Chapter 4. Severe trauma and its consequences

4.1. Polytrauma

Classification

The number of sufferers with polytrauma is growing all the time, and today it is 14-15% of all inpatient trauma patients. In extreme situations (natural and man-made disasters, armed conflicts), the proportion of such injuries increases significantly and reaches 30-40%. The peculiarities of polytrauma are a grave condition of the injured, difficulties in diagnosis and treatment, and a high percentage of deaths.

Mechanical injuries are divided into isolated trauma and polytrauma (Fig. 4.1).

Fig. 4.1. Types of injuries

Isolated trauma - damage to one anatomical and functional segment (for the musculoskeletal system), one internal organ, vessel or nerve within one anatomical region.

These lesions can be mono- or multifocal. Thus, fractures of both bones of the lower leg or multiple injuries of the small intestine are attributed to an isolated multifocal injury, and a fracture of the femoral neck - to an isolated monofocal injury. A fracture accompanied by damage to a vessel or nerve is called complicated injury.

Polytrauma is a collective term that includes multiple damage to different tissues and organs in one surgical patient. In polytrauma, multiple, mixed, and combined injuries are distinguished.

Multiple mechanical trauma is simultaneous damage to two or more organs within one cavity, or damage to different segments of the musculoskeletal system. For example, damage to the liver and intestines (trauma within the abdominal cavity), or fractures of the hip and lower leg.

Combined traumas are simultaneous damage of two or more organs in different cavities, or damage to an internal organ in combination with a fracture of a segment of the musculoskeletal system. For example, damage to the liver and lung (injury in different body cavities), hip fracture, and TBI. Most frequently, damage to the musculoskeletal system is combined with TBI (50%), damage to the organs of the chest (20%) and abdominal (10%) cavities. The remaining 20% account for an extremely severe group of surgical patients with lesions of several anatomical areas (bone trauma in combination with thoracoabdominal injuries, TBI).

Combined trauma - injuries resulting from the impact of various traumatic factors: a combination of mechanical trauma with thermal burns, frostbite (temperature factor), radiation damage, etc.

Mechanisms of injury

For the reasons for the occurrence of polytrauma, the first place is occupied by transport injuries - 50%, followed by catatrauma (injury sustained when falling from a height) - 35%, and industrial injuries - 15%.

Analysis of the mechanism of injury showed a dependence on the etiological factor. There are simultaneous, sequential, and combined mechanisms of polytrauma occurrence.

Simultaneous mechanism

Several traumatic forces act simultaneously on the injured person in different places.

So, in case of road traffic accidents (in case of an unexpected collision with an obstacle, a head-on collision), the driver can be simultaneously affected by:

• impact of the knee joint on the front panel (there is either an injury of the knee joint with a fracture of the patella, rupture of the cruciate ligaments, or damage to the bottom of the acetabulum due to an indirect mechanism);
• a hit with the chest on the steering wheel (can lead to a fracture of the sternum, ribs, bruised heart, damage to the lung);
• sharp bending and then hyperextension of the neck with a typical "whiplash" injury of the cervical spine.

When falling from a height (catatrauma), the traumatic forces also act simultaneously. When falling on the legs or arms, identical injuries with similar fracture lines, the same type of displacement ("mirror" fractures) often occurs on the segments of the same name (shins, forearms, heel bones). Especially when falling from a great height, multiple injuries of internal organs are also very likely.

Sequential mechanism

Damages do not occur simultaneously. So, when a pedestrian is hit by a vehicle, they first get hit by the bumper of the car in the shin area (the first phase), then their body is thrown on the hood with possible injuries to the head, chest, spine (the second phase), and then they are thrown onto the road (the third phase), where, in addition to injury from hitting the ground, run-over of another car passing by is possible.

Combined mechanism

Damage occurs from the effects of various damaging factors, for example, as a result of a road traffic accident with inflammation of the emergency vehicle or a gas explosion in a mine (in addition to mechanical damage, the sufferer receives thermal burns).

Features of the clinical course and diagnosis

The multiplicity and multifocality of injuries determine the severity of the general state and a special clinical picture characteristic of polytrauma. The condition of the sufferers is aggravated, as a rule, not only by severe pain syndrome and massive blood loss (which can reach 2-3 liters or more) but also by damage to vital organs (heart, lungs, brain, liver, kidneys, etc.).

There are four characteristic features of polytrauma:

• mutual burden syndrome;
• increased frequency and aggravation of shock;
• difficulties in diagnosis;
• incompatibility of therapy (impossibility of simultaneous implementation of adequate treatment in case of damage to several segments of the musculoskeletal system or anatomical regions).

Mutual burden syndrome

The aggregate of the injuries sustained is always more severe than their simple arithmetic sum. This is due to the limited compensatory capabilities of the body. As a result, multiple injuries, even of obviously non-shockogenic zones, can lead to the development of a severe shock.