On the severity of polytrauma show fatality rates: in isolated fractures, it is 2%, in the presence of rates: in isolated fractures, it is 2%, in the presence of two isolated heavy damage - 4.9%, with severe associated two isolated heavy damage - 4.9%, with severe associated trauma, when there trauma, when there are severe and not severe isolated trauma (eg fractured pelare severe and not severe isolated trauma (eg fractured pelvis and a closed fracture forearm), mortality is 30.6% vis and a closed fracture forearm), mortality is 30.6% with extremely severe associated trauma, when there with extremely severe associated trauma, when there are two serious injuries (eg fracture of the cranial are two serious injuries (eg fracture of the cranial vault with cerebral contusion and a fractured pelvic vault with cerebral contusion and a fractured pelvic bone), mortality was 61.3%, with a combination of three or bone), mortality was 61.3%, with a combination of three or more serious damage to the probability of death increases more serious damage to the probability of death increases to 84.4%.to 84.4%.

Consequently, the phenomenon of mutual complication is Consequently, the phenomenon of mutual complication is not caused by simple addition of a functional failure of not caused by simple addition of a functional failure of individual organs and systems, and is one caused individual organs and systems, and is one caused by pathophysiologic process.by pathophysiologic process.

Injury-related deaths occur in one of the following time periods:Injury-related deaths occur in one of the following time periods: The first peak of mortality around the time of the The first peak of mortality around the time of the

trauma, when death occurs immediately or within the trauma, when death occurs immediately or within the first few minutes, which is primarily due to the severity of first few minutes, which is primarily due to the severity of traumatic injury to vital organs or structures such as brain, traumatic injury to vital organs or structures such as brain, heart and major blood vessels. In most cases, these heart and major blood vessels. In most cases, these injuries are fatal, but quickly started treatment at the scene injuries are fatal, but quickly started treatment at the scene and the victim to a hospital delivery can save some of the and the victim to a hospital delivery can save some of the patients. During this period, according to many authors kill patients. During this period, according to many authors kill nearly 60% of the victims.nearly 60% of the victims.

The second peak falls on the first few hours of stay in The second peak falls on the first few hours of stay in hospital, when the frequency of deaths and complications hospital, when the frequency of deaths and complications can be reduced through prevention and treatment of can be reduced through prevention and treatment of ventilation, hemic and tissue hypoxia: ventilation (mechanical ventilation, hemic and tissue hypoxia: ventilation (mechanical ventilation) and respiratory support, the final stop of the ventilation) and respiratory support, the final stop of the external and internal bleeding, adequate replenishment external and internal bleeding, adequate replenishment of the bcc to the restoration of tissue perfusion.of the bcc to the restoration of tissue perfusion.

It was during this period, with early It was during this period, with early diagnosis possible radical removal of diagnosis possible radical removal of intracranial hematoma, abdominal hemorrhage, pneumo-intracranial hematoma, abdominal hemorrhage, pneumo-and hemothorax.and hemothorax.

The third peak of mortality occurs within a few days or The third peak of mortality occurs within a few days or weeks after the injury and usually occurs from weeks after the injury and usually occurs from sepsis or multiple organ sepsis or multiple organ failure syndrome (MOFS). Progress in the possibilities failure syndrome (MOFS). Progress in the possibilities of intensive therapy, the use of new generations of of intensive therapy, the use of new generations of drugs, efferent methods of treatment can reduce mortality drugs, efferent methods of treatment can reduce mortality rates. Despite the adequate provision of specialized care, rates. Despite the adequate provision of specialized care, the mortality at this stage is 70% of those admitted.the mortality at this stage is 70% of those admitted.

The concept of traumatic diseaseThe concept of traumatic disease The concept of traumatic disease involves the The concept of traumatic disease involves the

examination and evaluation of complex phenomena that examination and evaluation of complex phenomena that occur in severe mechanical damage to the body is occur in severe mechanical damage to the body is inseparable connection with adaptive responses, the inseparable connection with adaptive responses, the adaptive nature of their complex relationships at all stages adaptive nature of their complex relationships at all stages of the disease - from the moment of injury to its of the disease - from the moment of injury to its outcome: cure (complete or incomplete) or death .outcome: cure (complete or incomplete) or death .

The main etiological factor for the disease The main etiological factor for the disease is traumatic mechanical injury of great strength. The is traumatic mechanical injury of great strength. The combined effects provided by mediators of injury, combined effects provided by mediators of injury, form systemic inflammatory response syndrome (SIRS).form systemic inflammatory response syndrome (SIRS).

Stages of the development of SIRS:Stages of the development of SIRS:

I. The stage production of local mediators in response I. The stage production of local mediators in response to injury than by the protective function - protecting cells to injury than by the protective function - protecting cells against pathogens, wound healing;against pathogens, wound healing;

II. Stage release small amounts of mediators into the II. Stage release small amounts of mediators into the bloodstream to maintain homeostasis; III. Stage of bloodstream to maintain homeostasis; III. Stage of generalization of the inflammatory response in which the generalization of the inflammatory response in which the regulatory system is not able to regulatory system is not able to provide homeostasis, inflammatory mediators provide homeostasis, inflammatory mediators become destructive quality, develop multiple organ become destructive quality, develop multiple organ failure syndrome (PIS).failure syndrome (PIS).

Pathogenetic classification of current period of traumatic Pathogenetic classification of current period of traumatic diseasedisease

I. During the acute response to trauma, corresponds to a I. During the acute response to trauma, corresponds to a period of traumatic shockperiod of traumatic shock and early postshock period, it should be and early postshock period, it should be viewed as a period of inductionviewed as a period of induction phase of PIS.phase of PIS.

II. The period of early manifestations of traumatic disease - initial II. The period of early manifestations of traumatic disease - initial phase of the PIS -is characterized by impaired or instability of phase of the PIS -is characterized by impaired or instability of the functions of individual organs and systems.the functions of individual organs and systems.

III. The period of the late manifestations of traumatic illness - III. The period of the late manifestations of traumatic illness - detailed SPON phase- if the patient has survived in the I period of detailed SPON phase- if the patient has survived in the I period of traumatic disease of the flow, then the occurrence of this traumatic disease of the flow, then the occurrence of this particular period is determined by the prognosis and outcome of particular period is determined by the prognosis and outcome of disease.disease.

IV. Period of rehabilitation - for the favorable IV. Period of rehabilitation - for the favorable outcome, characterized by complete or incomplete recovery. The outcome, characterized by complete or incomplete recovery. The above concept encourages treat traumatic shock, blood loss, above concept encourages treat traumatic shock, blood loss, post-traumatic toxicosis, thrombus disorders, post-traumatic fat post-traumatic toxicosis, thrombus disorders, post-traumatic fat embolism, PIS, sepsis as a complication of polytrauma not as embolism, PIS, sepsis as a complication of polytrauma not as well aspathogenesis-related links in a single process - traumatic well aspathogenesis-related links in a single process - traumatic decease.decease.

Periods of traumatic diseasePeriods of traumatic disease First period First period - traumatic shock - traumatic shock

- perfusion deficit syndrome (acute- perfusion deficit syndrome (acute hemodynamic disorders) hemodynamic disorders) in response to severe mechanical damagein response to severe mechanical damage with a with a predominant effect of blood loss.predominant effect of blood loss.

There is a notion of a critical pool of tissue, which is There is a notion of a critical pool of tissue, which is expressed as a percentage of the amount of expressed as a percentage of the amount of tissue necessary for survival. It is:tissue necessary for survival. It is:

for the liver - 15%for the liver - 15% the kidney - 25%the kidney - 25% for red blood cells - 35%for red blood cells - 35% to the lungs - 45%to the lungs - 45% for plasma volume - 70%for plasma volume - 70%

Thus, survival is not determined by the loss of the Thus, survival is not determined by the loss of the globular volume, and the loss of the liquid part globular volume, and the loss of the liquid part of blood, even profound anemiaof blood, even profound anemia hemoglobin 50-70 g / l) hemoglobin 50-70 g / l) with respect to satisfactorily compensatedwith respect to satisfactorily compensated patients. Immediately after bleeding deficiency of red blood patients. Immediately after bleeding deficiency of red blood cellscells and plasma is proportional to (hematocrit within the and plasma is proportional to (hematocrit within the normal range).Further, the plasma volume increases with normal range).Further, the plasma volume increases with time due to flow of fluid from the interstitial space in the time due to flow of fluid from the interstitial space in the bloodstream (hematocritbloodstream (hematocrit progressively reduced). This substitution is carried out byprogressively reduced). This substitution is carried out by transcapillary albumin mobilization of its stores (mainly the transcapillary albumin mobilization of its stores (mainly the liver), itliver), it proceeds to the blood and increase proceeds to the blood and increase the colloid osmotic pressure.the colloid osmotic pressure. Movement of fluid in order to Movement of fluid in order to keep the central hemodynamicskeep the central hemodynamics leading to a shortage leading to a shortage of water in the interstitial sector.of water in the interstitial sector.

Typical key points of the pathophysiology of shock, lack of Typical key points of the pathophysiology of shock, lack of effectiveeffective circulating blood circulating blood volume, real or only relative, always combined withvolume, real or only relative, always combined with a a primary or secondary reduction in flow rate of the heart andprimary or secondary reduction in flow rate of the heart and increase PR, link catecholamine.increase PR, link catecholamine.

The modern view of polytrauma intensive The modern view of polytrauma intensive care embodiescare embodies these factors in a large circle  these factors in a large circle of deteriorating hemodynamic itself.of deteriorating hemodynamic itself.

The main stimulants release of The main stimulants release of catecholamines - hypovolemia, hypoxia, hypotension, lactic catecholamines - hypovolemia, hypoxia, hypotension, lactic acidosis are pathogenetic factorsconstant state of acidosis are pathogenetic factorsconstant state of shock. Reodinamic disorders inshock. Reodinamic disorders in micromicro circulation. Cellular hypoxia directs enzymatic chains in the circulation. Cellular hypoxia directs enzymatic chains in the direction of catabolic processes, a consequence of direction of catabolic processes, a consequence of this is imperfectthis is imperfect energogenez by anaerobic way, under energogenez by anaerobic way, under conditions of high load,conditions of high load, which is subject to the macrowhich is subject to the macro system and the excessive accumulation system and the excessive accumulation of "metabolic waste", which leads to the development of "metabolic waste", which leads to the development of acidosis.of acidosis.The presence in the extracellular space of The presence in the extracellular space of vasoactive amines, activation of kallikrein-kinin vasoactive amines, activation of kallikrein-kinin system, giperkateholaminemiya,system, giperkateholaminemiya, acidemia have a toxic acidemia have a toxic effect, mainly on the myocardium.effect, mainly on the myocardium.

Progressive acidosis, reaching a critical point, the cessation of lifeProgressive acidosis, reaching a critical point, the cessation of life cells, causes the appearance of foci of necrosis, which latercells, causes the appearance of foci of necrosis, which later merged and eventually became generalized. Hypotension as a merged and eventually became generalized. Hypotension as a symptom of secondary importance: a state of shock, seeminglysymptom of secondary importance: a state of shock, seemingly compensated according to the criteria of blood pressure, stillcompensated according to the criteria of blood pressure, still accompanied by inadequate tissue perfusion. Preferable to dealaccompanied by inadequate tissue perfusion. Preferable to deal with with low blood pressure, if provided adequate perfusion of cells.low blood pressure, if provided adequate perfusion of cells. Regardless Regardless of the cause and course of the shock position reachesof the cause and course of the shock position reaches of cellular lesions, broken organellnye intracellular interactions, of cellular lesions, broken organellnye intracellular interactions, enzymatic chain of the cytoplasm and, finally, cellenzymatic chain of the cytoplasm and, finally, cell.. Ob.ki, the  Ob.ki, the disappearance of their archdisappearance of their arch. . and the emergence of irreversibility.dezorg-and the emergence of irreversibility.dezorg-tion cell.tion cell.

The second period The second period of traumatic disease characterized clinics expanded SPON -disorders or of traumatic disease characterized clinics expanded SPON -disorders or dysfunction of individual organs and systems. If you receive a patient'sdysfunction of individual organs and systems. If you receive a patient's organ or multiple organ failure may be the result of direct damage to organ or multiple organ failure may be the result of direct damage to the traumaticthe traumatic fact of the body or several bodies, in this period of fact of the body or several bodies, in this period of traumatic disease of the OPA is the result traumatic disease of the OPA is the result of generalized systemic response to injury. The degree of its severityof generalized systemic response to injury. The degree of its severity correlates with the severity of the injury. PIS should be regarded as a correlates with the severity of the injury. PIS should be regarded as a grave degree of SIRS.grave degree of SIRS.

Current stage of the OPA:Current stage of the OPA: induction (synthesis of a number of humoral factors that induction (synthesis of a number of humoral factors that

initiate SIRS);initiate SIRS); cascade (the development of acute lung injury, activation of cascade (the development of acute lung injury, activation of

the kallikrein-kinincascade systems, arachidonic the kallikrein-kinincascade systems, arachidonic acid, clotting, etc.);acid, clotting, etc.);

secondary autosecondary auto aggression (as expressed aggression (as expressed by organ dysfunction, andby organ dysfunction, and hyperhyper metabolism, loss metabolism, loss of organisms are capable of self-regulation of homeostasis).of organisms are capable of self-regulation of homeostasis).

The combined effects initiated by mediators of inflammation The combined effects initiated by mediators of inflammation and damage, form a generalized systemic inflammatory and damage, form a generalized systemic inflammatory response.response.

Clinical criteria for SIRS:Clinical criteria for SIRS: SIRS SIRS - syndrome, characterized by severe inflammatory - syndrome, characterized by severe inflammatory

response primarily in theresponse primarily in the endothelial cells, and thus determines endothelial cells, and thus determines the direction of the inflammatory response to injury.the direction of the inflammatory response to injury.

SPON-the heaviest degree of SIRS.SPON-the heaviest degree of SIRS. Mechanisms of development of PIS:Mechanisms of development of PIS:

- Mediator and autoimmune;- Mediator and autoimmune;- Ischemia - reperfusion;- Ischemia - reperfusion;- Infectious - toxic;- Infectious - toxic;- "The phenomenon of double whammy."- "The phenomenon of double whammy."

At this period of surgery and anesthetic-s benefits, At this period of surgery and anesthetic-s benefits, transportation, should be considered as iatrogenic factors that transportation, should be considered as iatrogenic factors that may lead to the progression of PIS and death.may lead to the progression of PIS and death.

More or less marked recovery of function of organs and More or less marked recovery of function of organs and systems occurs at the endsystems occurs at the end of this period (14-30th day), not always in of this period (14-30th day), not always in full V.full V.

The two remaining period of traumatic disease course usually takes The two remaining period of traumatic disease course usually takes place outside the purview of a physician anesthesiologist, because in a place outside the purview of a physician anesthesiologist, because in a favorable favorable ис-де ис-де characterized stabilization function life support systems.characterized stabilization function life support systems.

The third period of traumatic disease - during the The third period of traumatic disease - during the late manifestations of traumatic disease late manifestations of traumatic disease with a with a favorable course characterized by development favorable course characterized by development of regenerative and reparative processes in of regenerative and reparative processes in damaged tissues and organs. In some cases, patients in damaged tissues and organs. In some cases, patients in this period come dystrophic and sclerotic changes in this period come dystrophic and sclerotic changes in damaged organs, secondary disturbances of their damaged organs, secondary disturbances of their functions, there are various complications includingfunctions, there are various complications including abscesses, cellulitis, osteomyelitis, wound depletion, abscesses, cellulitis, osteomyelitis, wound depletion, thrombophlebitis, sepsis.thrombophlebitis, sepsis. This period can last for months This period can last for months and requires appropriate treatment. Restore the and requires appropriate treatment. Restore the original (pre-injury) of hemoglobin can be regarded as a original (pre-injury) of hemoglobin can be regarded as a sign of completion of the late period of traumatic disease.sign of completion of the late period of traumatic disease.

The fourth period of traumatic disease -The fourth period of traumatic disease - during the  during the rehabilitation period is characterized by complete or rehabilitation period is characterized by complete or incomplete recovery (disability).incomplete recovery (disability).

Hepato Splanhnic region in polytraumaHepato Splanhnic region in polytrauma Gepatosplanhnitic system suffers from one of the first in the Gepatosplanhnitic system suffers from one of the first in the

centralization of circulation, as the loss of blood centralization of circulation, as the loss of blood volume within the 20-40% decreases in systolicvolume within the 20-40% decreases in systolic blood blood pressure to 75-60 mmHg, which in turn leads to a decrease pressure to 75-60 mmHg, which in turn leads to a decrease in blood flow in the celiac trunk on 33%, and, lining the in blood flow in the celiac trunk on 33%, and, lining the proximal stomach and duodenum is the most sensitive to proximal stomach and duodenum is the most sensitive to ischemia because of the maximum density α-adrenergic ischemia because of the maximum density α-adrenergic receptors, as well as reduction of blood flow in the superior receptors, as well as reduction of blood flow in the superior mesenteric artery by 35%. If the blood flow in mesenteric artery by 35%. If the blood flow in these arterial roads is reduced by 20-30%, tissue these arterial roads is reduced by 20-30%, tissue oxygenation is reduced by 40-60%.oxygenation is reduced by 40-60%.

Together, MULTIPLE AND COMBINED INJURYTogether, MULTIPLE AND COMBINED INJURY Multiple injuriesMultiple injuries - the simultaneous damage of two or  - the simultaneous damage of two or

more of the seven anatomicalmore of the seven anatomical areas of the body (head, areas of the body (head, neck, chest, abdomen, legs, pelvis, spine), at least one of neck, chest, abdomen, legs, pelvis, spine), at least one of which is heavy.which is heavy.

Polytrauma is divided into 3 groups:Polytrauma is divided into 3 groups: Associated injuries, which include damage to internal Associated injuries, which include damage to internal

organs, musculoskeletal system, organs, musculoskeletal system, wounds, skin and placental tissue, crush syndrome, long wounds, skin and placental tissue, crush syndrome, long 

limbs;limbs; multiple injuries - some damage within a cavity of the body multiple injuries - some damage within a cavity of the body

(eg, liver and spleen(eg, liver and spleen rupture), or within a time but the motor rupture), or within a time but the motor system (multiple fractures of the extremities, pelvis, spine);system (multiple fractures of the extremities, pelvis, spine);

combined injuries - injuries are applied in combined injuries - injuries are applied in several wounding tools - mechanical,thermal, radiation.several wounding tools - mechanical,thermal, radiation.

THE MAIN SYNDROMESTHE MAIN SYNDROMES Acute blood loss in combination with the shock. Acute blood loss in combination with the shock. The The

severity depends on the size(caliber damaged vessel, the severity depends on the size(caliber damaged vessel, the number of streamed blood, blood pressure), time elapsed number of streamed blood, blood pressure), time elapsed since the injury.since the injury.

In the rate of bleeding is divided into profuse (more than In the rate of bleeding is divided into profuse (more than 100 ml / min), severe(more than 50 ml / min), moderate (30-100 ml / min), severe(more than 50 ml / min), moderate (30-50 mL / min.). Profuse bleeding leading to death at the 50 mL / min.). Profuse bleeding leading to death at the scene within minutes and are resistant cupping. Their scene within minutes and are resistant cupping. Their reason: injury of the aorta, venae cavae and large their reason: injury of the aorta, venae cavae and large their branches, the large vessels of the abdomen. Victims with branches, the large vessels of the abdomen. Victims with moderate bleeding and a small make up the group of moderate bleeding and a small make up the group of patients with associated trauma, accompanied by a patients with associated trauma, accompanied by a classic traumatic shock. The level of systolic blood classic traumatic shock. The level of systolic blood pressure may be about to determine the total blood loss: a pressure may be about to determine the total blood loss: a fall to 100mm Hg - 1.8-2 l, 60 mm Hg - 2.5-fall to 100mm Hg - 1.8-2 l, 60 mm Hg - 2.5-3 liters. Indicative of blood loss can be represented and the 3 liters. Indicative of blood loss can be represented and the nature of the injury.nature of the injury.

Brain coma Brain coma - the main manifestation of brain damage. The - the main manifestation of brain damage. The degree of coma, the easiest way to determine according to the degree of coma, the easiest way to determine according to the scale of Glasgow, which only considersscale of Glasgow, which only considers three indicators: the three indicators: the opening of the eyes, speech function and limb movement.opening of the eyes, speech function and limb movement.

ABI - the main breach in the chest associated trauma, as well ABI - the main breach in the chest associated trauma, as well as the injured V! group (see below), where one of the as the injured V! group (see below), where one of the leading injury is trauma chest. Causes of acute respiratory leading injury is trauma chest. Causes of acute respiratory failure - a violation of the airway, a compression of one or both failure - a violation of the airway, a compression of one or both lungs due to pneumothorax, a violation of the excursions of the lungs due to pneumothorax, a violation of the excursions of the thorax (the mechanism of respiration) due to rib fractures on thorax (the mechanism of respiration) due to rib fractures on several lines with the formation of the free valve (floating chest)several lines with the formation of the free valve (floating chest)

Apnea and airway obstructionApnea and airway obstruction vomit and blood, most  vomit and blood, most often occur in patients with head trauma leading. When the often occur in patients with head trauma leading. When the leading trauma chest obstruction occurs when the internal rupture leading trauma chest obstruction occurs when the internal rupture of the lungs with pulmonary hemorrhage, rupture of major of the lungs with pulmonary hemorrhage, rupture of major bronchi, clogged mucus. The main symptom of this bronchi, clogged mucus. The main symptom of this disease - common segmental or total atelectasis of the lung.disease - common segmental or total atelectasis of the lung.

CLASSIFICATION OF POLYTRAUMACLASSIFICATION OF POLYTRAUMA The classification includes the identification of The classification includes the identification of

victims of injury, damage establishing the lead, forming a victims of injury, damage establishing the lead, forming a diagnosis in a certain sequence and the assignment diagnosis in a certain sequence and the assignment of damages suffered by one of the of damages suffered by one of the seven groups. Completely reliable ranking is possible only in seven groups. Completely reliable ranking is possible only in a hospital after a thorough examination of the victims.a hospital after a thorough examination of the victims.

The diagnosis includes the following topics:The diagnosis includes the following topics: leading (dominant) damage - damage, life-threatening, leading (dominant) damage - damage, life-threatening,

which is fatal without treatment, and treatment gives a case which is fatal without treatment, and treatment gives a case fatality rate of more than 20% but less severe injuries fatality rate of more than 20% but less severe injuries - not life threatening but requiring hospital treatment;- not life threatening but requiring hospital treatment;

Other injuries - injuries requiring outpatient Other injuries - injuries requiring outpatient treatment, and complications of traumatic and non treatment, and complications of traumatic and non traumatic origin;traumatic origin;

concomitant serious disease;concomitant serious disease; ageage..

When targeting the leading combined damage to all types When targeting the leading combined damage to all types of injuries can be attributed to the seven groups.of injuries can be attributed to the seven groups.

Group 1: Group 1: severe head injury, contusion of the brain with a severe head injury, contusion of the brain with a fractured bones of the skull base and whether or fractured bones of the skull base and whether or not those accompanied by coma or gross violations of focal, not those accompanied by coma or gross violations of focal, intracranial hematoma, severe maxillofacial trauma with intracranial hematoma, severe maxillofacial trauma with damage to the skull base.damage to the skull base.

Group 2:Group 2: a spinal injury in violation of the conductivity of the  a spinal injury in violation of the conductivity of the spinal cord, quadriplegic or paraplegic.spinal cord, quadriplegic or paraplegic.

Group 3: Group 3: damage to the heart, damage to the heart, aorta, large gaps pulmonary hemorrhage, aorta, large gaps pulmonary hemorrhage, pneumothorax, tense, floating chest, bilateral or unilateral larpneumothorax, tense, floating chest, bilateral or unilateral large hemothorax, ge hemothorax, traumatic open pneumothorax, traumatic asphyxia, severe.traumatic open pneumothorax, traumatic asphyxia, severe.

Group 4:Group 4: ruptures of the parenchymatous abdominal  ruptures of the parenchymatous abdominal organs, mesentery, with bleeding into the organs, mesentery, with bleeding into the abdominal cavity, hollow organs of the abdominal cavity, hollow organs of the abdomen ruptures, internal and abdomen ruptures, internal and external gaps renal hemorrhage.external gaps renal hemorrhage.

5th group:5th group: long- long-term crush syndrome; detachments femur, term crush syndrome; detachments femur, tibia, shoulder, fractures of the limbs of large segments tibia, shoulder, fractures of the limbs of large segments of the great arteries with injury, fractures of the of the great arteries with injury, fractures of the pelvis with damage to the anterior and posterior half-pelvis with damage to the anterior and posterior half-ring; fractures of two or more segments of ring; fractures of two or more segments of the limbs, scalp skin in the area more than 20% of the limbs, scalp skin in the area more than 20% of the body.the body.

6th group: 6th group: a combination of major damage to the brain a combination of major damage to the brain and spine, chest and abdomen, musculoskeletal and spine, chest and abdomen, musculoskeletal system in different ways.system in different ways.

ASSESSMENT OF SEVERITY OF STATE ASSESSMENT OF SEVERITY OF STATE AND SCREENING OF VICTIMS with polytraumaAND SCREENING OF VICTIMS with polytrauma

Severity of the patient depends mainly on the intensity Severity of the patient depends mainly on the intensity of internal and external bleeding, disorders of the of internal and external bleeding, disorders of the airway and breathing mechanism, dysregulation of airway and breathing mechanism, dysregulation of respiration and circulation as a result of brain injury and respiration and circulation as a result of brain injury and high spinal cord injuries. The degree of severity is judged high spinal cord injuries. The degree of severity is judged by the depth of disorders of vital functions -by the depth of disorders of vital functions -breathing, circulation, brain function. In the pre-breathing, circulation, brain function. In the pre-hospital stage there is no time or opportunity to hospital stage there is no time or opportunity to evaluate more complex, especially as laboratory values evaluate more complex, especially as laboratory values , but even on simple indicators can accurately determine , but even on simple indicators can accurately determine the prognosis of polytrauma, and most importantly - to the prognosis of polytrauma, and most importantly - to focus on the most seriously injured patients, which is focus on the most seriously injured patients, which is essential for group accidents and mass disasters .essential for group accidents and mass disasters .

Algorithm of SMP team in assisting the victims with Algorithm of SMP team in assisting the victims with combined and multiple traumacombined and multiple trauma

When obstructions of the upper airway should be removal of When obstructions of the upper airway should be removal of foreign bodies, dental prostheses, suctioning vomit, blood, foreign bodies, dental prostheses, suctioning vomit, blood, mucus from the oropharynx.mucus from the oropharynx.

Apnea, bradypnea are an indication for mechanical Apnea, bradypnea are an indication for mechanical ventilation with a mask,Intubation, mechanical ventilation with the ventilation with a mask,Intubation, mechanical ventilation with the aid of the apparatus.aid of the apparatus.

In the case of aspiration required intubation, suctioning of In the case of aspiration required intubation, suctioning of blood, vomit from the trachea, ventilation through the device.blood, vomit from the trachea, ventilation through the device.

In acute blood loss, shock I-II degree shows venipuncture, blood In acute blood loss, shock I-II degree shows venipuncture, blood transfusionpoliglyukina a dose of 400 ml, and with the transfusionpoliglyukina a dose of 400 ml, and with the continued fall in blood pressure - the imposition of antishock suitcontinued fall in blood pressure - the imposition of antishock suit

Acute blood loss, shock, III-IV level are an indication for the Acute blood loss, shock, III-IV level are an indication for the imposition of antishock suit, venipuncture, blood imposition of antishock suit, venipuncture, blood transfusion and blood substitutes crystalloid solutions.transfusion and blood substitutes crystalloid solutions.

Tachypnea with cyanosis and participation in the Tachypnea with cyanosis and participation in the breath support muscles:breath support muscles:

with a with a tight hold pneumothorax drainage plevrialnoy cavity valve drainage,tight hold pneumothorax drainage plevrialnoy cavity valve drainage, intubation, suctioning of the trachea containing, with intubation, suctioning of the trachea containing, with the ventilator machine, anesthesia.the ventilator machine, anesthesia.

in cases of open pneumothorax required occlusive dressing, drain valve, in cases of open pneumothorax required occlusive dressing, drain valve, and with severe respiratory failure - intubation and mechanical and with severe respiratory failure - intubation and mechanical ventilation.ventilation.

with a large hemothorax prescribe intravenous transfusion of blood with a large hemothorax prescribe intravenous transfusion of blood products andproducts and crystalloid solutions, oxygen therapy, elevated position, crystalloid solutions, oxygen therapy, elevated position, and with the continued fall of blood pressure imposed foot section and with the continued fall of blood pressure imposed foot section of antishock suits.of antishock suits.

Injury of intra-abdominal bleeding with an indication for imposition Injury of intra-abdominal bleeding with an indication for imposition of antishock suit,by of antishock suit,by intravenous krovezamenitelnoy and antishock therapy (with an intensity intravenous krovezamenitelnoy and antishock therapy (with an intensity of 1000 ml infusion over 30 min), anesthesia narcotic analgesics.of 1000 ml infusion over 30 min), anesthesia narcotic analgesics.

In case of injury of hollow abdominal organs is carried out In case of injury of hollow abdominal organs is carried out intravenously antishocktherapy, non-narcotic analgesia analgitamiintravenously antishocktherapy, non-narcotic analgesia analgitami ..

In the separation of limbs, traumatic amputation of a In the separation of limbs, traumatic amputation of a pneumatic tourniquet imposepneumatic tourniquet impose a maximum pressure of 250 mm Hg the a maximum pressure of 250 mm Hg the upper limb and 500 mm Hg the lower limb,upper limb and 500 mm Hg the lower limb, the bandage the bandage from hlorgsksidin or aseptic bandage on the wound of the stump, carried from hlorgsksidin or aseptic bandage on the wound of the stump, carried out intravenous anesthesia and transfusion of blood substitutesout intravenous anesthesia and transfusion of blood substitutes

Fracture of the pelvis (in the presence of indisputable signs) is Fracture of the pelvis (in the presence of indisputable signs) is considered an indication for use of antishock suit considered an indication for use of antishock suit or vacuum stretcher and intravenous anesthesia.or vacuum stretcher and intravenous anesthesia.

In the case of fracture of the cervical spine impose neck brace, In the case of fracture of the cervical spine impose neck brace, prescribed intravenous analgesia.prescribed intravenous analgesia.

At the turn of the thoracic and lumbar spine shows the position of the At the turn of the thoracic and lumbar spine shows the position of the patient supine on hard stretchers, patient supine on hard stretchers, vacuum stretcher and intravenous anesthesia.vacuum stretcher and intravenous anesthesia.

Limb fractures are an indicator for intravenous analgesia (tramadol, but Limb fractures are an indicator for intravenous analgesia (tramadol, but orphanoland diphenhydramine or trimeperidin) and immobilization.orphanoland diphenhydramine or trimeperidin) and immobilization.

When the external wound is bleeding spend the time to When the external wound is bleeding spend the time to stop bleeding, bandage, in shock and acute blood loss, stop bleeding, bandage, in shock and acute blood loss, intravenous transfusion of blood products intravenous transfusion of blood products aministered, intravenous therapy and antishock analgesiaaministered, intravenous therapy and antishock analgesia

HOSPITALIZATIONHOSPITALIZATION Hospitalized patients with multiple and combined injuries in Hospitalized patients with multiple and combined injuries in

the intensive care unit. During transport continue the intensive care unit. During transport continue to intravenous infusion of blood substitutes in the absence or to intravenous infusion of blood substitutes in the absence or violation of breath - artificial respiration through a mask, violation of breath - artificial respiration through a mask, and bleeding from the skull base and the inability and bleeding from the skull base and the inability to secure airway - intubation, continue artificial to secure airway - intubation, continue artificial respiration through a tracheal tube.respiration through a tracheal tube.

TRAUMATIC SHOCKTRAUMATIC SHOCK Traumatic shock -Traumatic shock - the system's inability to provide  the system's inability to provide

adequate hemodynamic oxygen delivery to tissues. The adequate hemodynamic oxygen delivery to tissues. The acute period of traumatic disease accompanied acute period of traumatic disease accompanied by severe blood loss, intoxication-related damage to by severe blood loss, intoxication-related damage to the vast array of tissue and often the phenomena of fat the vast array of tissue and often the phenomena of fat embolism. This period is during the phase.embolism. This period is during the phase.

1. Hypoperfusion phase1. Hypoperfusion phase (initial phase is characterized  (initial phase is characterized by impaired} system, organ and microvascular  by impaired} system, organ and microvascular  hemodynamics and metabolism.hemodynamics and metabolism.

2. Phase stabilization function2. Phase stabilization function - the restoration  - the restoration of blood flow in visceral organs.of blood flow in visceral organs.

3. Phase compensation function 3. Phase compensation function with restoration of a with restoration of a natural system, organ perfusion, microcirculation, natural system, organ perfusion, microcirculation, and the basic parameters of homeostasis.and the basic parameters of homeostasis.

CLASSIFICATIONCLASSIFICATION Grade I (mild shock). The victim Grade I (mild shock). The victim

may be somewhat inhibited, skin pale and cold, a symptom may be somewhat inhibited, skin pale and cold, a symptom of the "white spots" strongly positive, learning of the "white spots" strongly positive, learning the breathing. Tachycardia with a frequency of up to 100 in the breathing. Tachycardia with a frequency of up to 100 in 1 min. Systolic blood pressure in the range of 90-100 mm Hg1 min. Systolic blood pressure in the range of 90-100 mm Hg

Grade II (moderate shock). Patients with a Grade II (moderate shock). Patients with a dynamic and inhibited. Pale and cold skin may have a marble dynamic and inhibited. Pale and cold skin may have a marble pattern. Heart rate increases to 110-120 in 1 min. Systolic pattern. Heart rate increases to 110-120 in 1 min. Systolic blood pressure is lowered to 80-75 mmHg, urine blood pressure is lowered to 80-75 mmHg, urine output decreased.output decreased.

Grade III (severe shock). Patient inhibited and indifferent to Grade III (severe shock). Patient inhibited and indifferent to the outside, his skin has a sallow hue. Heart rate increased the outside, his skin has a sallow hue. Heart rate increased to 130-140 per minute, systolic blood pressure decreased to 130-140 per minute, systolic blood pressure decreased to 60 mmHg and below. Diastolic blood pressure more often to 60 mmHg and below. Diastolic blood pressure more often than not defined, developed anuria.than not defined, developed anuria.

AN EMERGENCY CAREAN EMERGENCY CARE Turning to the specifics of giving help to victim Turning to the specifics of giving help to victim

with shock and genetic mechanical injuries (polytrauma), with shock and genetic mechanical injuries (polytrauma), we note the following provisions, which are essential for we note the following provisions, which are essential for the expert who provides emergency assistance:the expert who provides emergency assistance:

lack of time allotted to both the diagnosis of lack of time allotted to both the diagnosis of injury and to therapeutic measures;injury and to therapeutic measures;

All attempts to stabilize homodynamic and gas All attempts to stabilize homodynamic and gas exchange should be undertaken on the route in trauma exchange should be undertaken on the route in trauma center.center.

If circulatory disorders in If circulatory disorders in traumatic shock eliminated later than 1 traumatic shock eliminated later than 1 hour after injury, severe disorders of the life support hour after injury, severe disorders of the life support systems of the body may become irreversible. Thus, we systems of the body may become irreversible. Thus, we should stick to the rules of the "golden hour".should stick to the rules of the "golden hour".

All victims of traumatic shock require pre-All victims of traumatic shock require pre-hospital complex in carrying out remedial measures, the hospital complex in carrying out remedial measures, the main components are the following: a temporary main components are the following: a temporary stop external bleeding, eliminating deficit BCC, correction stop external bleeding, eliminating deficit BCC, correction of gas exchange, interrupting shock and genetic impulses of gas exchange, interrupting shock and genetic impulses from the injury site, the transportation immobilization, drug from the injury site, the transportation immobilization, drug therapy.therapy.

4. Transportation immobilization4. Transportation immobilization in injuries shows the bones  in injuries shows the bones and joints, major vessels and nerves, extensive soft and joints, major vessels and nerves, extensive soft tissue damage. For its performance using tissue damage. For its performance using standard transport bus (Cramer Dieterichs), standard transport bus (Cramer Dieterichs), vacuum mattresses and tires, wooden board with a set of belts.vacuum mattresses and tires, wooden board with a set of belts.

5. Interruption shokogennoy impulses from the damage5. Interruption shokogennoy impulses from the damage In traumatic shock from severe combined trauma demonstrates In traumatic shock from severe combined trauma demonstrates

the use of general anesthesia, have the least impact on the use of general anesthesia, have the least impact on hemodynamicshemodynamics

Methods ataralgesia is as follows:Methods ataralgesia is as follows: premedication - atropine 0.5-0.7 mg intravenously;premedication - atropine 0.5-0.7 mg intravenously; diazepam 0.3 mg / kg (20 mg for patients weighing 70 kg);diazepam 0.3 mg / kg (20 mg for patients weighing 70 kg); tramadol dose of 2-3 mg / kg (150-200 mg body weight 70 kg).tramadol dose of 2-3 mg / kg (150-200 mg body weight 70 kg). Immobilization is carried out only after the anesthesia (unless the Immobilization is carried out only after the anesthesia (unless the

application for the immobilization of the vacuum mattress, application for the immobilization of the vacuum mattress, air protivoshokovym pants, neck collar anda special corset to air protivoshokovym pants, neck collar anda special corset to retrieve the victim).retrieve the victim).

6. Drug therapy aimed at correction of circulatory 6. Drug therapy aimed at correction of circulatory disorders and metabolism.disorders and metabolism. The traditional treatment  The traditional treatment for patients with traumatic shock - glucocorticoids. They for patients with traumatic shock - glucocorticoids. They contribute to hemodynamic stabilization due to narrowing contribute to hemodynamic stabilization due to narrowing of the capacitanceof the capacitance vessels (veins), increasing volume of vessels (veins), increasing volume of circulatory blood (VCB) without microcirculation. In circulatory blood (VCB) without microcirculation. In addition, these drugsaddition, these drugs are potent blockers of lipid are potent blockers of lipid peroxidation and thereby reduce the formation ofperoxidation and thereby reduce the formation of degradation products of arachidonic acid peripheral degradation products of arachidonic acid peripheral circulation.circulation.

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