Lesson 8.
Injury to the chest, abdomen.Crash – syndrom. Multihle injuries. Burn trauma .
Radiationes and chemical injuries.
TRAUMA of the CHEST
The modern traumatism represents the important social problem. Recently observed the increase of major combined trauma, which complications often result in death. The trauma of the chest is usually accompanied by dysfunction of the vital organs. Therefrom it is necessary constantly to improve diagnostics and treatment of the patients who suffer from trauma.
Classification
The closed damages of the chest are divided:
І. According to the injury of other organs:
1. Isolated trauma.
2. Combined trauma (craniocerebral, with damage of abdominal organs, with damage of bones).
ІІ. According to the mechanism of trauma:
1. Contusion.
2. Compression.
3. Commotion.
4. Fracture.
ІII. According to the character of the chest viscerae damage:
1. Without damage of viscerae.
2. With damage of viscerae (lungs, trachea, bronchi, esophagus, heart, vessels, diaphragm etc.).
IV. According to the character of complications:
1. Uncomplicated.
2. Complicated:
1) Early (pneumothorax, hemothorax, subcutaneous, mediastinal emphysema floative rib fracture, traumatic shock, asphyxia);
2) Late (posttraumatic pneumonia, posttraumatic pleurisy, suppurative diseases of lungs and pleura).
V. According to the state of cardiopulmonary system:
1. Without phenomena of respiratory failure.
2. Acute respiratory failure (of І, ІІ, ІІІ degree).
3. Without phenomena of cardiovascular failure.
4. Acute cardiovascular failure (of І, ІІ, ІІІ degree).
VІ. According to the gravity of a trauma:
1. Mild.
2. Moderate.
3. Severe.
Rib fracture
The direct force of traumatizing factor on the chest wall results in rib fracture.
The pain localized in the zone of damage, is the chief clinical manifestation. The pain intensifies at respiration, cough and change of a body position of the patient. The overwhelming majority of the patients complain of crepitation of ribs in the fracture site.
At examination the respiratory lag on affected side is observed.
Crepitating of osseous fragment revealed by palpation, and depending oumber of injured ribs – diminished breathing sounds by auscultation.
On chest roentgenograms the break in continuity of bone fragments of ribs is observed.
The fracture of the VI-VIII left ribs
Floating rib fracture (flail chest)
This is one of the most severe complication of the closed trauma of the chest. The floation arises from fracture of three and more ribs along two anatomic lines. The multiple rib fractures produce an unstable segment of chest wall that moves paradoxically inward upon inspiration and balloons outward during expiration (flail chest). Thereby the respiration disturbed not only in the area of a floating segment, but also in all lungs. The permanent movement of flail chest result in rocking shift of mediastinum, which causes deviation of its organs. As a result the respiratory failure is associated with cardiovascular.
Flail chest
Classification
1. Central floative segment – a multiple rib fracture along parasternal or midclavicular lines.
2. Anterolateral floative segment – a multiple rib fracture along parasternal and anteaxillary lines.
3. Lateral floative segment – a multiple rib fracture along anterior and posterior axillary lines.
4. Posterior floative segment – a multiple rib fracture along postaxillary and paravertebral lines.
Symptomatology and clinical course
The patients state is grave or extremely grave. The expressed pain syndrome frequently results in traumatic shock. The patient is restless. Observed the cyanosis of skin, tachypnea, and tachycardia to 120-160 beat/min of weak filling and tension. Arterial pressure at first elevated, then its decrease observed. At examination characteristic paradoxical respiratory movements of chest, inward upon inspiration and outward during expiration, crepitus of bone fragments by palpation are revealed. Breathing sounds diminished on the side of damage by auscultation.
In case of floative rib fracture the chest X-ray examination reveals multiple, double rib fracture with deformity of the chest.
Flail chest
In 75 % of cases the multiple rib fracture is the cause of injury of lungs, pneumothorax or pneumohemothorax.
Treatment
Pain relief in closed trauma of the chest is achieved by means of different blocks:
1. Vagosympathetic block;
2. Alcohol – novocaine block of the site of fracture;
3. Paravertebral block.
Alcohol – novocaine block of the site of fracture
Except blocks, in some cases analgesics and opiates are instituted. On 2-3 day desirable the administration of electrophoresis with novocaine. For prophylaxis of congested phenomena in a pulmonary tissue used respiratory gymnastics, forced ventilation of lungs, inhalations.
The methods of reduction of the skeleton of the flail chest are divided onto three groups:
1. External fixation of a movable segment by means of suturing for intercostal muscles and traction during 2-3 weeks;
2. Intrmedullary costal osteosynthesis;
3. Mechanical ventilation (often with positive end-expiratory pressure).
Breastbone Fracture
The fracture of breastbone is commonly caused by direct forces at the site of the sternum. Usually it is the outcome of compression or result of trauma to vehicle helm.
The fracture in most cases located in the upper and medial thirds of breastbone.
The patients complain of severe pain in the site of fracture, which intensifies at respiration and movements. The pain behind the sternum and in the heart area follows the contusion of lungs and heart. Sometimes hemoptysis is observed.
Examination reveals the deformity of breastbone in the site of fracture. Displaced fragments are palpated here, that accompanied by severe pain syndrome.
By auscultation, if there are no intrapleural complications, the respiration in the first 2-3 days is vesicular from both sides. Then the fine bubbling rales are auscultated which is the first objective manifestation of a posttraumatic pneumonia.
The complete fracture of breastbone is characterized by a break in continuity of both cortical plates with a local dislocation of fragments.
Fracture of breastbone
The diagnostic program
1. Complaints and history of the disease.
2. Physical findings.
3. Chest roentgenograms in two planes.
Treatment
The sternal fracture without displacement of fragments requires conservative treatment. The fracture of the corpus of breastbone with dislocation of fragments quite often requires operative treatment with performance of osteosynthesis.
рosttraumatic pneumothorax
Posttraumatic pneumothorax is the presence of air in a pleural space, caused by mechanical injury of lung or chest wall as a result of trauma.
Classification
І. According to extension of process:
1. Unilateral.
2. Bilateral.
ІІ. According to degree of a lung collapse:
1. Partial (collapse of lung to 1/3 of its volume).
2. Subtotal (collapse of lung to 2/3 of its volume).
3. Total (collapse of lung exceeding 2/3 of its volume).
ІІІ. According to the mechanism of occurrence:
1. Closed.
2. Open.
3. Valvular.
The closed pneumothorax is the complication, which arises from the damage of visceral pleural membrane, which results in entry of air in a pleural space and atelectasis of lung. In chest trauma the cause of occurrence of the closed pneumothorax is the perforation of a visceral pleura and pulmonary tissue by the fragment of fractured rib.
The open pneumothorax results from formation of hole in a chest wall at massive trauma and free entry of air during inspiration inward a pleural space, and during expiration – outward.
The valvular pneumothorax occurs at damage of a pulmonary tissue or chest wall with formation of the valve, when the air during inspiration enters a pleural space, and during expiration, due to valve closure, does not exits outside. It is the most dangerous form of pneumothorax, which results in a complete pulmonary collapse, shift of mediastinum, inflection of major vessels and cardiac arrest.
Symptomatology and clinical course
The chief clinical manifestation of posttraumatic pneumothorax, which results from a pulmonary collapse, is the rest dyspnea, which amplifies at a minor exertion. This sign arises due to atelectasis of lung and its exclusion from breathing. On the background of collapsed lung only the main and lobar bronchi and pleural space are ventilated. The oxygenation of blood in collapsed lungs does not occur, therefore the shunting of a venous blood arise.
The chest pain is more characteristic manifestation for trauma with the damage of ribs, however pulmonary collapse also can associate with a pain syndrome. Nevertheless the patients promptly adapt for it and the dyspnea finally remains the basic clinical manifestation of such complication.
On the background of severe trauma of the chest the signs of damage dominate in clinical manifestation on inappreciable entry of air in a pleural space. Pneumothorax mostly revealed during X-ray examination. Progressing of air entry in a pleural space and pulmonary collapse cause the respiratory lag on affected side. By palpation the vocal fremitus is absent. It indicates the origin of the complication – rib fracture.
Percussion obtains bandbox sound, or pulmonary sound with tympanitis. By auscultation – weak or absent breathing sounds, sometimes – amphoric respiration. The expressiveness of clinical pattern depends on degree of a pulmonary collapse.
Pulmonary atelectasis and presence of air in a pleural space are the X-ray findings that enable to establish the final diagnosis.
Right-side pneumothorax
The diagnostic program
1. Complaints and history of the disease.
2. Physical examination.
3. Chest X-radiography in 2 planes.
4. Thoracentesis.
5. ECG.
Treatment
A chest trauma, which complicated by pneumothorax with a partial pulmonary collapse (to 1/3 of volume) is indication to aspiration of air by means of thoracentesis. The cases, if the negative pressure in a pleural space is not obtained, and also subtotal, and total pneumothorax require closed drainage of a pleural space.
Under the local anesthesia by solution of novocaine in ІІ intercostal space in the midclavicular line by means of a trocar in a pleural space inserted a plastic tube, which fixed to skin. The drainage connects to aspirative system or according to method of Bulau. In the majority of patients the pneumothorax liquidates in some hours, or during 1-2 days.
The absence of effect (incomplete expansion of lung) of active aspiration, and also valvular closed pneumothorax is the indications to operative management – suturing of the pulmonary wound. In some cases a segmental resection of lung, or lobectomy is carried out.
Hemothorax
Hemothorax is the accumulation of blood in a pleural space. The cause of occurrence of this complication is the damage of vessels of the chest wall, pleura, lungs and mediastinum.
Classification
І. According to extent:
1. Unilateral.
2. Bilateral.
ІІ. According to degree of hemorrhage:
1. Small (the loss less 10 % of volume of circulating blood).
2. Moderate (loss of 10-20 % of volume of circulating blood).
3. Great (loss of 20-40 % of volume of circulating blood).
4. Total (exceeds 40 % of volume of circulating blood).
ІІІ. According to duration of bleeding:
1. With persistent hemorrhage.
2. With the stopped bleeding.
ІV. According to the presence of clots in a pleural space:
1. Coagulated.
2. No- coagulated.
V. According to the presence of infection:
1. Not infected.
2. Infected (suppurative).
Symptomatology and clinical course
If hemothorax is the complication of blunt chest trauma, the clinical manifestations depend on the gravity of trauma and degree of hemorrhage. Also hemothorax by itself results in pulmonary compression and shift of mediastinum.
In case of small hemothorax clinical manifestations of hemorrhage are slightly expressed or absent at all.
Dyspnea, cough, general malaise and dizziness are obvious in moderate hemothorax. The skin is pale. The hemodynamic disturbances – tachycardia and decreased arterial pressure are observed.
The great and total hemothorax are associated with extremely grave condition. The patients are troubled with expressed general malaise, dizziness, dyspnea and difficult breathing. In some cases they enter medical hospitals in a terminal state. The skin is sharply pale. The peripheral pulse impaired or absent. Tachycardia, weak cardiac tones, low arterial pressure are obvious.
By percussion the dullness is revealed. On auscultation – the breathing over the site of hemothorax is sharply diminished or is not heard.
The X-ray picture of hemothorax is rather specific. The intensive homogeneous shadow on the side of the lesion with oblique upper contour (Damuaso’ line) is observed. The costal sinus does not visualized. In small hemothorax, depending on the degree of intrapleural bleeding, the shadow observed only in the region of sinus. In moderate hemothorax it achieves a scapular angle (on the back surface) or V rib on anterior surface of the chest wall. In great hemothorax this shadow achieves ІІІ rib, and total hemothorax characterized by complete shadow of a pleural space, and in some cases – mediastinal shift to the healthy side.
Left side small hemothorax
Left side moderate hemothorax
Right side great hemothorax
Left side total hemothorax
The diagnostic program
1. Complaint and anamnesis of the disease.
2. Physical examination.
3. Chest roentgenograms in 2 planes.
4. Thoracentesis.
5. Investigation of a pleural content.
6. Test by Revilour-Greguar.
7. General blood analysis.
8. Biochemical blood analysis.
9. Determining of the blood group and Rh factor.
Variants of clinical course and complications
The coagulated hemothorax. The patient’s late apply for medical aid or major bleeding results in formation of clots in a pleural space, and in some cases all blood, which has accumulated in a pleural space, forms by itself a major entire clot.
Depending on degree of bleeding and, consequently, size of clot, the patients complain of chest pain, which intensifies at respiration, dyspnea, general malaise, and dizziness. As a rule, on 3-5 day the fever to 37,5-38°С is observed.
The physical findings (diminishing and absence of vocal fremitus by palpation, dullness by percussion and sharply diminished or absent breathing by auscultation) suggest the presence of pathological process in a pleural space.
Chest roentgenogram reveals the intensive shadow, sometimes heterogeneous (with enlightenments and multiple levels).
The needle aspiration obtains small amount of a liquid hemolyzed blood and small bloody thrombi (according to inner diameter of the needle).
Suppurative hemothorax. The coagulated hemothorax in overwhelming majority is infected, that results in occurrence of a pleural empyema (clinical manifestations, diagnostics and treatment look in chapter ” pleural empyema”).
Treatment
A treatment of small hemothorax requires needle aspiration or drainage of pleural space and elimination of blood. The manipulation is carried out in VІ-VІІ intercostal spaces in the postaxillary or scapular lines.
Total, great or moderate hemothorax with persistent bleeding (positive test by Revilour-Greguar) requires thoracotomy for liquidation of a bleeding source.
The bleeding wounds of lungs are sewed up by twist suture. If the pleural space contains liquid blood, the surgeon carries out its reinfusion. The clots are removed from pleural space.
Subcutaneous emphysema
The cause of this complication of blunt chest trauma is the damage by edge of the broken rib of parietal and visceral pleural membranes with the following entering of air from a pulmonary tissue into a pleural space and through damaged chest wall (ruptured intercostal muscles) into subcutaneous fat.
In overwhelming majority the subcutaneous emphysema is the outcome of a valvular pneumothorax and pneumothorax in obliterated pleural space.
Classification
Subcutaneous emphysema is divided on:
1. Localized.
2. Widespread.
3. Total.
Symptomatology and clinical course
As the subcutaneous emphysema is the outcome of trauma complicated by a rib fracture and posttraumatic pneumothorax, the chief complaints are of chest pain and dyspnea, which intensify at respiration, movements and minor physical activity.
In localized subcutaneous emphysema the patients the complaints of the chest trauma are predominant in symptomatology. On examination observed a swelling of a chest wall in the place of damage. By palpation a subcutaneous crepitation is felt over this region. Percussion reveals a bandbox sound or tympanitis. Auscultation of lungs over subcutaneous emphysema is usually impossible.
The widespread and total subcutaneous emphysema represents a serious moral problem for the patient. Owing to extent of air all over the chest, abdominal wall, neck (wide-spread emphysema), and also face, arms and legs (total emphysema), the patients has a specific appearance: swelling face, thick neck, enlargement of the chest, arms, and legs. Subcutaneous emphysema by itself usually causes no respiratory and cardiovascular disturbances. However the patients note the change of the quality of voice. By palpation the subcutaneous emphysema is felt in whole body (“crisping snow”).
It is necessary to note, that in widespread and total emphysema the auscultation is impossible. However the presence of subcutaneous emphysema at the closed trauma of the chest enables to suspect the presence of posttraumatic pneumothorax.
On the chest roentgenogram the enlightenment of a subcutaneous fat (presence of air) is observed.
Subcutaneous emphysema
The diagnostic program
1. Complaint and history of the disease.
2. Physical findings.
3. Chest X-radiography.
Treatment
Widespread and total subcutaneous emphysema requires the draining of subcutaneous space by plastic tubes in infra- and supraclavicular region, and also in the zone of the most expressed emphysema. Also performed the drainage of a pleural space.
The subcutaneous emphysema resolves depending on its extent from several days to 2-3,5 weeks.
Traumatic injury of trachea and main bronchi
The isolated injuries of trachea and bronchi as the result of blunt trauma of the chest occur rarely and located mainly in a cervical part.
The main causes of tearing of trachea and bronchi are:
1) shearing forces, which arises at the moment of trauma owing to a sudden rise of intraluminal pressure against a closed glottis when the airway is compressed against the spine.;
2) compressing of a bronchial tree between a breastbone and vertebral column;
3) shift of lungs in sudden and rapid deceleration or acceleration of a body occurs with greater amplitude, than fixed bifurcation of trachea.
Such disruptions most often occurs as a result of vehicular impacts, falls from great heights, direct blows to the chest. In most cases disruption of trachea and bronchi are accompanied with the other visceral damages: lungs, skull and brain, heart, liver and flail chest.
Classification
І. According to degree of disruption:
1. Partial:
· without damage of cartilaginous rings (I degree);
· with fracture of cartilaginous rings (II degree).
2. Partial disruption of all layers (ІІІ degree).
3. Complete transverse disruption of all walls without disjunction of the of trachea, (bronchus) (ІV degree).
4. Abruption with disjunction of the edges of trachea (bronchus) (V degree).
ІІ. According to direction of rupture:
1. Longitudinal.
2. Oblique.
3. Transversal.
4. Mixed.
ІІІ. According to localization of the damage:
1. Tracheo-laryngeal.
2. Cervico-tracheal.
3. Mediastino-bronchial.
4. Bifurcational.
5. Bronchial.
ІV. According to the size of injury:
1. Combined damages of trachea (bronchi) and adjacent organs.
2. Damage of trachea (bronchi) and other segments of the body.
3. Damage of a trachea (bronchi). adjacent organs and other segments of the body.
Symptomatology and clinical course
The clinical manifestations of the injury of trachea depend on the type of disruption, its degree and presence of concomitant damages.
Incomplete isolated disruption of trachea commonly manifests by cough and hemoptysis. Respiration is not disturbed as a rule.
The small disruptions are characterized by various clinics. If the hole is occluded by clot and mediastinal tissues, the signs, which had appeared earlier (cough, hemoptysis, mediastinal emphysema), can disappear. Nevertheless the repeated occurrence of cough, as a rule, leads to severe aggravation of the patient state.
Major and circular disruptions of trachea cause a grave state of the patients. They manifest except difficult breathing by such signs:
1) mediastinal emphysema or pneumothorax;
2) compression syndrome – compression and inflection of major vessels due to tension pneumothorax or mediastinal emphysema with transmission into acute cardiopulmonary failure;
3) hemorrhage syndrome;
4) aspiration syndrome, which is the outcome of bleeding into airways or aspirations of the gastric content;
5) traumatic shock.
The injuries of bronchi occur in the way of abruption of main bronchi or their disruption in the zone of bifurcation. In the zone of a tracheal bifurcation observed multiple (2-4) disruptions, which can be longitudinal, transversal or oblique.
Depending on the character of trauma, it is necessary to distinguish direct and secondary disruptions of bronchi. The direct injuries arise from the gunshot and knife wounds, penetration of rib fragments or other subjects in mediastinum or endoscopic manipulations.
The overwhelming majority of bronchial disruption is the part of blunt trauma of the chest. By the way, the damage of vessels of a lung root occurs in 41,3 %.
The predominant clinical signs of a bronchial disruption are the respiratory disturbance, gas syndrome, hemoptysis and hemothorax. However these signs may be observed only in isolated injuries of lungs.
The patients state is grave. Rest dyspnea and acute pain behind a breastbone are the most troubling manifestations. The difficult swallowing, hoarseness, swelling face and subcutaneous crepitation are observed. Auscultatory on the side of trauma the breathing sounds are weak or absent at all.
The sequence of examination of the patients with injuries of trachea and bronchi depends on the character and gravity of trauma, clinical signs and concomitant damages, which threatening life.
If the state of the patient allows, a chest X-radiography is performed. Commonly it is possible to find out mediastinal emphysema, sometimes the sign of discontinuing of trachea.
The injuries of bronchi manifest by the distension of mediastinum and presence of air strips along its borders, and in some cases total or tension pneumothorax observed.
Final and most informative diagnostic method is the tracheobronchoscopy, which can be also the therapeutic method. However it is necessary to carry out decompression of a mediastinal emphysema and pneumothorax before such investigation.
Before examination the clots and liquid blood are aspirated from airways, then adjusted the localization and character of disruption. The incomplete disruptions are usually longitudinal and oblique and located on the line of membranous and cartilaginous part, circular – mainly in a cervical part of trachea. Except disruption of the wall, observed the absence of cartilaginous rings in this region and filled by blood parabronchial fat.
The open damages of trachea take place mainly in a cervical part and rarely – in thoracic. In all cases of neck trauma it is necessary always suspect the opportunity of damage of trachea and esophagus.
Such variants of clinical course are distinguished:
– acute course (first 30 days after operation);
– chronic course (complication of trauma).
Acute course is divided onto three stages:
1. The initial stage (lasts during 2 days after the trauma with typical signs of disruption; the urgent resuscitation measures are required).
2. The stage of temporary compensation (lasts during 2 weeks; at this time it is possible to carry out diagnostic examination).
3. The stage of persistent compensation (lasts during 30 days; during this time a stenosis and other persistent complications of disruption of trachea and bronchi develops).
The diagnostic program
1. Complaint and the history of disease.
2. Physical findings.
3. Chest X-radiography.
4. Diagnostic thoracentesis.
5. General blood and urine analyses.
6. Biochemical blood analysis.
7. Tracheobronchoscopy.
8. Tomography.
Treatment
There are primary operations in acute stage (first two days after the trauma) and late repairing operations (in 1 month after the trauma). The operation is based in resection of injured tissues, edges of bronchus with the further suturing of disruption, or wedge-like or circular resection with following anastomosis. In series of cases lobe-, bilobe- or pneumonectomy is performed.
Mediastinal emphysema
Mediastinal emphysema is the complication of the blunt trauma of the chest, which is characterized by entering and accumulation of air in mediastinum.
The causes of mediastinal emphysema is partial (damage of a membranous part) or complete disruptions of trachea, bronchi, esophagus and in some cases – tension pneumothorax.
The entry of air in mediastinum leads to compressing of superior cava vein and right atrium, which results in the expressed discirculation.
Symptomatology and clinical course
The patients complain of difficult breathing and swallowing, pain behind breastbone, hoarseness, cough attacks. As a rule, the patient’s position is forced – semi-sitting. The neck and face are thickened, cervical veins distended, the skin is cyanotic. By palpation – the crepitation of neck, face, and shoulder area. By auscultation heart tones are diminished with tachycardia.
On X-ray film on the background of enlightenment observed well-defined contour of a mediastinal pleura. If there is the damage of mediastinal pleural membrane a pneumothorax (mainly total or intense) is revealed.
Mediastinal emphysema with left-side pneumothorax
The diagnostic program
1. Complaint and history of the disease.
2. Physical findings.
3. Examination X-radiography of organs of the chest.
4. Definition of central venous pressure.
5. Control of hemodynamic data.
6. ECG.
Tactics and choice of treatment
Progressing mediastinal emphysema requires the urgent drainage of a forward mediastinum in order to prevent external cardiac tamponade.
Tension mediastinal emphysema resulting from disruption of trachea or bronchus operative management, pneumothorax, etc., requires the treatment, which is described in previous chapters.
Drainage of anterior mediastinum
Traumatic damages at extraordinary situations
Quantitative characteristic of injuries:
Trauma- injury of the body, it’s tissues or parts caused by the influence of mechanic, physical, chemical or mental factors, which is conducted with local and general reactions.
Isolated trauma- is every single injury at any anatomic and functional region of the body or organ.
Multitrauma- few injuries at one anatomic and functional region.
Associated trauma- few injuries, at different anatomic and functional regions.
Combined trauma- injury, which appears as a result of simultaneous or sequential influence of several traumatic agents.
Polytrauma- severe multiple and combined injuries, which cause the beginning of traumatic disease (wound dystrophy) and need immediate medical help by life-saving indications.
Obligatory condition for using of term polytrauma is the occurrence of traumatic shock and life-threatening injury or a combination of such injuries.
In case of associated trauma dominates the syndrome of mutual complexification, what means that every single injury might be not lethal, but together injuries might become life-threatening.
(Fracture+ rupture of intestine+ injury of liver, spleen)
Polytrauma is characterised with: syndrome of mutual complexification, atypical symptoms of damages, complicacy of diagnostic, necessity of permanent estimation of the patient’s state, immediate need in adequate treatment, development of traumatic disease, large number of complications and high lethality.
“Traumatic disease” – is a phase pathologic process, which gradually develops in case of severe injuries, which are based on homeostatic disorders, disorders of general and local adaptation processes; it’s clinic depends on the character, quantity and localisation of damages.
Traumatic disease is usually divided into 4 periods:
I – shock
II – period of early manifestations of traumatic disease
III – period of late manifestations of traumatic disease
IV – period of rehabilitation
According to the conception of “golden hour” all injuries were divided into 3 groups:
1. Unrecoverable, extremely severe damages, in case of which even immediate medical help will not bring positive consequences.
2. Damages, in case of which consequences of trauma (death or invalidity) depend on the timeliness and quality of the medical help. To those patients medical aid should be provided at the place of accident and they should be hospitalized to the specific department of medical institution ( in the
3. Damages, in case of which specific medical aid might be delayed for 1 hour from the moment of injuring without risk for the life and health of the patient.
Periods of lethality after injury:
First pick of lethality falls on the moment of injury, when death comes in first few seconds or minutes from the moment of injury, what first of all is caused because of the damage of life-important organs, e.g. brain, heart, big vessels. In most cases such injuries are fatal, although in-time treatment at the place of accident might save a certaiumber of victims. At this period nearly 60% of victims die because of:
1. Damage of brainstem.
2. High damage of the spinal marrow.
3. Damage of the heart.
4. Damage of aorta or other great vessels.
Second pick of lethality falls on the time between first few minutes and few hours from the moment of injury, when the frequency of fatal outcomes might be reduced with prophylactic measures and treatment of ventilate, haemic and tissue hypoxia through conducting of artificial lung ventilation, arrest of external and internal bleedings, adjustment of circulating blood volume and tissue perfusion. In this period the reasons of death are next:
1. Subdural and epidural haematoma.
2. Haemopneumothorax
3. Splenic rupture
4. Damage of liver
Fracture of the pelvic bones or/and other injuries associated with large blood loss.
The third pick of lethality appears in few days or weeks after moment of injury and is usually connected with multiple organ failure and sepsis.
Polytrauma in most cases is connected with traffic accident and fall from a height.
After fall from a height (accidental), polytrauma is stated in 66-76% cases, what includes 63% of cranial-skeletal trauma, 52% of thoracic-skeletal trauma. Craniocerebral trauma as an isolated injury exists only in 35,3% of cases.
Victims with polytrauma have associated injuries of limbs (closed and open fractures) in 76-90% of cases, associated craniocerebral trauma and fractures of cranial bones in 66-76% of cases, associated thoracic trauma in 62-80% of cases. The most common combination of injuries is head+limbs (63%) thorax+limbs (52%).
Actions of emergency team at the place of accident.
Emergency team at the place of accident should first of all:
1. Carefully examine the place of accident.
2. Get to know, what happened?
3. Determine the quantity of victims
Identification of the injury-mechanism and inspection of the place of accident let the emergency team to give objective evaluation of accident complicacy and to prognose the probable traumatic injuries of victims.
Emergency medical aid is often provided in extreme conditions, when additional factors might harm not only patients, but also their rescuers. In such cases medical workers should follow next rules:
1. Check the safety of the place of accident and
if necessary ask professional rescuers or
police to help.
2. Determine the quantity of victims, way of
injuring, sources of danger in environment.
3. To define the necessity in additional
emergencies in case of many victims.
Emergency medical aid
The main purpose of EMA to injured at this stage is prevention of development of early and late complications- hypoxia, reperfusion ischemia and multiple organ failure. Positive results should come as a consequence of transportation time reduction (to the place of accident and to the hospital). During pre hospital stage priority of first medical aid is the detection of life-threatening states, such as:
Shock
Obstruction of upper air passages
Massive bleeding
Severe damages of thorax, which might cause the development of respiratory distress syndrome
Severe craniocerebral trauma and cervical spine trauma
Extent of medical help at pre hospital stage is limited with immediate measures of returning and maintenance main vital functions (breathing and circulation).
Programme oh help at pre hospital stage consists of next steps:
Evaluation of severity of patients condition, detection of life-threatening disorders of breathing and circulation.
Resuscitation ain case of acute disorders of vital functions
Anaesthetization and immobilisation
Immediate hospitalization to the special in-patient department.
Components of emergency medical aid at the pre hospital stage:
Primary inspection ABCC’
Medical sorting
Intensive therapy
Secondary inspection (ABCDE)
Constant observation of the patients condition
Qualified and specialised medical help airways
B-breathing
Circulation
C’- cervical spine- with using of neck collar
Traumatic shock-is a hard pathologic process, which appears as a general response to severe mechanic damage of tissues and organs and becomes evident through disorders of systemic circulation, microcirculation and metabolic reactions in tissues. In this shock (hypovolemic, traumatic) condition there are two phases: erectile and torpid. Erectile phase appears not always. It develops at pre hospital stage, lasts for a short period (few minutes or 10-20 minutes) and is characterised with the excitement of the patient. Torpid phase is characterised with depression of vital systems.
Classification of shock
Open fracture of forearm bones
Probable complication of fracture or transportation without immobilisation
Mechanism ofradial nerve damage
Splintered open fracture of both bones of right forearm at the level of lower 1/3
1 Combined MOS 2
3 4 5
Fractures of the pelvis
Without breaking of pelvic circle continuity
A.B. Fractures of the wing of ilium
C.D. Fractures of sacrum
E. Fractures at the level of iliosacralis articulation
F. Fractures of ishiadic and pubic bone
G. Fracture of pubic bone (horizontal ramous)
H. fracture of ishiadic bone
I. Fracture of pubic articulation
Fractures of the pelvis
With breaking of pelvic circle continuity (Malign)
1. Fracture at iliosacralis articulation with dislocation.
2. Fracture of pubic bone with dislocation.
3. Fracture of the ischiadic bone with dislocation
Fracture-displacement of half-pelvis
Fracture of pelvic and iliosacralis articulation with dislocation of pelvic circle
Fractures of the pelvis
Mechanisms of injury- direct and indirect
Clinic: pain, deformation of the pelvic circle, specific position of the limb, depends on the type of fracture, pathologic mobility. Usually the clinic of pelvic fracture with rupture of pelvic circle is completed with trauma or haemorrhagic shock. In case of pelvic fractures intrapelvic haematoma have 2-
Transportation of the patient with pelvic fracture
Patient with pelvic fracture should be transported on the stretcher in position with flexed (30º-40º) knees and femoral articulation (abduction 10º). This position is the most physiological for the muscles, which are connected with the pelvis and doesn’t cause additional dislocation (so called “frog-position”).
Shaft of femur fractures
Fractures of this localisation consist 40% of all femoral fractures.
Mechanism of the trauma: direct and indirect.
Clinic: pain, oedema, pathologic mobility, bone fragments crepitating. The specific feature of this trauma is often development of trauma shock and blood loss (0,5-
There are fractures of upper, middle and lower 1/3 of femoral bone.
Clinical examples
Combined trauma: fracture of heel bone+burns (treatment- mod apparatus of Elizarov with compression of bone fragments).
Displacements of foot
Subtalar open displacement of the foot
Transporting immobilisation
The main principle is the immobilisation of joints, which are above and lower than fracture
a – immobilisation with Cramer’s splint in case of crus’ fracture; b – immobilisation with Diterichs’ splint.
Emergency aid and principles of intensive care of injured patientsFirst of all you should stop arterial bleeding pressing artery to the bone above the place of injury or using arterial tourniquet or garrot above the place of trauma. You also need to notice the exact time of this manipulation.Then you will have to inspect the state of the victim (central and peripheral pulse, degree of consciousness’ depression, air path, effectiveness of breathing).You should provide the correct position of the injured. If he (or she) is unconsciousness, you turn him (her) on one side. Specific position demands a vertebral fracture (on the hard surface) and pelvic fracture (described before). You should not move the head if the fracture of cervical part of backbone is suspected!!!
Use the rule of 4 catheters:
Nasal for oxygen
Gastric for evacuation of its contents (when patient is unconscious)
Intravenous for infusions
Urinary for measuring of diuresis
Also important part of treatment is infusion therapy.
Anaesthetization:
a narcotic analgesics-morphine hydrochloride10-20 mg, omnopon 10-20 mg,
promidon 20-40mg, fentanil 0,05-0,1 mg, dipidolor 7,5-15 mg i/v
or i/m:3-4 times aday under control of breathing:
b tramal 50-100 mg, stadol 2-4mg, nubain 0,15-1,3 mg/kg, pentazocyn 30-45 mg, buprenorfin 0,3-0,6 mg i/v or i/m
c nonsteroid anti-inflammatory- ketanov 30-60 mg, dicloberl 75 mg
i/m 2-3 times a day
a – general anaesthetics- NO with O2 2:1
b – ketamin 0,5-1 mg i/v or 3-5 mg i/m, Na oxybutyrat 20-30 of 20% solution ml i/v slowly
c – novocaine blocks of fracture places, blocks of nerves and nervous interlacement, vago-sympatic blocks , paravertebral and epidural anaesthesia (if CHD is stabil)
Glucocorticoids like in case of hypovolemic shock. Immobilisation of fractures- standard and improvisational splints, contra shock clothes.
A/B therapy, beginning from “wide” antibiotics (cyfran, zanocyn, cephalosporins). Prevention of supercooling- warm coats, the optimal climate control, warm liquids for drinking (except abdominal trauma), warm infusion solutions 35º- 40º. Symptomatic syndromes and corrective therapy.
Transportation of patient with polytrauma.Treatment of patients at pre hospital stage needs experienced medical workers and expensive medical equipment. Every delay might cause life-threatening complications. Those statements cause the necessity of hospitalisation of such patients to the specific in-patient departments, where exists the possibility to involve into treatment surgeons, neurosurgeons, traumatologists, anaesthesiologists.
All victims with polytrauma should be hospitalized to the intensive care department or antishock ward.
Genesis of Damage:
• primary (squashing. haematoma, hemorrhage);
• second (violation of circulation of the blood and spinal fluid, edema – swelling, hyperaemia of brains , infectious inflammation);
Types of SBТ:
• isolated ;
• united;
• combined;
By descent:
• closed (without violation of integrity of skin cover and damage of aponeurosis);
• open (wounds + damages aponeurosis; breaks and damages soft tissues, break of basis of skull + pour out spinal fluid);
• penetrable (with damage of ТМО);
• Not penetrable.
By severe:
• Easy degree (13-15 by Glazgo scale)
• Middle degree (8-12 by Glazgo scale+ sub sharp and chronic compression);
• Heavy degree (3-7 by Glazgo scale)
Clinical forms of SBТ :
• Concussion of the head brain;
• Backwall of cerebrum – easy degree
• Backwall of cerebrum – middle degree
• Backwall of cerebrum – heavy degree;
• Compression of brain;
• Compression of head;
By Compression of brain:
• – sharp (threatening clinical growth during 24 hours after CBТ);
• – sub sharp (threatening clinical growth 24 hours after CBТ );
• – chronicle (threatening clinical growth >15 days after CBТ);
Gradation of the state of consciousness CBТ:
• Clear consciousness –complete orientation, adequate reaction. Retrograde amnesia is possible.
• Moderate stunning– moderate somnolence , insignificant errors of orientation in time , some slow implementation of commands and instructions , enhance able level of perception .
• Deep stunning – deep somnolence , disorientation, elementary instructions are implemented , elementary linguistic contact is possible.
• Sopor – linguistic contact is absent , presence of coordinated protective reactions, eyes opening as a reaction on pain, verbal commands are not implemented.
• Moderate comma –eyes are not opening, not coordinated protective reactions without localization of pain. Pupil and corneal reflexes are present.
General brain symptoms :
• Disorder of memory;
• Nausea, vomit;
• Head pain;
• meningeal symptoms;
• Change of tone of muscle;
• Vegetative reactions.
Diagnostic criteria:
w Break of vault and basis of skull;
w Focus change on CS
Bruise cerebrum of easy degree
• 10-15% patients with a SBТ
• 14 – 15%by Glazgo scale
Clinic:
• Lost of consciousness 30 min. – 1 hour. Amnesia not more then 1 hour.
• Cerebral and meningeal symptoms.
• Insignificantly expressed focal symptoms (anisocoria, decline of cornea reflexes, inertia convergence, increase or decline of reflexes of tendon, s-м
Marinecku – Radovichi)
• Absence of barrel disorders.
Treatment :
• duration (8 – 14 days)
• Analgesics, sedation, nootropic agent;
• Dehydration.
• Bruise cerebrum middle degree
• 8 – 10% patients with a CBТ.
Clinic:
• Lost of consciousness (10min.- few hours, amnesia > 1 hour.);
Retro and anterograde amnesia is expressed , disorders of vital functions (bradycardia, tachycardia, increase of BP, tachypnoae, mild pyrexia)
• Barrel systems : nistagm, bilateral pyramid signs;
• Clear focal symptoms.
Bruise cerebrum heavy degree
• 5 – 7% patients with a CBТ.
Clinic:
• Threatening violation of congratulatory functions;
• Prevailing of initially barrel symptoms (swimming of eyeballs, paresis of look, convergence of eyeballs, decerebrate rigidity, bilateral pathological signs);
• paresis, paralysis;
• Cramps;
• Vegetative disorders (decline of BP, increase of body temperature, hypersalivation);
• Lethality 30 – 40%
Epidural haematoma:
• 1% in all cases of CBТ;
Starts from:
• branch a meningea media
• sinus and parasagittal veins
• Forming rate – 2 –3 hours.
Phases of motion:
1. “light interval”
2. Growth of cerebral symptoms with oppression of consciousness; cerebral hemisphere symptoms
3. Barrel located symptoms.
4. Terminal phase (comma, apnoe, decline of BP).
Diagnostics:
• Estimation of neurological status;
• craniography;
• sonography;
• CS;
• In case of absence CS – searching trepanation.
TREATMANT
• Surgical (in first 3 hours after hospitalization)
• Lethality 8 – 50%
Subdural hematoma:
• 40% from all intracranialhaematomas;
• Source:
• Parasagittal vein
• focal of squashing of brain.
After the term of origin :
• sharp – till 3 days
• Sub sharp – till 20 days
• Chronicle – more then 21 days.
Diagnostics :
• Breaks of bones, vault, basis;
• CS;
Diagnostics:
• CS:increase of volume of the brain, compression lateral and ІІІ ventricle, cisterns, subarachnoid spaces, microfocus hemorrhage in white matter, barrel.
Signs of heavy cranial-cerebral trauma.
• Different pupils.
• Different mobile activity.
• Opern cranial-cerebral trauma with effusion spinal fluid.
• Neurological worsening.
• Break of bones of the skull.
• The second review is executed parallel with conducting of measures of intensive therapy.
During conducting of the second review it follows to examine a head of suffering and make palpation bones of skull, to estimate a size and symmetry of pupils, presence of paraorbital heamatomas, examine aural channels (presence of blood or spinal fluid can testify to the break f basis of skull).
Stage of operation removal subdural haematom
Absolute testimonies for application Neck collar:
1. Polytrauma.
3. Violation of consciousness is as a result of trauma or sharp poisoning.
4. Jaw-facial trauma.
5. Changes of configuration of spine or feeling suffering pain in the back.
Advanced Life Support Algorithm
CHAPTER
Objectives
To understand:
The function of the advanced life support (ALS) algorithm
The treatment of shockable rhythms The treatment of non-shockable rhythms The indications and technique for giving a precordial thump
The potentially reversible causes of cardiac arrest
Shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia)
In adults, the commonest initial rhythm at cardiac arrest is VF. Having confirmed cardiac arrest, summon help (including a request for a defibrillator) and start CPR, beginning with chest compressions, using a compression: ventilation ratio of 30:2 as described in the previous chapter. As soon as the defibrillator arrives, apply self-adhesive pads or paddles to the chest to diagnose the rhythm. If VF/VT is confirmed, follow the treatment steps below.
Introduction
Attempt defibrillation. Give one shock of 150-200 J biphasic (360 J monophasic).
Immediately resume chest compressions (30:2) without reassessing the rhythm or feeling for a pulse.
Continue CPR for 2 min, then pause briefly to check the monitor:
– If VF/VT persists:
Give a second shock (150-360 J biphasic or 360 J monophasic).
Resume CPR immediately and continue for 2 minutes.
Pause briefly to check the monitor.
If VF/VT persists give adrenaline 1 mg IV followed immediately by a third shock (150-360 J biphasic or 360 J monophasic).
Resume CPR immediately and continue for 2 minutes.
Pause briefly to check the monitor.
If VF/VT persists give amiodarone 300 mg IV followed immediately by a fourth shock (150-360 J biphasic or 360 J monophasic).
Resume CPR immediately and continue for 2 minutes.
Give adrenaline 1 mg IV immediately before alternate shocks (i.e., approximately every 3-5 minutes).
Heart rhythms associated with cardiac arrest are divided into two groups: shockable rhythms, which are ventricular fibrillation or pulseless ventricular tachycardia (VF/VT); and non-shockable rhythms, which are asystole and pulseless electrical activity (PEA). As you might expect, the main difference in the treatment of these two groups of arrhythmias is the need for attempted defibrillation in patients with VF/VT. Subsequent actions, including chest compressions, airway management and ventilation, venous access, administration of adrenaline and the identification and correction of reversible factors, are common to both groups.
The ALS algorithm (Figure 3.1) is a standardised approach to the patient with cardiorespiratory arrest. This has the advantage of enabling treatment to be delivered expediently, without protracted discussion. Each member of the resuscitation team can predict and prepare for the next stage in the patient’s treatment, making the team more efficient.
Early defibrillation for VF/VT and prompt and effective CPR (chest compressions and ventilations) unquestionably improve survival after cardiac arrest. Thus, during ALS, attention focuses on early defibrillation and high quality, uninterrupted CPR.
Chapter 5 deals with the recognition of cardiac arrest rhythms. If you are not experienced and trained in the recognition of cardiac arrest rhythms use an automated external defibrillator (AED). Some defibrillators have both a manual and AED capability. Once switched on, the AED will give voice and visual prompts that will guide you through the correct sequence of actions.
Treatment of shockable rhythms (VF/VT)
Adult Advanced Life Support Algorithm
If organised electrical activity compatible with a cardiac output is seen, check for signs of life and, or a pulse:
If there are signs of life or a pulse is present, start post-resuscitation care.
If no signs of life and, or no pulse is present (i.e., PEA), continue CPR and switch to the non-shockable algorithm.
If there is asystole, continue CPR and switch to the non-shockable algorithm.
The interval between stopping compressions and delivering a shock must be minimised and certainly should not exceed 10 seconds. Longer interruptions to chest compressions reduce the chance of a shock restoring a spontaneous circulation.
Chest compressions are resumed immediately after a shock without checking the rhythm or a pulse because, even if the defibrillation attempt is successful in restoring a perfusing rhythm, it is very rare for a pulse to be palpable immediately after defibrillation and the delay in trying to palpate a pulse will further compromise the myocardium if a perfusing rhythm has not been restored. If a perfusing rhythm has been restored, giving chest compressions does not increase the chance of VF recurring. In post-shock asystole, chest compressions may usefully induce VF.
The first dose of adrenaline is given immediately after confirmation of the rhythm as VF and just before delivery of the third shock (drug-shock-CPR-rhythm check sequence); subsequent doses of adrenaline are given just before alternate shocks for as long as VF/VT persists. Have the adrenaline ready to give so that the delay between stopping chest compressions and delivery of the shock is minimised. Adrenaline given immediately before the shock will be circulated by the CPR that immediately follows the shock.
Do not delay giving a shock to wait for adrenaline – if the adrenaline is not ready in time, give it after delivery of the shock.
When the rhythm is checked 2 minutes after giving a shock, if a non-shockable rhythm is present and the rhythm is organised (complexes appear regular or narrow), try to palpate a pulse and look for signs of life. Rhythm checks must be brief, and signs of life and pulse checks undertaken only if there is an oryanised rhythm. Even if an organised rhythm is seen during a 2 minute period of CPR, do not interrupt chest compressions to palpate a pulse unless the patient shows signs of life suggesting a return of spontaneous circulation (ROSC). If there is any doubt about signs of life or a pulse, even if there is an organised rhythm, resume CPR. If the patient has ROSC, begin post-resuscitation care. If the patient’s rhythm changes to asystole or PEA, see non-shockable rhythms below.
Lidocaine 100 mg IV is an alternative if amiodarone is not available, but do not give it if amiodarone has been given. If VF/VT is refractory to shocks, check the positions and contacts of the electrodes or defibrillating paddles.
The likelihood of a successful outcome will determine how long to continue with resuscitation. Seek a senior clinical opinion if you are unsure.
If there is doubt about whether the rhythm is asystole or very fine VF, do not attempt defibrillation; continue chest compressions and ventilation. Very fine VF that is difficult to distinguish from asystole is unlikely to be shocked successfully into a perfusing rhythm. Continuing good quality CPR may improve the amplitude and frequency of the VF and improve the chance of subsequent successful defibrillation to a perfusing rhythm. If the rhythm is clearly VF, attempt defibrillation.
Precordial thump
If a defibrillator is not immediately to hand, consider giving a single precordial thump when VF/VT cardiac arrest is confirmed rapidly after a witnessed and monitored sudden collapse. The precordial thump should be given only by healthcare professionals trained in the technique.
Using the ulnar edge of a tightly clenched fist, deliver a sharp blow to the lower half of the sternum from a height of about
Non-shockable rhythms (PEA and asystole)
Pulseless electrical activity (PEA) is defined as organised electrical cardiac activity in the absence of any palpable pulses. These patients often have myocardial contractions too weak to produce a detectable pulse or blood pressure. PEA may be caused by treatable conditions (see below), and survival after cardiac arrest with asystole or PEA is unlikely unless a reversible cause can be found and treated effectively.
Treatment for PEA
Start CPR 30:2.
Give adrenaline 1 mg IV as soon as possible.
Continue CPR 30:2 until the airway is secured (e.g., tracheal intubation), then continue chest compressions without pausing during ventilation.
Recheck the rhythm after 2 minutes.
– If organised electrical activity is seen, check for a pulse and, or signs of life:
If a pulse and, or signs of life are present, start post resuscitation care.
If no pulse and, or no signs of life are present (PEA):
· Continue CPR.
· Recheck the rhythm after 2 minutes and proceed accordingly.
· Give further adrenaline 1 mg IV every 3-5 minutes (alternate loops).
If VF/VT at rhythm check, change to shockable side of algorithm.
If asystole or an agonal rhythm seen at rhythm check:
· Continue CPR.
· Recheck the rhythm after 2 minutes and proceed accordingly.
· Give further adrenaline 1 mg IV every 3-5 minutes (alternate loops).
Treatment for asystole and slow PEA
(rate < 60 min M
· Start CPR 30:2.
· Check the ECG leads are attached correctly without stopping CPR.
· Give adrenaline 1 mg IV as soon as possible.
· Give atropine 3 mg IV (once only). This dose will provide maximum vagal blockade.
· Continue CPR 30:2 until airway secured; then continue chest compressions without pausing during ventilation.
· Recheck the rhythm after 2 minutes and proceed accordingly.
· Give adrenaline 1 mg IV every 3-5 minutes (alternate loops).
· Check the ECG carefully for P waves if there is asystole. Sometimes this rhythm responds to cardiac pacing. There is no point pacing in true asystole.
· If VF/VT, change to the shockable rhythm algorithm.
During CPR
During the treatment of persistent VF/VT or PEA/asystole, emphasis is placed on good quality chest compressions between defibrillation attempts, recognising and treating reversible causes, and obtaining a secure airway and intravenous access.
During CPR with a 30:2 ratio you will be able to see the underlying rhythm on the monitor during the pause for ventilation. IfVF is seen during this brief pause (whether you are on the shockable or non-shockable side of the algorithm), do not stop CPR to attempt defibrillation. Continue until you have completed 2 minutes of CPR. Knowing that the rhythm is VF, the team should be fully prepared to deliver a shock with minimal delay at the end of the 2 minute period of CPR.
Outcome depends on effective chest compression and ventilation, which are not always done well by healthcare professionals. Providing CPR with a ratio of 30:2 is tiring. As soon as the airway is secured, continue chest compressions without pausing during ventilation. To reduce fatigue, perform compressions in 2 minute shifts, sharing the work between members of the team.
Airway and ventilation
Tracheal intubation provides the most reliable airway but should be attempted only by the properly trained. Laryngoscopy should be attempted without stopping chest compressions, although there may need to be a brief pause in chest compressions as the tracheal tube is passed through the vocal cords. It may be better not to attempt intubation until the circulation has been restored. No attempt at intubation should take longer than 30 seconds: if not achieved after this time, recommence pocket mask or two person bag-mask ventilation. After tracheal intubation, confirm correct tube position, secure the tube and continue chest compressions at a rate of 100 min 1 without pausing during ventilation. Coronary perfusion pressure decreases during any pause in the chest compressions. There is then some delay on resumption before perfusion pressure is restored, thus uninterrupted chest compressions produce a substantially higher mean coronary perfusion pressure. A higher coronary perfusion pressure is associated with improved survival. Ventilate the lungs at 10 breaths min ‘.
It is important not to hyperventilate the patient as this will also lower coronary perfusion pressure. If there is no one skilled in tracheal intubation, acceptable alternatives are the laryngeal mask airway (LMA), ProSeal LMA, or other supraglottic airway devices (chapter 4). After insertion, attempt to deliver chest compressions uninterrupted during ventilation. If too much air leaks and ventilation is inadequate, chest compressions will have to be interrupted to enable ventilation.
Intravenous access
Insert an intravenous cannula if this has not been done already. Although peak drug concentrations are higher and circulation times are shorter when drugs are injected into a central venous catheter, inserting a catheter means interrupting CPR and can have complications. Cannulating a peripheral vein is quicker, easier, and safer. Drugs injected peripherally must be flushed with at least 20 ml saline. Lifting the limb for 10-20 seconds will speed drug delivery to the central circulation. Alternative routes, such as intraosseous or tracheal, are discussed in chapter 7.
Reversible causes
Potential causes or aggravating factors that have specific treatment must be considered during any cardiac arrest. For ease of memory, these are divided into two groups of four based on their initial letter – either H orT.
· Hypoxia
· Hypovolaemia
· Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidosis and other metabolic disorders
· Hypothermia
· Tension pneumothorax
· Tamponade
· Toxins
· Thrombosis (pulmonary embolism or coronary thrombosis)
The four Hs need urgent control of bleeding by surgery or other means.
Hyperkalaemia, hypokalaemia, hypocalcaemia, acidosis and other metabolic disorders are suggested by the patient’s medical history, e.g., renal failure, and confirmed by biochemical tests. A 12-lead ECG may help diagnosis. Intravenous calcium chloride is indicated in hyperkalaemia, hypocalcaemia, and calcium channel-blocker overdose. Always measure the blood glucose to exclude hypoglycaemia. If below 3 mmol I’, give 50 ml of 10% glucose solution intravenously.
Consider hypothermia; use a low reading thermometer.
The four Ts
A tension pneumothorax may cause PEA. It can be a complication of inserting a central venous catheter, especially if there were multiple attempts. The diagnosis is made clinically. Signs of tension pneumothorax include: decreased air entry, decreased expansion and hyper-resonance to percussion on affected side; tracheal deviation away from affected side. Decompress rapidly by needle thoracocentesis, and insert a chest drain.
Cardiac tamponade is difficult to diagnose because the typical signs of distended neck veins and hypotension are usually masked by the arrest itself. Cardiac arrest after penetrating chest trauma, if not due to hypovolaemia is highly suggestive of tamponade, which is an indication for needle pericardiocentesis or resuscitative thoracotomy.
If there is no history, accidental or deliberate ingestion of toxins (therapeutic or toxic substances) may only be shown by laboratory investigations. Where available, the appropriate antidotes should be used, but most often treatment is supportive.
The commonest cause of thrombosis or mechanical circulatory obstruction is massive pulmonary embolus. If cardiac arrest is thought to be caused by pulmonary embolism consider giving a thrombolytic drug immediately.
Minimise the risk of hypoxia by ensuring that the patient’s lungs are ventilated adequately with 100% oxygen. Make sure there is adequate chest rise and bilateral breath sounds. Using the techniques described in chapter 4, check carefully that the tracheal tube is not misplaced in a bronchus or the oesophagus.
Pulseless electrical activity caused by hypovolaemia is usually due to severe bleeding, such as might be caused by trauma, gastrointestinal bleeding, ruptured ectopic pregnancy or rupture of an aortic aneurysm. Intravascular volume should be restored rapidly with 0.9% saline, Hartmann’s solution, or colloid. Obviously, such patients.
Signs of life
If during CPR there are signs of life, such as regular respiratory effort, or movements, or if readings from patient monitors suggest there is return of spontaneous circulation, e.g., increasing exhaled carbon dioxide, satisfactory arterial blood pressure), stop CPR and quickly check the monitor. If there is an organised rhythm, check for a pulse. If a pulse is palpable, continue post resuscitation care, treating any peri-arrest arrhythmia as necessary. If there are no signs of life and, or no pulse, or any doubt continue CPR.
to compensate for wide variations in external temperature. Circulating blood both provides and dissipates heat. Heat dissipation is efficient under normal conditions. When heat is applied to the skin, the temperature of the immediate subdermal layer rises rapidly. As soon as the heat source is removed, the body’s compensatory mechanisms quickly return the area to a normal temperature. If the heat source is not removed, or if it is applied at a rate or level that exceeds the skin’s capacity to dissipate it, cellular destruction occurs.
The skin can tolerate temperatures up to 104° F (40° C) without sustaining injury. At temperatures of 158° F (70° C) and above, cell destruction is so rapid that brief periods of exposure damage the skin down to and including the subcutaneous level. Figure 68-1 shows the relationship between temperature and exposure time for an experimental model of burn injury.
Burn is the lesion of tissues, caused by the influence of heat (thermal), chemicals, electricity, radiation. According to this, there are heat, chemical, electric burns. Among surgical diseases burns take 2 %.
Depth of burn depends on duration of the heat factor’s influence. Heat agents with lower temperature but longer duration of their influence cause the same lesion as heat agents with higher temperature but shorter duration of influence.
Severity of burn depends on area and depth of the lesion.
Estimation of the lesions’ area: right estimation helps to choose the method of treatment. There are many schemes of the lesions area estimation. Here are some of them:
1) rule of “nines” – area of different areas of the body is proportional anterior surface of the trunk – 18 %, posterior – 18 %, lower limb – 18 %, external genitals – 1 %);
2) rule of “palm”. It is used if burns are limited and located on different areas of the body. According to the rule palm takes 1 % of skin surface.
Estimation of burn’s depth: is carried out according to the classification (adopted on the 27 congress of surgeons 1960). Division of the burns on superficial (I, II, IIIA st.) and deep (IIIB-IV st.) is connected with possibility of independent epithelization of the cover at superficial burns.
As a rule burns are mixed (superficial and deep), that is why evaluation of the burn’s depth in early terms is very important.
I stage – hyperemia of the skin
II stage – separation of epidermis with formation of bullas/
III A stage – necrosis of superficial layers of the skin with saving of bulbs hair, sweat glands and sebaceous, glands.
IIIB stage – necrosis of all the derma
IV stage – necrosis of the skin and underlying tissues.
Methods of determination of burn depth
1) primary examination :
– color of epidermis and derma ( epidermis – red or pink in case of I,II stages, white or yellow or black in case of deep burns ; derma – red inII stage, pail in IIIA, grey in IIIB)
– edema
– vesicles
– is or not necrosis (IIIB, IV)
2) needle test ( hyper aesthesia in II st., superficial hypoaestesia in case of IIAst. and so on)
3)aplication of wet gause with special solutions (spiritus)
4) epilatory test ( painfull in 1,2,3Ast., easy, without pain in case of deep burns)
5) instrumental methods:
a) usage of radioactive isotopes
b) impedance measuring
c) thermography
d) infrared zonding
e) hystological and hystochemical methods
Prediction of burn’s severity
In adults the rule of “hundred” is used. (age + total area of burns in %)
up to 60 – prognosis is favorable
61-80 – prognosis is relatively favorable
81-100 – doubtful
101 and more – unfavorable
Frank’s index is more exact. It takes into account area and depth of the lesion. It is based on the fact that patient’s with deep burns is 3 times severe than with superficial burns, That is why if 1 % of superficial burn is 1, unit than 1 % deep burn takes 3-4 units. The sum of these proofs makes the Frank’s index.
So, the stage of burn’s severity is estimated by the Lesion Severity Index. (LSI) 1 % of the burn of I or II stage = 1 unit of LSI
1 % of the burn of IIIA stage = 2 units of LSI
1 % of the burn of IIIB stage = 3 units of LSI
1 % of the burn of IV stage = 4 units of LSI
It there are heat lesions of respiratory ways (BRW) we have to add:
– if BRW is of light degree = 15 units LSI (respiratory disorders are not fixed);
– if BRW is of middle degree = 30 units LSI (respiratory disorders are fixed first 6-12 hours after trauma);
– if BRW is of severe degree = 45 units LSI (respiratory insufficiency from the moment of the burn is fixed)
Prognosis of burns is favorable, if Frank’s index is not more than 30 units
is relatively favorable, if 30-60 un.
is doubtful – 61-90 units unfavorable – more than 90 units.
Formulation of the diagnosis in case of burns
1. The word ‘burn’
2. The etiological factor: flame, hot water, steam, acid…
3. The stage of burn ( I, II, III, IV)
4. The burn area in % (area of deep burns is putting in the brackets)
5. Injured organs, areas.
6. Accompanying injuries that deal with the action of thermal agent ( respiratory burns, carbon monoxide poisoning )
7. Dates about burn shock with it’s degree or another period of the burn disease ( toxemia, septic toxemia, recovery)
8. LSI (lesion severity index)
9. Complications
10. Accompanying traumas and diseases
For example:
Clinical diagnosis: Burn by the fire I and II st. 25% of face, neck, right upper limb, chest
Respiratory burn of light degree
Burn shock, medium degree
LSI – 40 units
Accompanying diagnosis: Stomach ulcer
First aid for burned patients should be directed on the elimination influence of the heat agent’s and cooling the burned areas. For cooling one can use cold water, ice-bladders, snow during at least 10-15 minutes. After stopping the pain we apply aseptic bandage, give Analgin, Amidopirin, warm tea, mineral water. Usage of therapeutic bandages during the first aid is contraindicated.
Before transporting patients should be given analgesics, neuroleptics, antihistaminic drugs.
Duration of transporting should de not more than 1 hour. Longer duration of transporting needs intravenous infusions of electrolytes and blood substitutes, oxygen therapy and narcosis, usage of cardio-vascular preparations
The burn disease develops when there are superficial burns (II-IIIA st.) area of 10 % skin surface and deep burns – more than 5 %. The burn disease is the complex of clinical symptoms, that’s developed due to heat lesion of skin cover and underlying tissues.
The are 4 periods in the duration of burn disease: 1 – burn shock, 2 – acute burn toxemia, 3 – septic toxemia, 4 – recovery.
Burn shock
According to the degrees of severity, there are:
Light burn shock (LSI up to 30 units, duration 24-36 hours)
Middle burn shock (LSI is 31-60 units, duration 36-48 hours)
Severe burn shock (LSI is 61-90 units, duration up to 64 hours)
Most severe burn shock (LSI > units, duration up to 72 hours and more)
Infusion antishock therapy
It has to be start in the place of incident with intravenous infusions of saline solutions. Volume and speed of infusions depend on the severity of patient’s state and daily volume of blood deficiency. Daily volume of deficient liquid we can determine in such a way:
4ml * % area of burn * body weight (kg) = ml of liquid for a 24 hours
And 25% of this volume you have to use during first 4 hours after trauma, then 25% during next 4 hours, 25% during next 8 hours, and 25% during next 8 hours.
The volume of daily infusions could not be more than 160ml/kg/day.
Infusions are:
|
Severity of burn shock |
Koloid: saline: not saline solutions and periodoty of its using 1 day 2 day 3 day 4 day |
|||
|
LSI to 30 |
0:1:0 |
0:1:1 |
|
|
|
31-60 |
0,5:1:0 |
0,5:0,5:2 |
0,5:0,5:2 |
0,5:0,25:2,75 |
|
61-90 |
1:1:0 |
1:0,5:1,5 |
1:0,25:1,75 |
1:0,25:1,75 |
|
>90 |
1,5:1:0 |
1:0,5:1,5 |
1:0,25:1,75 |
1:0,25:1,75 |
Quick restoring of blood volume by saline solutions decrease vessel’s spasm, improve miocardial function, decrease acidosis.It is not good to use koloid solutions in first hours after trauma cause they have high agregative action, low speed of outcoming from the organism, and could worse limpho drenage. From koloid solutions it is better to use lowermolecular solutions such as refortan.
It’s function is to: – restore haemodynamic
– prevent increasing of passableness of capillars
– prevent activation of endothelial cells and block the development of sedcondary injuries
– defence of monocytes of blood.
Glucose during first hours after hard trauma is not used , cause it is going throu cappilar membran to between cellular space and cause the edema and makes injury deeper.
After 24 hours from the beginning of infusion therapy by electrolitic solutions perftoran ( plasmosubstitute) could be used. It is used in dosage 2,5-3,5 ml/kg for one inserting.
It’s function is to: – normilize oxygen transport
– restore the haemodynamic
– improving of reological function of blood
– sorbtive and diuretic influence
– imunoprotector
– antiedematous influence
– block Ca chanals
– block appearing of inflamatory mediators.
It is very important to correct agregative state of blood. We use lowmolecular heparines – fraxiparin, klexan from the first hours after the burn. Fraxiparin is used in dosage i/v 0,3 ml 1 or 2 times a day
For the decreasing of agregation of elements of blood we use desagregants. For example – trental (pentoxifilin) 200-400 mg i/v on 400 ml of NaCl 1-2 times a day.
Of course in complex treatment of burn shock we use drugs for preventing complications with heart, kidneys, liver. For example: dofamin (2,5-10 mkg/kg/min), eufillin every 4-6 hours 2,4% 5 ml, 4% Na hydrocarbonate 100-200ml, dexametazon 0,5 mg/kg/day.
It is imporant to prevent infection by usage of antibiotics. One of them is zinacef from cefalosporines
Criteria of effectiveness of therapy of shock:
1) restoring of adequate conciousness
2) stabilization of haemodynamic
3) haemodillution ( Ht 33-38%)
4) protein of blood > 60g/l
5) normalization of breathing
6) restoring of kidneys’ function
7) normilizing of skin temperature.
The second day of shock deals with the deceasing of transfusion volume for 1/3 .Plasma or albumin could be used in fourth 8 hours after burn.we use kvamatel ( H2 blocker) 20 mg 2 times a day, maalox, almagel, smecta. Eubiotics are also could be used. In case of burns lower than 15% it should not be used artificial nutrition.
